(belated, because - ironically - I've been sick and am catching up on my reading list)
The thing about reform on the scale of what America's health care system needs - and I use the words "care" and "system" quite wrongly - is that it is, in fact, impossible to do.
It's too vast, too complex, too many details and vested interests and just too much. A solution that would fix everything correctly was not going to happen, because it didn't exist.
What is possible, and necessary, is to make a start. Obama managed that before he was even the Democratic nominee, because, for the first time, he somehow made the conversation be about how health care reform should happen instead of whether it should happen at all.
Currently, America spends more per capita than any other nation, to have almost a sixth of its population have no health care coverage at all - and even for those who do, the outcomes aren't better, and are often worse. That's insane, and incomprehensible to someone from a country like Australia, where universal health care is assumed as a right of citizenship. (Not even citizenship, actually - residence. Permanent residents and tourists also get health care in this country.)
But the thing is, even countries with universal health care generally didn't start out with a flawless system. What you do is start with something flawed, but well-intentioned, and then you make it better, iteratively.
Of course, one of America's biggest problems is the aversion to tax, which does seem to be a conservative thing. The American people, as a group, seem to want everything, but to pay for nothing, which in the long term, doesn't work. And they really, really seem to object to paying for anything which doesn't benefit them directly, without recognising that sometimes, the benefit applies to society as a whole, and their recompense is living in a better country.
Australia's public health care system is called Medicare. Unlike the American version, our Medicare applies to *everyone* - everyone has a Medicare number and a Medicare card, and it covers a lot of things. I recently broke my leg in three places, and I had the ER trip, x-rays, hospitalisation, surgery, assistive equipment, and outpatient treatment and services *all* provided by Medicare.
So who pays for that?
Everyone. There's a thing called a Medicare Levy, which is collected alongside taxes but isn't part of the income tax. It *is* income-based - if you're poor, you pay nothing, and if you're rich, you pay quite a bit. Because if you're rich, you can afford to, and in Australia, it is taken for granted that those who are fortunate in society should help support the less fortunate.
(After devastating floods in Queensland recently, a levy was imposed to fund the disaster relief efforts and repairs to QLD infrastructure. This levy didn't even touch you if you made less than something like $52,000 a year, and was only assessed on that portion of your income which was over that boundary. This, in Australia, is considered to be fair and reasonable.)
I get that, I do -- I get all of that. I would be ok with a system that is actually administered by the government -- or at least more ok than having an extra layer of crap on top of a private for-profit insurance group (which is kind of what Medicare in the US is right now, and needs fixing, but whatever -- undoubtedly better than nothing for a lot of people). I would even be ok with paying something like the Social Security tax for health care -- if if was set up in such a way that such payments went to either the government fund if you were on the government health insurance, or to whatever provider you picked if someone else. But that isn't what they're doing at all.
My main beef is with the fact that they set this thing up as a income tax penalty -- if you don't have health insurance that they see as being fit, you pay the "tax penalty". That is not how things are done here. That is never how things have been done here. That is like smacking someone on the wrist for a personal decision made to not buy a product, except it's the government and several thousand dollars of money you have to pay out per year.
There are also, from what I understand, no real safeguards from abuse -- who decides whether an insurance company is meeting the necessary standards? what -are- all the necessary standards? who controls the list? and who controls the reporting and the time the tax penalty kicks in so that people won't be caught in the lurch? (Because it would be very easy to tweak things such that someone can have the 'proper' insurance 364 days of a year, and still end up paying out for the "tax penalty", and nobody would be happy with those shenanigans, but it's much more difficult to sue a government office than a private company when they try and pull stupid shit.) Plus, when the "tax penalty" kicks in, it hits the individual, not the insurer (and sometimes the business, if they're the ones doing the insuring to individuals, so there may even be some double-taxing going on if somebody suddenly ends up in the lurch through no fault of their own).
I might even feel a little better if it had a sweeping "everybody over 65 gets on the Medicare plan" dealy, because at least then I would know that once I hit retirement, I would be covered, having sort-of 'paid my dues' up-front a bit any year that I might have pitched in on the tax penalty. The only problem is, getting Medicare once you hit retirement isn't automatic here, and you need to be careful when and how you apply, and with all that fun paperwork. (I'm fairly sure that the bill didn't change that, at least.) And I had mixed feelings about the provision trying to force expansion to all poor people in each state, where a state wouldn't receive any federal funding at all to help pay for Medicaid if they didn't do the expansion, because that's kind of bullying the states to go along with the expansion or go it alone. --But that was the one provision out of the whole mess that they struck down! Which means that many states won't be pushing the expansion, if they can get the same amount of money for the same number of people, especially if they already hadn't been getting enough to cover everybody already on the previous rolls and having to pull funds from the state tax coffers elsewhere. So that pretty much kicks any 'all poor people will be covered' idea right out the window (assuming that the state(s) in question offered Medicaid in the first place).
I don't know -- I know it isn't and wasn't going to be perfect, but it -easily- could have been made better with a few changes, or at least a few lines of clarifications. The thing was several thousand pages long already!
I think the main crux of my worry in general is that, now that it's been passed, it'll stick around for all eternity as-is (which tends to happen with the larger bills that go through -- they don't usually get repealed). These beasts tend to only get minor changes in future bills, in very nontransparent ways. Complete overhauls are few and far between. Even worse might be a repeal -- because if that happens, I can't see that actually going through except for the entire bill (because nothing else any less drastic would gain enough momentum to get anywhere), and if that happens then we'll be in a huge chaotic flux all over again, and quite possibly or probably end up with something much worse (because hey, they did a whole bunch of backroom closed-door deals with the drug companies and the health insurance industry before, and didn't listen to the experts the first time... why would they do it any differently this time?). --Sorry if I'm a bit of a downer and jaded on all this BS. I tend to be very pessimistic about my federal government's ability to avoid drastically fucking things up these days (goes to show how high my expectations are, huh?)
But yeah, back to the original matter somewhat: I wouldn't mind paying more taxes to help pay for things we all need and use -- hell, even to bring down are debt with China (especially that). I don't like the national debt, and I understand that that means getting taxed more. I don't doubt that most people do. And I wouldn't mind paying a health care tax like a social security tax, if I knew that the funds wouldn't just be used to line the pockets of the private insurance industry and wouldn't be raided to pay for other shit rather than their intended purpose (health care for people who need it). But the way they've implemented it as of right now is in a very bad way, and opens the door for more shenanigans in the future (see previous post re: private companies begging the govt. to basically force a private product to be paid for, or a penalty levied).
Oh, and parting shot (which I think you agree with, but who knows who else might or might not be reading my crap): the bill ended up not really being about "health", "health care", or "reform" -- it was about expansion of private health insurance coverage. And people did end up talking about health care reform a lot -- but almost none of that made it into the bill. And a big, very real impact this thing is gonna have is a polarizing effect on the voters come the fall. A lot of people are probably gonna get booted out of office for this one, and a majority lead in Congress of either major party over here tends to not be a good thing -- stuff gets rammed through on either side when that happens; I don't like the idea of that in general, and especially not when it happens in practice.
Anyway, yeah. Very bleh all around. *sighs unhappily*
There's a whole bunch of very important stuff built around improving health care efficiency and lowering costs but not standards, with a whole bunch of pilot programs and other things that actually tend to work, which is important.
As for your "who decides" thing - well, the government does. Who else do you want to decide? There comes a point where you have to assume that the government will be doing things fairly, and if you find out they aren't, you fix that, but you still have to let the government do it. Because who else? The government are the only ones who have the authority and who have any real chance at operation on a basis of "for the benefit of everyone" rather than "for the benefit of shareholders".
Not that spectacular a chance, alas, given how comprehensively terrible campaign finance issues are in the US. But a chance.
In the legislation? (Admittedly I did not read all of it the first time -- merely skimmed -- and I have not read the final copy.) I would hope that they look at other sources for improving efficiency and things, but the fact that the structure itself isn't fully set up yet (policy still being written I think) means that many things are still up in the air. (I'll be happier when I only have specific things to complain about, I think ;) But yeah, that's important, I agree -- especially for improvements over time that actually make things better.
Well, yeah, you're right of course. Unfortunately, this is where my "erg" factor tends to come in. I trust state level government way more than federal, and the mob of legislators not so much at all to be smart, in a good way, for the public, at all, these days, but yeah. (wow that was a long set of clarifications, *woof*) ...I guess when it comes down to it, I overall view them like I view the police -- assume the individuals are smart and can do their jobs, but make sure there's lots of public oversight and that people can be held accountable if they do stupid shit. (And be wary of the membership of the larger decision-making groups, because they can get carried away with themselves if you're not careful.) All that fun checks and balances stuff.
I agree re: benefit of everyone that the government would be better at that side of it (otherwise I'd be a screaming mess right now, no doubt), but a lot of people get very squicky about the idea of the government deciding about the cost/benefit tradeoffs of whether to cover medical procedures for people and how much to pay out (because, hey, no unlimited funds there). I'm kind of undecided. It's probably pretty universal though, that when the government starts putting a price on human life, people get ansy. To me, it means that we really need the right, most ethical people we can find to be in charge, who are not just going to rubber stamp rejections to avoid rising costs. (I think that some people -- not just me -- worry that the government might not end up any 'nicer' about things than the insurance companies currently, because we don't have much of another model to work off of, and the insurance companies are still interwoven throughout the mix. ...Because lord help us if we ever actually looked at -another- country for a good way to model a system */sarcasm* *rolls eyes*)
"The government" is huge. I don't think anybody trusts all of it :-P ...The chunk they've just created / are and have been in the process of creating is new and untested. Change can be bad as well as good. *shrugs*
Heh, yeah, can't argue there re: campaign finance. Could be worse though. Damn Super PACs. (...Seriously, Supreme Court, wtf these days?) *sighs*
Anyway, ty for the chat, I'm feeling at least a little less stressed for all the venting and talkback; other points of view help :)
![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
Re: It is far from Universal
The thing about reform on the scale of what America's health care system needs - and I use the words "care" and "system" quite wrongly - is that it is, in fact, impossible to do.
It's too vast, too complex, too many details and vested interests and just too much. A solution that would fix everything correctly was not going to happen, because it didn't exist.
What is possible, and necessary, is to make a start. Obama managed that before he was even the Democratic nominee, because, for the first time, he somehow made the conversation be about how health care reform should happen instead of whether it should happen at all.
Currently, America spends more per capita than any other nation, to have almost a sixth of its population have no health care coverage at all - and even for those who do, the outcomes aren't better, and are often worse. That's insane, and incomprehensible to someone from a country like Australia, where universal health care is assumed as a right of citizenship. (Not even citizenship, actually - residence. Permanent residents and tourists also get health care in this country.)
But the thing is, even countries with universal health care generally didn't start out with a flawless system. What you do is start with something flawed, but well-intentioned, and then you make it better, iteratively.
Of course, one of America's biggest problems is the aversion to tax, which does seem to be a conservative thing. The American people, as a group, seem to want everything, but to pay for nothing, which in the long term, doesn't work. And they really, really seem to object to paying for anything which doesn't benefit them directly, without recognising that sometimes, the benefit applies to society as a whole, and their recompense is living in a better country.
Australia's public health care system is called Medicare. Unlike the American version, our Medicare applies to *everyone* - everyone has a Medicare number and a Medicare card, and it covers a lot of things. I recently broke my leg in three places, and I had the ER trip, x-rays, hospitalisation, surgery, assistive equipment, and outpatient treatment and services *all* provided by Medicare.
So who pays for that?
Everyone. There's a thing called a Medicare Levy, which is collected alongside taxes but isn't part of the income tax. It *is* income-based - if you're poor, you pay nothing, and if you're rich, you pay quite a bit. Because if you're rich, you can afford to, and in Australia, it is taken for granted that those who are fortunate in society should help support the less fortunate.
(After devastating floods in Queensland recently, a levy was imposed to fund the disaster relief efforts and repairs to QLD infrastructure. This levy didn't even touch you if you made less than something like $52,000 a year, and was only assessed on that portion of your income which was over that boundary. This, in Australia, is considered to be fair and reasonable.)
Re: It is far from Universal
My main beef is with the fact that they set this thing up as a income tax penalty -- if you don't have health insurance that they see as being fit, you pay the "tax penalty". That is not how things are done here. That is never how things have been done here. That is like smacking someone on the wrist for a personal decision made to not buy a product, except it's the government and several thousand dollars of money you have to pay out per year.
There are also, from what I understand, no real safeguards from abuse -- who decides whether an insurance company is meeting the necessary standards? what -are- all the necessary standards? who controls the list? and who controls the reporting and the time the tax penalty kicks in so that people won't be caught in the lurch? (Because it would be very easy to tweak things such that someone can have the 'proper' insurance 364 days of a year, and still end up paying out for the "tax penalty", and nobody would be happy with those shenanigans, but it's much more difficult to sue a government office than a private company when they try and pull stupid shit.) Plus, when the "tax penalty" kicks in, it hits the individual, not the insurer (and sometimes the business, if they're the ones doing the insuring to individuals, so there may even be some double-taxing going on if somebody suddenly ends up in the lurch through no fault of their own).
I might even feel a little better if it had a sweeping "everybody over 65 gets on the Medicare plan" dealy, because at least then I would know that once I hit retirement, I would be covered, having sort-of 'paid my dues' up-front a bit any year that I might have pitched in on the tax penalty. The only problem is, getting Medicare once you hit retirement isn't automatic here, and you need to be careful when and how you apply, and with all that fun paperwork. (I'm fairly sure that the bill didn't change that, at least.) And I had mixed feelings about the provision trying to force expansion to all poor people in each state, where a state wouldn't receive any federal funding at all to help pay for Medicaid if they didn't do the expansion, because that's kind of bullying the states to go along with the expansion or go it alone. --But that was the one provision out of the whole mess that they struck down! Which means that many states won't be pushing the expansion, if they can get the same amount of money for the same number of people, especially if they already hadn't been getting enough to cover everybody already on the previous rolls and having to pull funds from the state tax coffers elsewhere. So that pretty much kicks any 'all poor people will be covered' idea right out the window (assuming that the state(s) in question offered Medicaid in the first place).
I don't know -- I know it isn't and wasn't going to be perfect, but it -easily- could have been made better with a few changes, or at least a few lines of clarifications. The thing was several thousand pages long already!
I think the main crux of my worry in general is that, now that it's been passed, it'll stick around for all eternity as-is (which tends to happen with the larger bills that go through -- they don't usually get repealed). These beasts tend to only get minor changes in future bills, in very nontransparent ways. Complete overhauls are few and far between. Even worse might be a repeal -- because if that happens, I can't see that actually going through except for the entire bill (because nothing else any less drastic would gain enough momentum to get anywhere), and if that happens then we'll be in a huge chaotic flux all over again, and quite possibly or probably end up with something much worse (because hey, they did a whole bunch of backroom closed-door deals with the drug companies and the health insurance industry before, and didn't listen to the experts the first time... why would they do it any differently this time?). --Sorry if I'm a bit of a downer and jaded on all this BS. I tend to be very pessimistic about my federal government's ability to avoid drastically fucking things up these days (goes to show how high my expectations are, huh?)
But yeah, back to the original matter somewhat: I wouldn't mind paying more taxes to help pay for things we all need and use -- hell, even to bring down are debt with China (especially that). I don't like the national debt, and I understand that that means getting taxed more. I don't doubt that most people do. And I wouldn't mind paying a health care tax like a social security tax, if I knew that the funds wouldn't just be used to line the pockets of the private insurance industry and wouldn't be raided to pay for other shit rather than their intended purpose (health care for people who need it). But the way they've implemented it as of right now is in a very bad way, and opens the door for more shenanigans in the future (see previous post re: private companies begging the govt. to basically force a private product to be paid for, or a penalty levied).
Oh, and parting shot (which I think you agree with, but who knows who else might or might not be reading my crap): the bill ended up not really being about "health", "health care", or "reform" -- it was about expansion of private health insurance coverage. And people did end up talking about health care reform a lot -- but almost none of that made it into the bill. And a big, very real impact this thing is gonna have is a polarizing effect on the voters come the fall. A lot of people are probably gonna get booted out of office for this one, and a majority lead in Congress of either major party over here tends to not be a good thing -- stuff gets rammed through on either side when that happens; I don't like the idea of that in general, and especially not when it happens in practice.
Anyway, yeah. Very bleh all around. *sighs unhappily*
Re: It is far from Universal
As for your "who decides" thing - well, the government does. Who else do you want to decide? There comes a point where you have to assume that the government will be doing things fairly, and if you find out they aren't, you fix that, but you still have to let the government do it. Because who else? The government are the only ones who have the authority and who have any real chance at operation on a basis of "for the benefit of everyone" rather than "for the benefit of shareholders".
Not that spectacular a chance, alas, given how comprehensively terrible campaign finance issues are in the US. But a chance.
Re: It is far from Universal
Well, yeah, you're right of course. Unfortunately, this is where my "erg" factor tends to come in. I trust state level government way more than federal, and the mob of legislators not so much at all to be smart, in a good way, for the public, at all, these days, but yeah. (wow that was a long set of clarifications, *woof*) ...I guess when it comes down to it, I overall view them like I view the police -- assume the individuals are smart and can do their jobs, but make sure there's lots of public oversight and that people can be held accountable if they do stupid shit. (And be wary of the membership of the larger decision-making groups, because they can get carried away with themselves if you're not careful.) All that fun checks and balances stuff.
I agree re: benefit of everyone that the government would be better at that side of it (otherwise I'd be a screaming mess right now, no doubt), but a lot of people get very squicky about the idea of the government deciding about the cost/benefit tradeoffs of whether to cover medical procedures for people and how much to pay out (because, hey, no unlimited funds there). I'm kind of undecided. It's probably pretty universal though, that when the government starts putting a price on human life, people get ansy. To me, it means that we really need the right, most ethical people we can find to be in charge, who are not just going to rubber stamp rejections to avoid rising costs. (I think that some people -- not just me -- worry that the government might not end up any 'nicer' about things than the insurance companies currently, because we don't have much of another model to work off of, and the insurance companies are still interwoven throughout the mix. ...Because lord help us if we ever actually looked at -another- country for a good way to model a system */sarcasm* *rolls eyes*)
"The government" is huge. I don't think anybody trusts all of it :-P ...The chunk they've just created / are and have been in the process of creating is new and untested. Change can be bad as well as good. *shrugs*
Heh, yeah, can't argue there re: campaign finance. Could be worse though. Damn Super PACs. (...Seriously, Supreme Court, wtf these days?) *sighs*
Anyway, ty for the chat, I'm feeling at least a little less stressed for all the venting and talkback; other points of view help :)