Health Care as Entitlement for All

State involvement in health care can be traced back to 1773 when the "Public Hospital for Persons of Insane and Disordered Minds" opened in Williamsburg.

Virginia”s state involvement in health care can be traced back to 1773 when the “Public Hospital for Persons of Insane and Disordered Minds” opened in Williamsburg.

by Allen Barringer

For seven years now we have lived with “Obamacare,” the Affordable Care Act, and now we are engaged in rewriting it as the American Health Care Act, and, yes, it’s “all very complicated.” One thing already is clear: both Democrats and Republicans talk about “affordable, quality health coverage for all Americans” — but neither the ACA nor the proposed ACHA truly lives up to that description.

I understand that standards of health care are contentious. We don’t agree on what is “quality” or “adequate” care, let alone “humane,” and we don’t even agree how limited medical resources, such as transplantable organs, should be allocated. But until this year, I thought we did agree on equal access to whatever it is the government provides. If there is a health entitlement at all, it should be available to all.

Health care has long been a government responsibility. From medieval times, the established Church organized hospitals and administered the poor house and other components of the social safety net, while the King dealt with public sanitation, quarantines and military health. The Enlightenment brought about a greatly expanded government role in public improvements, including public health, during the 17th and 18th centuries. Those traditions were brought to the American Colonies; indeed, persons drafted for their medical skills were among the earliest settlers in Virginia and in New England. By the 19th century, and particularly after the Civil War, public health (including, individual care for the ill and the indigent) was generally recognized as a concern and a responsibility of the States.

In Virginia, the first mental hospital was built in Williamsburg in 1773 at the urging of Governor Fauquier, and Western State opened in Staunton in 1825. Jefferson’s Anatomical Hall, completed in 1826, was an early building for medical instruction at the University of Virginia. The Hampden-Sydney “Richmond Department of Medicine” opened in 1834, becoming the Medical College of Virginia in 1854. After the Civil War health activity in Virginia exploded due to the legacy of military health care and new learning about the importance of cleanliness, the source of infections and epidemics, and use of anesthesia.

Virginia’s State Board of Health came in 1872. Virginia mandated vaccinations and sanitary sewers and quarantine regulations in its port cities. In 1889, a young doctor recently trained in Vienna, Austria, in the latest medical and public health practices, was hired as Professor of Medicine at the University of Virginia. He quickly convinced Charlottesville and university authorities that to maintain the good health of university students and faculty it was necessary to address the health of the whole community they lived in. Eventually he persuaded the General Assembly to support this approach also. Teaching students through the practice of public health was the hospital’s mission. Teaching better health practices to the community and abating communicable disease at the source was its outreach.

Health care for the community means everyone in the community. Disease afflicts rich and poor and all races and occupations alike; every occupation has its hazards. The University hospital which Professor Barringer, my grandfather, founded and promoted so tirelessly was from its inception open to the Charlottesville community without regard for university affiliation, status, gender, race, or ability to pay. Many medical professionals and hospital administrators in Virginia still provide medical care on those principles, although they try to obtain payment when they can. And health remains an object of State concern and appropriations. For example, just a few months ago, Governor Terry McAuliffe announced State measures to make counteragents available at little or no charge aimed at combating the growth of opioid addiction, which he described as “a public health emergency” in Virginia.

The involvement of our state and federal governments in providing health care is so pervasive that we cannot pretend this is, “by default,” a private responsibility. The details of how the government goes about providing “affordable, quality health coverage for all Americans” are not as important as the affordability, the quality, the coverage offered. And this is a Virginia issue, not just a federal one.

Medicaid has a state budget impact, and there is talk of turning the entire health entitlement spectrum into federal block grants to the States. When McAuliffe tried to expand Medicaid under the ACA (essentially “free” to Virginians for a time, at the expense of the federal government), the General Assembly turned him down. That seemed to many observers (including me) to be more a partisan rejection of Obamacare than a vote against the public health and economic welfare of Virginians — but it certainly had the latter effect. And according to the Congressional Budget Office, the ACHA as proposed would substantially aggravate that effect.

Government support for health care has two rationales. One is economic. A healthy community is more productive, with less missed work, less down-time, less family distraction and dysfunction, and less threat of a catastrophic epidemic. Even if it isn’t you who is ill, you have an economic stake in the health of those around you, and you receive a direct benefit from the investment of your tax dollars in health care for others, not to mention the indirect benefit of a higher quality of community life. There is no distinction between individual health and public health in this regard.

The other rationale, of course, is compassion. Compassion is a moral imperative, and while I hear very little about compassion from Republicans these days it’s high time they re-discover it. The parable of the Good Samaritan is in the Bible, not a book of etiquette. Working in health care is an intensely rewarding endeavor, which attracts churches, charities, and all those many individual volunteers who devote their time to helping others. Not incidentally, compassionate policies also appeal to voters.

The problem with economic benefit and compassion as rationales for action is that both are open-ended. There is always something more that can be done to improve health, although at greater cost, with diminishing returns. And, each of us has some social (if not legal) responsibility for our own good health practices and diet. For these reasons “quality” care does not imply “unlimited” care; a health “entitlement” cannot be unconstrained. But constraining it by granting the entitlement in full to some people, denying it in full to others, is just not consistent with our American tradition of non-discriminatory, equal treatment under the law. There is certainly room to argue that our current entitlement programs are too generous; but whatever they offer should be “for all Americans.”

The ACHA does not reduce the level of health care for all; instead, it reduces access to health care for some. The way it proposes to retreat from “affordable, quality health coverage for all Americans” means some additional increment of the population will not have that coverage. The uninsured may nevertheless obtain crisis health care in crowded emergency rooms and, occasionally, free preventive care in community health clinics (although the ACHA would reduce government funding for those services also). The practical response of the educated taxpayer should be, emergency rooms are not free; we end up paying for them through inflated charges to those who have insurance, and we end up paying for the inefficiency of using hospitals for the delivery of community health care. In any event, not everyone can get the care they need from these crowded, stop-gap venues, which are increasingly inaccessible to many rural residents without transportation. We should rationalize our health care system by making quality care affordable, not by offering a lower quality substitute. But many taxpayers have not thought about this.

The denial of health care to some Americans and not to others certainly seems discriminatory to those affected by it. I have heard today’s two-tiered health system defended on grounds that the denial of access to “quality” care is not due to any legal barrier but mere un-affordability, and the government has no legal obligation to make things affordable – therefore, if the government provides some people with health insurance but not others, that’s tough luck, not discrimination. This disingenuous argument has been rejected many times in other discrimination contexts. Suffice it to say, if the withdrawal of insurance subsidies results in unaffordable health insurance which results in unaffordable health care, the result (I believe) is no less discriminatory than a law allowing health care only to those with certain income levels. One hoped-for result of “affordable, quality health coverage for all Americans” is to rationalize the way we charge and pay for emergency care and community health and regular health professionals, without hidden cross-subsidies and without discrimination based on ability to pay.

The bottom line: regardless of anyone’s legal right to “affordable, quality health coverage,” I believe we have to embrace some level of health entitlement for “all Americans” because, by choosing who can afford it, whatever the mechanism, the government also chooses whose health gets cared for, who gets denied care. And, that is a moral choice, not merely a legal one.

Are you willing that health care providers turn patients away if they cannot prove they can pay? Are you willing that your neighbor, whose financial resources have been exhausted by a chronic condition (that also prevents him from working), be told he’s simply out of luck? Does it matter if he brought this medical need on himself through addiction or neglect? If you say yes to any of these, do you accept that, if you ever find yourself in your neighbor’s position, you are asking others to treat you the same? That is what “affordable, quality health coverage for all Americans” really means.

Allen Barringer is retired and lives in McLean, Virginia.

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29 responses to “Health Care as Entitlement for All

  1. Awesome Editorial Acbar!

    good thoughts and much to chew on!

    and while I have much to say – and will.. I might hold up to give others
    a chance to weigh in…

  2. Excellent perspective, including sound justification along the spectrum of conservative-libertarian-liberal etc.

    A quibble (maybe) on the use of the word “entitlement”: We can have healht insurance reform, and a separate topic, health care reform, without them being an “entitlement”. “Entitlements” are often used as a budgetary term meaning, if someone meets the criteria, they get the allotment. Clinton and Congress’ modification of “welfare” took it out of an “entitlement” (worth a whole ‘nother blog). Medicare, Medicaid, and Social Security are “entitlements” – they are not adjustable in the budget….the Beltway-wonk use of the term became mooshed by punditry with concepts of an entitlement society, and feeling entitled to things like a social safety net – when they *aren’t* entitled to that any more. (Tho many in comment strings don’t understand how TANF works.) OTOH, people who get Social Security are, wrongly, objecting to it being called an “entitlement” – “I worked for that, gosh darnnit!”

    Anyway, so I think clarity is helpful.

    I also kind of like the Constitutional limit of rights to the Bill of Rights and, life liberty and the pursuit of happiness. I had a friendly Thanksgiving argument with a friend on, do we have a “right” to clean water. Aside from it being essential for us to pay for water, I think it’s probably a bad idea to say Americans should have a “right” to health care, food, housing……if we choose to subsidize those things, OK, but that doesn’t make it a right. (I think K-12 children may have a right to public education?)

    • “Entitlement” means exactly what you say to a budget maven, but I feel the term has an unsavory colloquial connotation today. “He acts entitled” suggests someone who claims an array of government handouts with disdain for those providing them. When I wrote this essay, I did not give it a caption (“Health Care as Entitlement for All” was Jim’s choice, which plays off that sense of greed in the word) but both uses of “entitlement” are appropriate here. Many people used to view accepting government-subsidized health care as degrading, a mark of inability or unwillingness to stand on one’s own two feet, and that view still has political currency. But we have that conflicting moral imperative that says, “your neighbors will take care of you and get you medical assistance (whether you want it or not)”. We do not allow people to die on park benches (if we notice them, that is). Historically, we haven’t for a long time.

      I suppose my point is, the notion of universal health care is both distasteful and inevitable. We have to figure out how to do it right, but retreating from doing it at all is morally and politically unsustainable in America. The ACA is one mechanism to provide it, the ACHA another, but universal health care must be the goal however much we pretend otherwise.

  3. I sense the issue is defining cost and finding a fair way to pay. I am not yet 65 but getting close enough to belatedly realize the cost of Medicare coverage escalates vs. income (generally based your tax return two years before of coverage). As a married couple filing jointly, we are somewhat sheltered by higher income limits, but my single colleagues (in some cases due to death of spouse) are hit pretty hard. In addition to this already pre-existing progressive nature, Obamacare sort of triples down on hitting moderate incomes harder by increasing employee share of Medicare payroll tax on high incomes, and the added 3.8% surcharge on investment income. If you were elderly, single, and fairly well off re: IRA’s etc, which are mandated past age 70 to be taken as income (RMD), you might understandably feel a bit hammered by Medicare/Obamacare, I am thinking.

  4. re: “entitlement” – I agree with Kdavis.

    for instance, is it an “entitlement” if people on employer-provided receive a govt tax benefit of being able to buy their health insurance with pre-tax money while others without employer-provided cannot use pre-tax dollars to buy insurance.

    Second, the govt REQUIRES insurance companies that offer employer-provided insurance to not only cover all employees regardless of age or health status but that they all pay the same premium whereas that’s not the case for others without employer-provided who must purchase market insurance.

    so is employer-provided insurance – the tax-free part of it and the “must cover everyone and at one price) – a government-provided “entitlement” and if the govt were to make those same benefits available to others who bought their own insurance – would that be a government “entitlement”?

    Acbar discussed equity in access to health care. is it “equitable” to provide different benefits to different people Vis–à–vis people who get their insurance through their employer versus having to buy it themselves outside their employer?

    • We have never provided health care “equitably.” The ACA supplementing Medicaid/ Medicare was an attempt to get closer, yes, but it did not pretend to get all the way there. You can argue for greater health benefits for employer-based plans on the grounds that someone who is working is “entitled” (that word again) to more help from society than someone who’s not. I think that’s wrong, that health care should be divorced from “worth” to society, but it’s a view that’s out there.

      • re: someone who works..

        yep –

        AND, I AM – talking about people who DO WORK but their employer does not offer health insurance.

        Are those people treated equitably with respect to workers whose employers DO offer health insurance?

        that’s what the ObamaCare health exchanges are for. You can’t get insurance from the ACA if you do not work.

        Even then – the MedicAid Expansion – which Virginia did not take -is primarily for people who DO WORK but do not make enough money to afford insurance -even with the ACA tax credits.

  5. Excellent Post. Hope to see many more by Allen.

  6. The problem is that we are not able to support, either by the # of doctors/services or the cost, of the USA having everyone with health care.

    Its as simple as that. Rationing will occur. Those who end up paying into the system are going to say those who don’t (or haven’t) have to take what is left over. There are going to have to be priorities.

    The big issue is that Americans are getting sicker due to the food we eat and the lack of exercise. Simple home care is no longer around either, with the breakdown of the family it is worse.

    The decisions are that health care is a business that requires payment one way or another. You either have the priorities and waiting for care or the systems where there is a crappy govt one and then people who can pay get better and faster service. It will always be that way.

  7. all health care is rationed… that’s the reality – whether it’s the VA. Medicare, private insurance, or health care in other countries.

    there is no health care that is not rationed unless you are paying for all of it out of your own pocket and you can afford to.

    everyone else is buying insurance and the insurance limits your benefits.

    and if you don”t have insurance, you are “rationed” even more.

    and it’s not a situation where some are paying for it and others not when those who have employer-provided are allowed to buy their insurance with pre-tax dollars while others who also work – cannot.

    whatever we can “afford” as a country – it should be done on an equitable basis – we should not have winners and losers based on discriminatory govt policies. If the govt is going to give tax benefits for health insurance it should apply to all workers not just workers in certain kinds of companies.

    The bigger question is how come we pay twice as much per capita as other countries that cover everyone – and all of them have better life expectancies than us.

    why do we pay so much for health care and not even cover everyone?

    that ought not to be a political or ideological issue but rather one we would want to find the answer to – because – when it costs that much more to provide health care then it means – we end up not being able to afford health care for everyone. The same thing would likely happen to other countries if they also had twice the costs. We’re talking about every other advanced economy countries in the world – from Canada to England to Germany – to China to Japan to Australia to New Zealand and 20 other countries.

  8. I commend the excellent article. And good Dr. Barringer’s efforts and compassion.

    But who is going to pay for this? If health care were the only big-ticket item on the radar, it might be doable. But we, at least those of us in NoVA, are faced with virtually unlimited demands for tax dollars. WMATA is under water. Fairfax County Executive Ed Long says Metro-related expenses are a major challenge to the County’s ability to deliver other services and keep real estate taxes at “affordable” levels. Fairfax County public pensions (County, School, Police, Uniformed Services and two supplemental plans) cost taxpayers $1.1 billion per year and growing. That’s more than 46 cents of real estate taxes.

    The Schools are losing mid-career teachers due to salary differences with other nearby public school systems. Although when all compensation is considered, FCPS ranks number 3 in the Metro Area.

    Fairfax County police aren’t able to staff to recommended levels or keep supervision of officers at recommended levels. The County cannot afford to complete its Diversion First program that attempts to get treatment before incarceration for people with drug and mental problems who are arrested.

    Despite the largest tax increase in Commonwealth history, we don’t have adequate roads or transit to serve demand. Yet, Fairfax County is driving out many retirees who cannot afford to stay in their homes due to real estate taxes. FCPS has more poor children than most Virginia School Divisions have children. And let’s be blunt, many of these children are associated with families without legal status and have many expensive needs. Imagine what the social service and health care costs will be if Congress adopts another amnesty program.

    There is no job growth at higher levels. And that has been the case for several years. All the growth comes at low-paying service jobs. Fairfax County has more commercial office vacancies at anytime since 1991. Most of the existing office space is obsolete and harms the efforts to attract more business to Fairfax County.

    So Mr. Barringer, who is going to pay for universal health care, transportation, public sector pensions, higher salaries for teachers, many more needy children and families, police and public safety needs, etc., etc., etc.? How much more should we pay? And when can we expect to see the tax burdens stop growing faster than people’s income?

  9. Part 2. And what makes anyone think universal health care will be less expensive? I will acknowledge there can be some savings as people can get care earlier. But there is also evidence from some states that expanding coverage causes more ER use. And where are the Obama-promised savings from the ACA? He told Americans that his health plan would save a typical family $2400 per year. Didn’t happen. Premiums continue to rise. What happened to Obama’s promise that, if you like your current health care plan and doctor, you can keep them? Didn’t happen. There are countless stories of people who lost their trusted doctors and were kicked out of plans.

    And of course, the Democrats took care of their plaintiff lawyers friends who donate millions to candidates. Despite many studies showing doctors order many unneeded tests and procedures to avoid malpractice, the ACA has no “no-fault” plan similar to Virginia’s plan for birth defects.

    And how about all the economic growth that health care reform promised? The economic growth rate in the United States is anemic.

    My torts professor in law school always reminded us that every tub must sit on its own bottom. We have too many people in the United State who cannot produce enough to support themselves. And we have imported more and more every year. Just like Social Security, Medicare, Medicaid and defined benefit retirement plans, universal health care will soon be an unaffordable and on its way to bankruptcy. Washington, D.C.; Wall Street and academics are corrupt to the core.

  10. re: “who is going to pay”

    IF one set of people get tax credits – are you asking who is going to pay for tax credits for others who do not get them now?

    Do you think people who get them now should decide that people who don’t get the same treatment should be prevented from being treated equally?

    How can anyone of any reasonable conscience oppose others getting the same benefit they are getting?

    no one has said anything about universal care..

    instead – we’re taking about equal treatment under the law – for the same benefits … in this case – whatever health care benefits – we as a nation decide we can afford – we provide that benefit to all people equally.

    If we cannot afford to treat everyone equally – what does that mean – that we are fine with the govt discriminating against some so the others can continue to enjoy special treatment?

  11. “We have too many people in the United State who cannot produce enough to support themselves. And we have imported more and more every year. Just like Social Security, Medicare, Medicaid and defined benefit retirement plans, universal health care will soon be an unaffordable and on its way to bankruptcy. Washington, D.C.; Wall Street and academics are corrupt to the core.”

    That is it in a nutshell. There is simply a point where you have to get people to produce or do without.

  12. V N – We’re talking about people who DO WORK and actually could afford health insurance if they got the same tax credits that those who are provided with employer-provided get.

    Those who get employer-provided, effectively get a 40% discount on it because they can buy it with pretax money – that is not taxed Fed, State nor FICA. People who don’t get employer-provided have to pay almost twice as much for the same level of health insurance.

    why can’t we provide these same tax credits EQUALLY to people who do work but their employers don’t offer health insurance and they have to go buy it on the market? What justifies treating them differently? All of us should be in favor of that.

    But how can all these other countries cover ALL of their people for 1/2 what we do and they all live longer?

    The way we “do” health insurance is ALSO killing us in the global economy because companies from other countries do not have embedded health insurance costs in the cost of their product while our companies do and more and more of our companies are going to stop providing insurance so they can stay in business and compete with companies that don’t have those costs.

    Many of our products we cannot export because they can’t compete against foreign companies who don’t have embedded health care costs in their product so they beat us on price. They even can import to this country and sell cheaper than our companies because, again, our companies pay for health insurance and foreign companies do not.

    We’re going to go bankrupt …yes – because our companies cannot compete in the global market because of or embedded health care costs which would be bad enough if they were just equal to other countries cost – but it’s doubly worse because our costs are twice what their costs are and NONE of their health care costs are embedded in their products.

    You can’t blame that on people “who don’t work” – it don’t wash.

  13. TMT, thank you for zeroing in on THE issue with health care: if we can’t afford to do it all with our limited tax dollars, then how allocate (or “ration”) the shortfall?

    A couple of observations. First, if the choice is between spending on health care versus other things, I think history and logic support State spending on people — specifically, health and public safety/defense, and in this country, add environmental health and education — before most else, like infrastructure. If these four are so important and the other three are provided to all, why is universal access to health care not also provided to all? Second, if the choice forced by the budget is full health care coverage for some and zero for others, or, 3/4 coverage for everybody, at the same cost to the government, it’s obvious which is more equitable. Yet our system is full-plus-zero. ; This means people are being divided by the government into health haves and have nots, and the have nots are hurting and lives are being lost because of this division while the haves get 100% care. I think this should give us great pause. It’s not a matter of bleeding heart politics; it’s simply inconsistent with our tradition of equal protection and due process.

    • Acabar & Larry – I get your points. But we are all being hammered by every interest group for more public spending – on everything. So long as taxpayers have a dime left in their pockets, interest groups want more and more.

      Yes, health care is important. But so is education and housing, as well as wages for the lower rung. Larry and others have made reasonable arguments that two years of post-high school education should be free to the students. I served on a special Fairfax County citizens task force to look at land use changes to enable more affordable housing. Fairfax County has been able to add only 11 police officers for all of Tysons. Etc. Where would you draw the line? We are losing teachers because they cannot handle the long drives to school on jammed roadways. Where would you say “no”?

      We live in a country that refuses to enforce its immigration laws to keep greedy employers from paying higher wages; keep Democratic-voting social service employees employed; and pave the way for more Democratic voters with amnesty. School and county officials tell the public regularly a major reason costs keep increasing is because of the large numbers of poor and poorly educated people coming to the U.S. Do we stop providing these people with any services?

      Again – where would you say “no”? How can ordinary people, including those who are well off, but far, far from wealthy, stop seeing their taxes rise faster than their incomes? Who doesn’t get funded?

    • I do, in fact, agree with you. “Who doesn’t get funded” is the issue. And the way we pass many of these costs on to employers does hurt us internationally. And having paid the private costs of education for four children I understand the economic pressures on families today. But as we debate how to replace Obamacare, let’s not undo our older health care heritage, and who we are today as a result.

      • Acbar – the issue of who pays seems more complex to me. If we ended employer-provided health care, the costs of operating many businesses would fall, allowing higher profits, lower prices, more investment, spending on other items, higher salaries, or combinations thereof. But wouldn’t we need massive tax increases to fund the replacement?

        If a comparable tax burden were placed on businesses, what would we have achieved economically? If placed on individuals, the middle class will be hit extremely hard such that I believe their standard of living would fall even more. I seriously doubt that businesses shedding the costs for employee health insurance would keep their employees whole. It would likely be more Obama pain – “The ACA will drive down insurance costs. ” If you like your doctor, you can keep your doctor.”

        It’s this very cavalier attitude of “working people be damned” that shifted so many Obama voters from 2008 & 2012 to Trump in 2016 or caused them to stay home from the polls.

        Given economic realities there is a definite limit as to how many people who don’t earn their way can be supported by the rest of society. We have elderly, children, and those with severe disabilities. But we are also importing poverty and low-skilled labor that is driving down wages and making the number of people who don’t earn enough or produce enough to earn their way. It explains the appeal of Trump’s “America First” to so many. And while some parts will certainly bite me in the ^&&, I do take some joy in anticipating significant cutbacks in federal government spending, which, in turn, will knock down a lot of the people who generated the conditions that led to the rise of Trump.

        • “Given economic realities there is a definite limit as to how many people who don’t earn their way can be supported by the rest of society.” Yes. “But we are also importing poverty and low-skilled labor that is driving down wages and [increas]ing the number of people who don’t earn enough or produce enough to earn their way.” The data are in conflict on that; what I read says most do “earn their way” and overall they contribute a net positive to the economy. But regardless, my hope is we can do better with health care than the patchwork support for it we have, yet do a better job than the House has put forward (even as amended yesterday). Here’s a cut from a Meet the Press With Chuck Todd interview on March 12 with Gov. John Kasich that captures my feelings about this:

          “Look, the [ACA] needs fix[ing]. The current system doesn’t work. That’s why it’s possible to get Democrats involved. But you don’t want to throw the baby out with the bathwater. . . . the exchange needs to be fixed. Because in some places there’s only one insurance company. I mean, that can be fixed. I’ve said it all along. It’s not like we love Obamacare. It means don’t throw the baby out with the bathwater. Don’t kill Medicaid expansion. And you’ve got to fix the exchange, but you have to have an ability to subsidize people at lower income levels.
          “Chuck, let’s forget all this [detail]. Here’s what we’re talking about. If you’re drug addicted, if you’re mentally ill, you have to consistently see the doctor. From what I see in this House bill, the resources are not there. If you’re chronically ill, you’re going to have to have consistent coverage. Under this bill [the ACHA], you don’t have it. . . . Now, that doesn’t mean that we can’t fix this along the way. But we need to have Democrats involved so that what we do is going to be not only significant but will last. And then we get to the real problem, Chuck, which is the rising cost of healthcare. And that’s where [Rick] Santelli [of CNBC] really hit the nail on the head. We need to get to more of a market-driven system where we pay for quality, not for quantity in health care.”

          I particularly like the Governor’s last sentence. It’s not just support for citizens to help pay for health care but reform of health care payment system itself that’s so needed: greater transparency, reduced cross-subsidies, incentives to reward quality, prevention to reduce crisis intervention. And Republicans might have a future if they backed that horse.

          • TooManyTaxes

            We are still at the point where many hands are out looking for more tax money, while incomes for most people are flat. If one gives in on healthcare expansion, it will not be the end of “we want more; you must pay more.”

            Absent a return to economic growth levels of 4-5% or more, we simply cannot afford to extend more benefits, pay the pension debt, add funding to schools and transportation. And if people don’t like this, move to Europe. My ancestors all left Europe. I suspect most of yours did too.

        • re: ” If we ended employer-provided health care, the costs of operating many businesses would fall, allowing higher profits, lower prices, more investment, spending on other items, higher salaries, or combinations thereof. But wouldn’t we need massive tax increases to fund the replacement?”

          pick one side or the other – either give everyone who works the same tax break – or not.

          if you believe the GOP – people like you and me will be “empowered” to go shop for the best deal and that will cause competition … and choice and reduce costs.. Patient-centered health care you know – you CAN CHOOSE your own doctors AND the prices will be lower!! sound familiar?

          If you dont’ know how Obamacare is funded -you ought to find out – because it is NOT funded from general revenues… and if you want more people covered – it won’t increase the deficit.

          if you do what the GOP is proposing – it WILL increase the deficit IF people use the credits to buy insurance – instead of choosing to not have insurance and instead rely on the ERs and stiffing the hospitals for their debts.

          First – do people actually KNOW how much their employer-provided benefit actually costs? You can find out pretty easy…

          That 15K would be 21K if the money was taxed.

          consider also – that’s 15K the wage earner does not get.

          consider the taxes owed on that income – 15K – does NOT go into the treasury – it actually contributes to the deficit instead. In other words, we are giving tax credits to those on employer-provided and paying for it with deficit funding.

          consider for the company – how much their products and services costs if they are paying 15K per employee for health care.

          finally , consider what 10K in health care benefits translates to in dollars per hour of pay – $5 per hour is what 10K of health benefits costs ( 10K/2080).

          but first – find out where the tax credits for people on Obamacare come from if not the general fund.

  14. re: ” It’s not a matter of bleeding heart politics; it’s simply inconsistent with our tradition of equal protection and due process.”

    Dead on Correct!

    The most odd thing – is that the people who DO get THEIR health insurance tax free – they call it an “earned benefit” , but that very same benefit for others – they call it an “unaffordable entitlement”!

    In essence – Obamacare/ACA is about equivalent tax credits for those who work but do not get employer-provided yet opposed as an “entitlement”.

    The hypocrisy of that position is astounding for a country where we SAY we pride ourselves on equal treatment under the law!

    The issue is actually NOT about a “moral imperative” to “help” others – it’s not even about “helping others” at all. It’s about opposing equal treatment of others when it comes to health insurance.

    At that point, we have lost something far more than mere moral compass – we have become unprincipled grabbers of “stuff” and willing to walk on others to get it.

    As Americans – we should stand for equal treatment of each other – especially when it comes to health care – and that’s before we even get to the reality about how the way we do health care; it severely damages us economically in the global economy – and is a direct cause of job losses to foreign companies whose products do not have embedded health insurance costs in their prices. Health care costs are DRIVING automation and the importation of cheap labor that does not get health insurance!

    We’re blaming others for this. It’s us. We own it.

  15. re: ” Look, the [ACA] needs fix[ing]. The current system doesn’t work.”

    what the ACA did was two-fold. It got rid of the pre-existing conditions as well as the lifetime caps – not only for Obamacare but ALL insurance including employer-provided… and it was premised on a lot of healthy people also buying insurance – encouraged by the penalty.

    if you want to get rid of the mandate – it will make things much worse as the remaining pools will be predominately people with pre-existing conditions who would run out of benefits due to lifetime caps before that was taken away from the insurance companies so the insurance companies did what they could do – increase the deductibles and co-pays so that “regular” insurance did not pay benefits. It only pays for catastrophic…and it does protect people from bankruptcy – AND it is what some folks say is how insurance SHOULD work.

    but if you want to get rid of the mandate – it will make things even worse ..

    and if you let people buy what they want – they’ll buy lower cost policies that have lifetime caps on them… etc, etc.

    the insurance companies have to have a way to cover their costs.

    there is no magic potion.

  16. The KIND of insurance many people had – including employer-provided prior to ObamaCare – was designed to pay for routine care for subscribers but if they got seriously sick with cancer – there were annual and lifetime caps.

    that’s how the insurance companies made their money – by limiting the amount of payout to people with chronic or acute illnesses.

    You’d see this all the time… glass jars in 7-11s for kids or moms or dads who had some terrible disease and they HAD insurance, even employer-provided insurance but they had run into the annual/lifetime caps and they were done getting benefits.

    This is basically what the GOP is promising to go back to if they can REPEAL.

    and yes – it WILL be cheaper for everyone else – but not for the people who get terrible disease, chronic disease, genetic/birth defects, etc. Those folks will run out of benefits and end up selling all their assets until they have no more money – and then declare bankruptcy.

    Perhaps that IS what people DO want… instead…

    the question is – do they know that’s the difference between ObamaCare and the “replacement”.

    there is no special elixir. If you require insurance companies to accept all pre-existing people and pay all costs with no annual or lifetime caps -they’re going to have high deductibles. It’s not a “flaw” of ObamaCare… ObamaCare was designed explicitly to do just that – and they were going to pay for it – in part – with sign-ups from people who were healthy.

    this is how most insurance actually works. if car insurance companies did not have people signing up who did not have accidents – and the only people who signed up – had accidents – the premiums would go through the ceiling!

    People have to recognize these realities.. if they really want to understand the choices … if you want no denial of pre-existing, no annual or lifetime caps and no mandate to buy insurance.. then you’re going to have a problem with “reality”.

  17. The latest from the GOP on how they will make health insurance more “affordable” is to let the insurance companies offer products that essentially do not cover some things or have capped how much they will cover – and consumers will pick what they feel they can afford.

    For instance, some policies may not cover ER admissions or will cap how much they pay for cancer or won’t pay for x-rays, maternity, etc.

    Obamacare calls these 10 essential benefits and mandates that they be present in all insurance including market and employer-provided.

    That means if many people get $2500 credits – for the year – they’re going to go look for what they can buy for $2500 and insurance companies will begin offering ” free” insurance for the credit.. and virtually everyone who is eligible for the credit will buy insurance.

    that would be good, right?

    or would it lead to something like we see with the govt giving loans for education and the for-profit companies providing what the “market” wants and what people end up with – is not a real education.

    The critics of the “choice” health insurance say that many people won’t pay much attention to what is or is not covered.. the’ll just get whatever “bundle” is offered for the amount of their credit.. and then only later realize they didn’t have near enough coverage for what actually happened to them.

    So – the “new” plan from the GOP is to dismantle the 10 essential benefits provision of ObamaCare.

    I’ve tried to describe it fairly and accurately. If someone thinks otherwise, please correct..

    but how about it – TMT, Ackbar , KVDAVIS, V R, others? what say you?

    is this a good thing or a bad thing or what?

  18. There’s no magic here. Three choices:

    1. Stop the rise in health care costs (beyind inflation).
    2. Tax some people more to pay for the rising costs of healthcare for everyone.
    3. Let an ever growing percentage of the population have inadequate or no healthcare.

    Larry wants to tax the value of employer provided health care benefits and (presumably) use the proceeds to underwrite the costs of healthcare for those who can’t afford healthcare. While it actually hurts my fingers to type this – I kind of agree with Larry. I just wonder why health care is such as unique thing. I’d eliminate all deductions and go to a much simplified tax system (with lower tax rates). However, neither Larry’s plan nor mine would reduce health care costs.

    Some would say that insurance provides for preventative care which will reduce health care costs. I am not so sure. Contrary to popular opinion, boozing, smoking and eating too much reduce healthcare costs. The costs are reduced because the drinkers, smokestacks and chow hounds have the decency to die young. If you live long enough and you have good enough insurance you’ll eventually have your hips and knees replaced, cataracts treated, pacemaker implanted, etc. All of which will occur before you ultimately die of some expensive malady like Alzheimer’s Disease.

    https://www.forbes.com/sites/timworstall/2012/03/22/alcohol-obesity-and-smoking-do-not-cost-health-care-systems-money/#21abb95a64aa

  19. So if we tax the value of fringe benefits, why shouldn’t we tax the value of government benefits? Today, some portion of Social Security and Unemployment benefits can be taxed, at least for some people? Why not the value of public school education, SS Disability, welfare, housing benefits, health care subsidies? What’s the difference?

    The government could raise the personal exemption and tax these benefits. Why should John Doe pay income tax on the value of his health insurance when provided by his employer, but his brother Joe be exempt when he gets ACA subsidies?

    Of course, the left would scream this is hurting “poor” people. But income is income or isn’t it?

  20. The comments seeking additional funding for WMATA located on the post about Governor McAuliffe’s decision to review WMATA, proves my point. Despite arguing that government needs to say “no,” the arguments are for more taxpayer money.

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