by Tyler Cowen
on March 10, 2017 at 8:44 am
in Current Affairs, Law, Medicine, Political Science
It is not easy to excerpt, so do read the whole thing. But here is the closing bit:
And in any case, momentum depends on a strong, successful push at the start. This could have started better, and it needs to end smarter.
“The architects of the House proposal seem to think they can’t do this because they can’t alter Obamacare’s community rating in reconciliation.”
This seems to ignore the fact that ‘preexisting conditions’ has become a household phrase, and that Trump specifically promised not to undo community rating. The problem isn’t procedural, it’s political.
I’m not convinced. As Levin notes, conservatives’ preferred plans also include a form of community rating, though it’s somewhat different than Obamacare. They could be sold as a fix to community rating rather than doing away with it. The 30% surcharge is effectively messing with the same thing, but doing it in a dumber way. It seems hard to explain as other than an attempt to play procedural games.
“preexisting conditions” =/= “community rating”.
“preexisting conditions” == “guarenteed issue”.
Not really. Community rating means the price of your insurance can’t be set based on pre-existing conditions, or health status in general.
It’s related, but not precisely the same concept. Without community rating guarenteed issue wouldn’t mean much – policies would just be priced out of people’s reach.
Personally, I think it’s crazy to say that insurers have to cover someone who walks in the door with stage 3 lung cancer at no extra charge.
When a lot of people say preexisting conditions, they really mean some previous minor resolved problem or a relatively minor chronic condition like diabetes. It should be possible to charge those people extra at a reasonable rate. The problems in the market were in places with community rating, if you couldn’t charge extra for pre-existing conditions insurers wouldn’t sell policies to people with diabetes.
but the people who think it’s unfair that they can’t buy coverage after they get cancer are just crazy and should have been ignored entirely.
In any case, the two concepts are closely related. I’m not sure why you objected to Matt’s quite nonspecific use of the two terms together, which is why I responded the way I did.
a relatively minor chronic condition like diabetes.
Come again? That entirely depends on treatment compliance. If you don’t work hard to manage your blood sugar the costs can be astronomical.
Well, my point is that Trump can keep his promise on pre-existing conditions, but simultaneously undermine it be allowing the community rating policy to change. People don’t understand community rating the way they do pre-existing conditions. So he can claim he kept his promise, but not actually keep it.
>but the people who think it’s unfair that they can’t buy coverage after they get cancer are just crazy and should have been ignored entirely.
Good point. They should just screw off and die already. Death is a fair and just punishment for those who lack the means or the foresight to purchase insurance in advance.
We’re doing caricatures of Libertarian moral bankruptcy, right?
No, they don’t die, they get treated and then they declare bankruptcy.
THAT is a fair price to pay for not having purchased insurance.
Hazel, I think we should be less focused on ensuring that people who make mistakes get what they deserve, and more focused on what is actually good for society as a whole. The “medical bankruptcy as incentive to purchase insurance” idea has been tried, and the outcomes haven’t been good in my opinion.
@Jon: personal responsibility is a thing, and a thing that libertarians take pretty seriously.
msgkings: the practical Libertarians I know view markets, deregulation, and consequences for personal choices as a means to an end; they view them as the most effective way to organize a society so that it may thrive. The ideological Libertarians who prioritize these things above, say, the good of society itself, are misguided in my opinion.
If you want to argue that the looming threat of medical bankruptcy ultimately makes for a more thriving society, then fine, make that argument. My perspective is that we already live in that world, and it sucks.
Death is a fair and just punishment for those who lack the means or the foresight to purchase insurance in advance.
It’s not punishment to refuse service to someone cannot afford to pay for it. You’re trying to turn it into a morality play in which the intent is to ensure distributive justice by punishing people who are improvident. Rather, you are the one who wants to punish people who do not conform to your moral ideal of charity.
Yes, and what’s good for society is cost control. Perhaps the fact that some people have to go through medical bankruptcy (if they are irresponsible enough to not purchase insurance) is a small price to pay in order to allow the choice and competitiveness in the health insurance market that will make prices lower for everyone who does.
Hazel: it’s a reasonable hypothesis that the threat of medical bankruptcy might cause very few people to go without insurance. But the empirical reality is that, for various reasons, over 15% of the US population was uninsured prior to the ACA, and many more had insurance too skimpy to prevent unexpected medical bills from being a massive financial burden. Turns out the incentive is not so effective.
Unpaid medical bills, of course, mean the costs fall on the rest of us anyway. Since you’re (thankfully) not one of those “let them die” libertarians, it’s unclear where you think the cost control is in this scheme.
“if they are irresponsible enough to not purchase insurance”
That is not a fair characterization. Without guaranteed issue and community rating, some people were frozen out of the individual insurance market and/or experienced unreasonable premium hikes when it came time to renew their (typically one-year) plans.
When it comes to health, stuff happens, especially in a country of more than 300 million people. There are people who develop serious medical problems when they are young and still covered by their parents’ insurance: there should be a way for these people to get affordable insurance without impoverishing themselves to qualify for Medicaid once they turn 26. Also, employers can and do lay off workers. COBRA may cover you for two years but there are circumstances under which even COBRA coverage can be cancelled. If any of these things happen and you have an expensive pre-existing condition, you are at the tender mercy of the individual insurance market.
Go back to what I wrote above.
There are “pre-existing conditions” where someone had an insurance plan through their employer, got sick or got a chronic condition, lost their job, lost their insurance, and then couldn’t get coverage.
And then there are “pre-existing conditions” where someone never bought insurance, got stage three lung cancer, and then bitched and moaned about how unfair it was that nobody would sell them insurance and they had to declare bankruptcy to pay for everything.
We can solve the first issue without wrecking the market by trying to pretend that the second issue isn’t stupid and crazy. You don’t have to force insurers to accept every joker than walks through the door at no extra charge, to stop them from canceling policies or jacking up rates for people who maintained their coverage.
it’s a reasonable hypothesis that the threat of medical bankruptcy might cause very few people to go without insurance. But the empirical reality is that, for various reasons, over 15% of the US population was uninsured prior to the ACA, and many more had insurance too skimpy to prevent unexpected medical bills from being a massive financial burden.
OMG. Save us from the threat of having a “massive financial burden”. That’s, like, so unfair. When I get in a massive auto accident and doctors save my life, it should go on as if nothing happened.
Again many of the uninsured were uninsured because they couldn’t buy insurance, so that is partially solvable by getting rid of the employer-based system.
The people who are voluntarily uninsured, I don’t see that as so much of a problem. That’s their own business to take that risk.
However, I believe we could probably have some sort of small “uninsured patient” tax on insurance policies which covers hospital expenses incurred in emergency rooms by patients who don’t pay their bills. Basically to reimburse the hospitals for uncompensated losses. So people who can’t afford to pay, they declare bankruptcy, the hospital collects what it can, and then the hospital collects the rest from the insurance tax.
Done. Pre-existing conditions solved. Nobody dies. Uncompensated treatment is covered. And no need for guarenteed issue or community rating or any of the other crap in the ACA.
Everyone dies. The question is to what extent people should be able to demand that society cover their efforts to stave off death, and to what extent we should interfere with people’s choices to enforce what we think is best for them.
We let people make choices all the time that greatly increase their probability of getting some disease later in life. I think it is inconsistent to say that we should let people be free to make bad choices that may end their lives early, but not allow them to make bad financial choices that may leave them financially ruined as a result of those poor health choices. You are free to smoke and get cancer, but you are not free to avoid purchasing insurance that will cover efforts to prolong your life once you get that cancer.
I think it is inconsistent to say that we should let people be free to make bad choices that may end their lives early, but not allow them to make bad financial choices that may leave them financially ruined as a result of those poor health choices. You are free to smoke and get cancer, but you are not free to avoid purchasing insurance that will cover efforts to prolong your life once you get that cancer.
+1. But that makes you a cold-hearted meanie.
Of course, the number one pre-existing condition is age. And everyone has a worsening pre-existing rating every birth day.
This bill says you will lose your existing policy every policy renewal, but get a higher priced replacement policy.
Unless you consider buying an Ford F-150 for $40,000 @ age 40, and $50,000 @ age 50, to be buying the same product.
Yeah, I stopped reading at “community rating”.
The problem is not political, but logical.
Everyone with a pre-existing condition started off without pre-existing condition.
The idea that an insurance pool should insure only those without pre-existing conditions, one of which is older age, but once insured you get to keep the policy after you get the primary pre-existing condition, older age, means the non-pre-existing are “community rated” with everyone with pre-existing conditions.
But actually, the law actually gives I insurers greater right to cancel you policy to kill the premium, but it calls this keeping your policy.
You but policy x and then a year later I also buy x with identical health status, but you are charged a higher rate. You have a new pre-existing condition, older age. To say you get the same product is like saying when you are charged $50 for the same flu shot I pay $25 for because you are ten years older because you would have been charged $25 if you were ten years younger is an absurd claim of free market operation.
Drug companies might argue you should pay more for a flu shot as you age because young kids don’t lose wages from being out sick and young workers are paid less than old workers.
Or burgers and fries should be priced higher for skinny people than for fat people – skinny people will starve and die sooner so they get more benefit from food. Of course, fast food vendors do price food cheaper for fat people, aka super-sized increase quantity faster than price.
Ugh, depressing reading. What a strategic failure by the Republicans–surrendering before the engagement has even begun!
They really ought to start off by proposing the health care bill they really want. Actually put it to a vote and make Democrats take the stand of filibustering it. Then pursue one or more of the following:
1) Wait and let Obamacare’s continued collapse put pressure on Democrats (I’m not being cynical here; this is better than passing a bad bill that doesn’t actually fix stuff, and makes it harder to fix in the future).
2) Pare back the bill into something that can be passed via reconciliation, in response to actual (rather than imagined) opposition.
3) Eliminate the filibuster.
yes, there are several obviously more sensible ways to do this
but you forget that we have a dysfunctional Congress that cannot even pass an annual budget — not just a good budget, but any budget at all
these Congressional Clowns are professionally incompetent
recognize the fundamental situation on Capitol Hill — they are incapable of sober, rational group action
I have started from a slightly less cynical place than you, but I’m approaching that viewpoint rapidly.
“They really ought to start off by proposing the health care bill they really want. ”
How does this one look like?
“Wait and let Obamacare’s continued collapse put pressure on Democrats (I’m not being cynical here; this is better than passing a bad bill that doesn’t actually fix stuff, and makes it harder to fix in the future).”
I was promissed death panels one years ago.
I think your approach would work for passing a bill, but it dramatically underestimates the political costs of failed expectations. Republicans–and especially Donald Trump–got elected while loudly promising that they have a solution to the problems of Obamacare. They promised that their new plan would make premiums AND deductibles lower, and they promised to cover everyone; it was a classic pony promise. Ultimately, that entails a tantrum on Christmas morning, and neither Trump nor the Congressional Republicans want to be the focus of the tantrum. Even waiting for Obamacare to fail, at this point, is not an option, since voters will rightly say, “Why are you allowing this train wreck to happen? Just bring out that trailer full of ponies that you told us about…”
The “waiting” I had in mind is not a passive activity. I would be an attempt to pass a good bill, then forcing Democrats to continue to sustain a filibuster.
Even in the short term, I think this would be better for Republicans. Republicans would still get some blame for not getting things done, but a large portion of blame would also go to Democrats. Compare that to the scenario right now: Republicans are already under fire for a watered down bill that is seen as “not really repeal”. They might not even get this bill passed, due to opposition on the right. And the heat is totally off the Democrats, since the Republicans caved based on an expected filibuster, rather than actually forcing Dems to put their money where their mouth is and stand up and oppose it.
The real political issue, though, is the longer term: do the Republicans pass a good bill that actually makes things better, or a dumb bill that results in a slightly modified mess that they now own? These are the political consequences that they should be most worried about (and this also happens to line up with real-world desirable outcomes…).
Explain a “good Bill.” Does it expand coverage, or does it cut taxes?
Something more like the previous proposals Levin refers to would be an example. Some subsidy to make catastrophic coverage affordable via tax credits, allow people with continuous coverage to keep their plans, and cap the tax break for employer-provided insurance.
As I say below, I think Republicans could pay the money and do such a plan. They are not now – because they still think a Republican plan must cut transfers and taxes. That’s what makes it JCW’s “classic pony promise.”
@Rags, the current proposal is for a refundable tax credit (i.e. a transfer payment) to subsidize catastrophic coverage for the poor, the same thing that would be required by the better proposals Levin mentions. I don’t think unwillingness to “pay the money” is the problem with this proposal. To me it appears the problems are misguided decisions about strategy (as Levin suggests).
Of course the Republicans (like every party platform ever) over-promised. I wish they hadn’t done so. But such is the political reality.
I count pre-release skirmishes with the CBO as evidence that tax credits are not sized for promises.
A debate with the CBO about cost is just a PR battle. The real test is what kind of plan they are willing to put forward.
That is a dangerous proposition, that accounting and modeling are just PR. If you yield on that, what do you believe about “the plan put forward?”
“That is a dangerous proposition, that accounting and modeling are just PR. ”
Obamacare gamed the CBO numbers by delayed implementation of the more costly parts of the plan. So, this isn’t a new pattern.
There is a difference between adding more accounting (good) and undermining the effort (bad).
“Given the likelihood of additional reforms to national health policy in future years, it is reassuring that, despite the many unforeseen factors surrounding the law’s rollout and participation in its reforms, the CBO’s forecast was reasonably accurate.”
The CBO’s Crystal Ball: How Well Did It Forecast the Effects of the Affordable Care Act?
>They really ought to start off by proposing the health care bill they really want. Actually put it to a vote and make Democrats take the stand of filibustering it. Then pursue one or more of the following:
There is no health care bill they really want.
Well, there is health care they want. It is free lunch free market. Meaning you can always buy exactly what you want at any time for free just like you get information for free from Google. Google is the perfect free market, as in the free means free.
Free lunch economics is totally detached from nature.
the health care bill they really want.
LOL! Such a thing does not exist.
certainly no such thing exists under the terms of the US Constitution, but the federal government parted ways with that quaint museum document a long time ago
we are now ruled by men, not law
Our Constitution, unlike many others, does not pretend to map out in any detail specific legislative outcomes.
but it does/did detail many specific limits on Federal powers & legislation
Lincoln erased such legal notions in 1865
Yes, and there’s nothing in the ACA that forbids a federal health program.
It is not the Constitution, et al, that is the constraint, but the laws of nature.
The GOP holds both the White House and Congress. Any pressure will be on them, not the Democrats.
“The GOP holds both the White House and Congress. Any pressure will be on them, not the Democrats.”
The premise was that the GOP brought a plan up for a vote and the Democrats fillibustered it. Naturally the majority of people would then believe that Democrats were more responsible for what happened to Obamacare in that scenario.
I grant you Left leaning partisans are going to blame the GOP in any conceivable scenario, but that’s irrelevant.
And right leaning partisans blame the Dems for everything, what’s your point?
That’s not the way it works though. “The buck stops here,” said Harry Truman. The GOP got away with huge amounts if obstructionism under Obama and was not blamed for by the general electorate.
You forget that no one’s life, liberty and property are safe when Congress is in session.
Best thing to do: leave it alone to implode. Anything else is bullshit.
What do you mean by “the health care bill they really want”? I’m not sure you can get Republicans in Congress to uniformly agree on goals, let alone how to achieve them. Some think the federal government should have zero role in healthcare. Some think some kind of universal coverage is the goal. Trump, for his part, promised not to cut Medicaid during the campaign.
These positions can not be easily reconciled.
“They really ought to start off by proposing the health care bill they really want.”
Very very cheap insurance.
No out of pocket costs.
No restrictions on where you get care.
No restrictions on what care is paid for.
High profit to insurers and provider corporations, and profits increasing every year to create wealth.
No taxes at all.
When you say “no restriction on where you get care” do you mean no governmental restrictions (though I assume you’d still be OK with prosecuting outright fraud and quackery) or would you ban insurers from having prefered provider networks?
“Exellent” is a misnomer here. I don’t see much difference in what Levin has written from what any other commenter has posted over the past several days (both from the liberal and conservative perspectives). What is most striking to me is how nobody seems to understand what is in Obamacare policies or how they are priced. I really wonder if they have any relatives at all who purchased such policies and looked at the costs. The central argument has been that we need to have catastrophic coverage only policies to bend the cost curve downward. Well the Bronze Obamacare policies pretty much do that and are quite affordable as well. I’ve looked at policies in a couple of different states as I have daughters who are freelance contractors and have to purchase their own insurance. Bronze plans were about $200/month for a young female. In the end, both opted for Silver plans as the coverage options were a little better. These prices were off the exchange as neither needed a subsidy. So we are looking at $2400/year for decent health insurance that carries with it some of the coverage advantages that were baked into Obamacare and certainly for young women free access to BC pills is a net plus. We do know that traditional insurance holds down the costs by setting up networks where prices are negotiated by the insurer. Would the same hold for catastrophic only policies or does the patient have to negotiate pricing?
Yes, the Medicaid situation has been pretty bad for a long time but this also varies by states. John Kasich has an op-ed in today’s Washington Post arguing that what Ohio has done should not be overlooked as the debate over replacement continues. He wants to preserve what Ohio has done (I think Senators Collins and Cassidy have legislation that would allow states to stay in Obamacare and others opt out). States have had the option to set up new Medicaid approaches and some of those that took the money did exactly that.
Is the new approach to encouraging young people to sign up any better than the tax penalty? I think not as their policy premiums are always going to be on the low side and so what if they have to pay 130% for a the first year of coverage. I don’t look at this as any major disincentive. the biggest disincentive is allowing young people to stay on a parent’s policy until the age of 26 as this sucks out of the system a lot of health kids who would keep premiums low regardless of which system is employed. Obviously, the penalty would be more severe for older Americans whose premiums are higher.
The tax credit proposal does not address the fundamental problem of insurance cost for those at the low end in the same way Obamacare does. Many of those people will see premium increases under this new approach as it is a fixed fee and doesn’t depend on income other than to decrease as incomes rise. However, because everyone under the income threshold gets the tax credit, a lot of young people will be able to take advantage of this whereas they don’t get help under Obamacare right now (my two daughters for example who don’t qualify for subsidies but would get the tax credit).
The Republicans lost their nerve and backed off of removing the corporate tax break for employer sponsored plans. this would freed up probably all the money needed to meet any adverse CBO score but they realized that it was not politically acceptable. If we are to encourage individuals to take care of the own healthcare decisions this would be one area to start. We still have very little portability in healthcare and COBRA is just a band-aid that is an expensive one depending on the type of insurance provided by the employer.
Obamacare was a kludge from the get go as any more comprehensive approach would not have passed, look at how the ‘public option’ disappeared. I wonder if the Republicans included this option into their bill if some Democrats would support it.
There are only a couple of approaches that will bring healthcare insurance to everyone (assuming that this is the goal). One can either go the route of Great Britain and set up a National Health Service that is government run or one can rely on the private insurance market to do the same thing which is what Holland and Switzerland do. the latter two countries both achieve universal coverage through a regulated insurance market. There have been several proposals as to how to use the private insurance market from providing vouchers to all Americans to purchase insurance (Emanuel and Fuchs) which ultimately eliminates both Medicare and Medicaid as everyone is insured to expanding something such as the Federal Employee Benefits program which provides a huge choice of insurers to over two million active and retired employees (Robert Moffitt of Heritage Foundation once published an op-ed in the WSJ on this but maybe has backed off given the new direction of the Foundation).
One thing is for certain, this latest Republican proposal will not end the debate.
“There are only a couple of approaches that will bring healthcare insurance to everyone (assuming that this is the goal).”
Acquiescing to the idea that healthcare insurance (let alone insurance with generous benefits) is now an entitlement is precisely the main source of the problem.
Yes, I understand that. I believe that there are some things government needs to do to protect the health and welfare of the country. If we need a huge standing military operation, then we should also provide for the healthcare of the country. I’m not a libertarian on this count.
I am a libertarian on this count. Therefore the Republicans should let the Democrats alone be the tax collectors for the big welfare state.
Re: The Republicans lost their nerve and backed off of removing the corporate tax break for employer sponsored plans.
To be fair, they bowed to overriding political reality. Ending that tax break would send most people’s tax bills skyrocketing. No one, I repeat no one, is going to do that. Especially not the party associated with cutting taxes.
Republicans made it more difficult by campaigning against the “Cadillac tax” on generous medical insurance plans, which was in effect a partial reduction of the tax break for employer sponsored plans.
“the biggest disincentive is allowing young people to stay on a parent’s policy until the age of 26 as this sucks out of the system a lot of health kids who would keep premiums low ”
But the low premiums are only for people under 26 because the young do not “subsidize” old much under Obamacare, and that vanishes with the Republican plan.
In fact, the Republican plan will price insurance for the young below cost to get them to get in the habit of buying high profit insurance at an early age.
After all, the number one pre-existing condition is age. And you do not get to keep the same policy if you maintain coverage under Obamacare or the Republican plan. For Obamacare, the policy you buy a year later at three break points is different. The Republican plan seems to give insurers the option of replacing the policy every year with a new higher priced policy based on you gaining one added year of age pre-existing condition.
With the Republican plan removing profit limits, insurers will set profits lowest for the hardest to sell, the “young and healthy” and then set profits at the highest for those over 50. (The price will not show as much variation because the insurance agent fees will likely be highest for the young, who will be buying a “new” policy more frequently. Ie, a 40% of premium paid to agent for year 1, but only 5% for years after 5th renewal. The agent will want to maintain contact to get the sales after marriage, after pregnancy, after moving to a house, after kids leave home. Under 30, insurance agents might sell an individual policy 2 to 4 times as the young person moves around.)
Here’ my suggestion for the one thing that Republicans could add to the bill that would get libertarians on board:
Expand the tax deduction for employer-based health insurance to include ALL health insurance, whether it is purchased via an employer or not, whether you are self-employed or not.
This make the tax code neutral as to whether people buy their employer-based plans or not, and thus removes the tax incentive favoring employer based insurance. It has the same effect as getting rid of the tax deduction entirely, but is less politically controversial.
And I will note that CBO scoring on this should be neutral as there are very few people who buy private insurance if their employer offers it.
If employers stop offering coverage that just means people get the same tax deduction they got before, only with individual policies. In fact, it should increase revenue because most people will buy less expensive plans once they see the cost up front, so there will be net less income deducted. The health insurers will be minor losers in this one if people buy cheaper policies – but politically, that doesn’t matter, nobody cares about the health insurers except the health insurers.
I dunno . . . in my opinion, as someone commenting on the internet, this seems problematic.
First, absent employers requiring employees to accept a large portion of their compensation in the form of health insurance, many workers would go without. even if insurance is tax deductible and a good deal, lots of workers (especially low income or young and healthy people) are going to choose more cash over insurance. This would have at least some of the negative effects we are seeing in the individual insurance market today.
Second, this assumes that if employers stopped offering health insurance they would pass along 100% of their savings to workers in the form of higher wages. Employers would fight hard to keep some or all of that amount. I presume you could enact a federal law requiring employers to pass along that cost in the form of higher wages (and employers would still come ahead because of lower HR costs and less administrative distractions) but such a mandate seems pretty unlikely from a Republican Congress and Administration. Absent 100% or close to 100% pass through, my guess is that lots of insureds are going to end up with worse (albeit) cheaper insurance.
1. Keep in mind that the tax deduction makes insurance cheaper than the market price. Individuals are still getting a discount. And there are other incentives to maintain coverage, not to mention the individual mandate/surcharge.
2. There is sound economic logic behind the idea that salaries would rise to match health insurance costs. Let’s suppose they didn’t. Suddenly the cost of labor is massively lower. It’s much cheaper to hire people, so employers go on a hiring spree. Now what happens? benefits are lower so there’s no incentive for millions of new workers to join the labor force. So labor markets have to get tighter. That means wages will go up. Ultimately the demand for labor hasn’t changed, and the supply of labor hasn’t changed, so the price equilibrium should settle at EXACTLY the same point. In other words, the total compensation should stay the same, which means salaries will rise to cover the amount saved on health insurance.
In any case, one way to perhaps ensure a smoother transition is to (as I suggested below), require employers to offer a subsidy or voucher for purchasing insurance in lieu of the actual insurance. Just tweak the employer mandate so they can offer a voucher instead of an actual insurance policy. Problem solved.
“Suddenly the cost of labor is massively lower. It’s much cheaper to hire people, so employers go on a hiring spree.”
Why would employers hire employees they don’t need just because hiring is cheaper? Employer’s aren’t running a charity and employers don’t start businesses because they enjoy having employees such that they are always wanting to hire more people. It makes no sense. If they needed the employees to service demand they would have hired them already.
Why do people buy more of something when the price of it drops? Do you think employers have maxed out and already hired everyone they could possibly use? Really?
efcdons is correct on this. Sure there would be some salary increase but it’s extremely naïve to think it will exactly match the lost benefits.
*sigh* it’s basic economics. If they could get away with lower total compensation packages they would already be doing so.
In any case, my suggestion is to add a deduction on the individual side and then allow employers to offer cash or a voucher in lieu of an insurance policy. That makes the salary increase explicit. Eventually, as employees opt out of employer-based plans into the individual market, it becomes moot as to whether the voucher is part of their salary or not. It just becomes salary.
Re: Why do people buy more of something when the price of it drops?
Most of us, not being shopaholics, don’t.
@JonFraz, so basically you’re saying labor markets are totally inelastic. There’s a fixed number of jobs and employers pay the employees what the government tells them to pay. In that case, why don’t we just mandate that employers double everyone’s salary right now? Obviously, that’s not going to cause employers to hire fewer people or lay them off.
One of innumerable reasons that no man’s life, liberty and property are safe when Congress is in session is they use the tax code not only for raising revenues, but for advancing whatever disastrous agenda du jour.
Today, the Dems own ACA. After this crap shoot, the GOP owns it.
Sit back and watch ACA implode. Let the good times roll! Leave in place sky-high ACA health insurance premiums and watch the system roll into the metaphorical ditch. Let the expanded Medicaid requirements bankrupt the already bankrupt states.
Any bill that does not entirely repeal ACA is bullshit. This draft shit sandwich-lite (like the 2008 and 2012 elections) proves Graham, McConnell, Ryan, et al are cowards and losers, and Trump doesn’t have cajones.
“Keep in mind that the tax deduction makes insurance cheaper than the market price”
Employer insurance if cheaper than individual insurance policies because of group rating that sets premiums the same for everyone, young and old.
The insurance is tax deductible only if “every” employee gets it. Carve outs eliminate the strict “every” in that employees covered by a spouse or some other source or due to where they live are allowed, but the “cash” they get paid must be very nominal, and essentially entirely used to pay insurance premiums. Ie, to be covered under a spouse policy, the worker must pay more, so the “cash” for taking the benefit is effectively paying the premium charged by the spouse employer. Ie, to get the “cash” from not buying insurance from the employer you must be insured, ie buy or have bought insurance. In theory, the IRS could audit employers to ensure compliance. But with tax snitches paid a portion of taxes and penalties, an employer paying employees cash as a tax exempt benefit systematically, would face IRS tax fraud investigations, triggered by a fired worker, this is not done to any degree.
So, with 95-98% of an employer’s workers getting exactly the same coverage, the employer will be motivated to eliminate profits and rent seeking, and group insurers have been forced to offer self insurance administration to even medium size corporations. GM, could afford to hire actuaries and benefit managers and not use insurers, piggy backing on their existing A/R, so insurers had to offer competitive outsourcing of tax compliant health benefit self insurance. The insurer does the actuarial work, provides the reinsurance, advises on the cost benefits of each policy benefit to minimize medical bills, builds the provider network, negotiating prices, and handles all bill payment with fraud detection, and coordinates charging other payers for such things as accident caused medical bills, whether from non-work car accidents or on the job accidents covered by workman’s compensation.
And with most employees getting very little tax advantage, the tax avoidance for the janitor or entry level worker is basically zero, 15% max. The high income workers in the 70s when ERISA was enacted setting the terms for tax advantage, got a 50% to 70% tax benefit from group coverage, but was that bigger than being charged the same rate as the age 30 median worker at age 55 to 65? The Republicans argue the CEO of a large corporations employing lots of younger workers should be charged 3 to 5 times higher premiums due to his age, so his dodging a 40% income tax that is that high due to the crushing Obamacare tax hikes is hardly much of an incentive to take the insurance instead of cash compared to the much lower premium imputed by employer health benefits.
Note, a small business can deduct 100% of all employee medical bills if it pays 100% of medical bills for all employees and dependents if, and only if, the business does not pay for insurance. That is self insurance just like IBM and GM. Or the small business can buy insurance for every employee and deduct that, but employees must pay copays and deductibles. They can pay the bills with tax exempt wages, but the wages not spent at the end of the year go to the Federal government, so that brings the small business closer to the big corporate self-insurer. But again, that tax avoidance on the health account is low for the majority of workers, unless they are high income.
Individuals with HSAs get a much better tax avoidance deal because they never pay taxes on wages that are saved and invested and spent possibly decades later.
I’m talking about the theoretical world in which individuals get a tax deduction for buying their own policies, not the actual world of the current employer based system.
“Employers would fight hard to keep some or all of that amount.”
What you are suggesting is that employers could get away with unilaterally imposing a pay cut on their employees. If that were true, they would have already cut pay (yes, right now most employees don’t think of the cost incurred by the employer for health insurance as part of their salary, but the soon would when they realize they need that money to buy their own insurance.)
I don’t think so. Imposing an effective pay cut, where salary doesn’t go down on paper, but your total effective earnings do, is different than a nominal pay cut. See discussions on this site about sticky wages. And in this case, employees will often not know the true cost of their health insurance, so they won’t know whether they are getting a pay cut or not.
Right. The price equilibrium for the labor market is the level of total compensation. That price equilibrium isn’t going to change if employers stop offering part of it in the form of insurance.
dan111, sticky wages only apply in a deflationary environment.
Yes, it’s possible that *some* employees might see a net pay cut, but that just means they were over-valued. On average, wages will rise so that total compensation stays the same. It might cause some labor market churn in the short term. But again, if you just let people opt out and take an individual deduction instead of buying their employer based plan, employers might just explicitly make the offer of higher salary in lieu of insurance.
Employers have been imposing such a pay cut for years as health plans get skimpier and skimpier. The effect however is camouflaged well enough that employees do not perceive it as a pay cut and are most angry at insurers and providers not their employers.
@JonFraz, the health plans have gotten skimpier as the cost of health insurance has risen faster then the rate of inflation.
If you account for the rising cost of health insurance, total compensation has roughly kept up with inflation.
“employees will often not know the true cost of their health insurance, so they won’t know whether they are getting a pay cut or not.”
Yes, they do!
The cost of their employer health benefit is on their W-2 in
“Box 12 amounts with the code DD signify the total cost of what you and your employer paid for your employer-sponsored health coverage plan. Code DD amounts are for informational purposes only – they won’t affect the numbers in your tax return.”
While I continue to support some version of universal insurance, I completely agree with you on this point. As long as the tax deduction stays in place, people will stay in jobs they otherwise hate as they do so just for the insurance.
Right well the goal is obviously to gently shift people into purchasing individual policies, which makes the problem go away. If you take away the deduction entirely, employers are going to see sudden cost increases which will make them drop those policies en masse. If you give individuals the same deduction, the transition will be slower as it will depend on individuals opting to buy their own insurance, and employers letting employees opt out in lieu of higher pay, or offering some sort of subsidy to purchase individual policies instead of employer-based plans. That will take some time, but it will allow individuals and businesses to make that choice on their own. I imagine that some smaller businesses will start just saying “we’re not going to offer insurance, instead we’re going to give you $500/month to go buy your own policy”. You change the regulations to make this legal under the employer mandate. Eventually it all becomes moot because we still have the individual mandate, so they have to buy insurance anyway, and the distinction between salary and subsidy vanishes. And over time large companies start doing this, and eventually the people who have traditional employer based plans become a small enough group of people that you can kill the deduction on that side.
My daughter just was offered $500/month on her freelance job for just that. She works 20 hours a week and is well compensated. They want to keep her on and that’s the carrot.
I think if there were more individuals purchasing insurance you would see more of the companies offering individual plans. Aetna is pretty much vacating this space and most of the individual plans are offered by the BlueCross/BlueShield affiliates. The bigger the pool the more competition. Pretty simple.
Right, so the thing is because she’s a freelancer, that means she is “self-employed”, which allows her to claim the tax deduction for self-employed health insurance policies. The problem right now is that if you are a formal employee you CAN’T get a tax deduction if you buy your own policy or if your employer offers you a higher salary to go purchase one.
@Hazel – yes, absolutely. We are on the same page on this one!!!!
So, her employer is saving money by paying less than what health coverage costs.
You will claim that she can buy insurance cheaper and never pay more than $6000 because she is you and she can renew forever no matter what without paying more for pre-existing conditions because when the policy goes from $2000 per year as she ages to $10,000 per year under the Republican plan, she is not paying for pre-existing condition of getting a year more in pre-existing age demerits each year.
Over 30 years of premiums increasing from $2000 to $10,000, her insurance will cost much less than $6000 per year, $4000 less per year!
Due to HIPPA, which has been in place for twenty years, you can change jobs without it affecting your insurability– but that assumes the new job offers similar insurance.
“Here’ my suggestion for the one thing that Republicans could add to the bill that would get libertarians on board:”
That’s nice. If we were talking about navies the libertarians are three row boats. The voters, on the other hand, is the entire WWII US and UK navy and the voters did not voted, at most, to just ‘fix’ Obamacare and not disrupt the insurance that 80% of non-elderly people have.
How does adding a tax deduction for anyone who WANTS to buy their own individual policy instead of their employer based plan, disrupt the insurance that 80% of non elderly people have?
Why would anyone want to do that? Most employer plans (yes, there are exceptions) are better quality than what you can buy on the individual market. Also, bear in mind there is a huge subsidy– usually– in the workplace plan since the employer, usually, pays a large fraction of the premium. And very few employers offer any sort of extra compensation to people opting out of their plans: most probably would not in order to maintain an incentive to keep people in their plans in order to prevent the risk pools from being tilted toward older, sicker workers. Workplace plans have a lot wrong with them, but they are very, very, VERY good at one crucial thing: given a large enough work force they create large risk pools with plenty of young and healthy people in them, thereby keeping premiums from going through the dreaded death spiral. Until you can duplicate that very necessary feature outside employment insurance you need to stick with it where it does exists.
Why would anyone want to do that? Most employer plans (yes, there are exceptions) are better quality than what you can buy on the individual market.
Because most employer plans cover way more than is rational, and many people would opt for a cheaper high-deductible policy if they could. Hence the concept being the “Cadillac” tax.
You are essentially saying that we should FORCE people, especially young, healthy people, to buy their expensive covers-everything employer-based plan because it’s good for older workers who are already in those plans. How is that fair? Are younger workers slaves to be used to subsidize older workers? Should they be forced to tie their health coverage to their job because workers before them have been forced to tie their health coverage to their job?
Anyway, all of the regulations in the individual market mean that individual market plans already have mean of the same features as group insurance. Young people are going to subsidize the old either way right now. Why shouldn’t they have a choice to buy their own policy? Why should they be FORCED to purchase the limited options their employer offers?
Yeah, employer plans cover getting older, while in the individual market you pay to get older in your higher and higher insurance premiums.
While we boomers took Working Man Blues to heart (die before I get old) and imagined ridding society of old people, Logans Run, Soylent Green, Zardoz, et al, I see no hint of Millennials planning to commit suicide at age 30. In fact, conservatives seem to have convinced them to be “pro life” and thus oppose all options for ridding society of the costly people with costly pre-existing conditions. We boomers remain the supporters of abortion and assisted suicide, which conservatives argue is always to cut medical costs, something conservatives see as ultimate evil, worse than shooting someone in the back who is running away.
So, conservatives in the Republican party want very high cost health care which generates high profits to providers and insurance, but they are only willing to pay a small price or a price of zero.
mulp, a large part of the high cost of premiums is driven by overuse of the health care system, which is in turn caused by insurance plans that cover everything at flat rates for everyone in the plan. i.e. Employer-based plans. People often cite the fact that the American healthcare system is very expensive. We spend a LOT more than other countries on health care per capita. This is why. Getting people off of employer-based plans means they directly see the cost of health care in the form of higher premiums. They will soon start deciding not to use insurance for silly things like birth control pills and getting CAT scans “just in case” and will reserve it for actually expensive and necessary medical procedures. And the result of that will mean that insurance and medical care in general will get a lot checper for everyone, including the old.
Hazel, it is not true that most workplace plans cover more than is rational – unless you assume that people have oracular powers and know with certainty what they will and will not need. We don’t. Hence a comprehensive insurance plan covering all illnesses and injuries is what everyone needs
Also there is nothing unfair about having both younger and older people in the same plans. Thus is how insurance works)- and it’s the only way it can! You might as well rail against gravity or 2+2=4. Besides young and old are nit fixed categories,unlike, say, racial categories. Young people become old people, so over a lifetime there is indeed fairness to the system.
It shouldn’t, and it is the kind of marginal step that is needed to gradually shift people away from employer-provided insurance. Anything that could involve a sudden shock to millions upon millions of people is probably doomed. Breaking the link between employers and health insurance is a worthy goal, but it needs to be done incrementally or the potential backlash makes it unlikely to ever get started.
For this to potentially incentivize someone with a job to purchase elsewhere, however, it would need to involve a credit to effectively refund payroll taxes paid on the income used to purchase it, as well as any State income taxes.
Good point. There should be a way to put it “above the line” as someone else put it, so that it is deducted from AGI, which is what states use to calculate their income taxes.
We could also apply payroll taxes to “total compensation” instead of wages, which would make it simpler, but I’m not opposed to having a credit line to give you back the amount you “overpaid” into social security if you purchased your own health insurance.
In the UK, it seems they might make a move in the other direction, to specifically increase taxes on the self employed.
But I imagine that in London this includes a lot of people earning well into 6 figure salaries and beyond, at least probably more so than in most other places. So I’m not sure if the issue is easily comparable.
“Here’ my suggestion for the one thing that Republicans could add to the bill that would get libertarians on board:
Expand the tax deduction for employer-based health insurance to include ALL health insurance, whether it is purchased via an employer or not, whether you are self-employed or not.”
I think you make some excellent points here, Hazel, the above being the best.
I think that while this helps in a way, it also tends to further cement the tax-advantaged status of health insurance, which leads to over-consumption. So while it might marginally shift us away from an employer-centric scheme, it also further entrenches health insurance spending as something that is, and should be, tax advantaged. Both are major problems, in my mind, and it seems like the marginal benefit on the employer-insurance link might be equal to or outweighed by the harm on the insurance-tax advantaged link.
But I don’t really have good alternatives in mind for how to start a gradual process of moving away from employer-provided insurance.
I think the employer-based system in 80% of the problem. The thing to keep in mind is that money spent on health care is still money you can’t spend on something else. it’s a 30% discount, but you still see cost in proportion to reality. The employer-based system however prevents price signals from reaching the consumer except in the very indirect form of premium increases for the entire company.
I don’t necessarily buy something just because I can get it 30% off on a clearance sale, but if I’m force to pay for an all-you-can-eat buffet, I’m going to load up my plate.
So, if you have comprehensive health care, you will have one baby per year, get two colonoscopies per year, blood tests 12 times per year, because you love disrupting your schedule and love to experience discomfort and love having to fast to get free medical procedures?
How old are you? I’m better you are under 30. Have you ever had some sort of vague undefinable medical problem? You can spend a shit ton of money trying to make sure that your joint pain isn’t bone cancer or whatnot. A lot of money is wasted on “defensive testing”. Doctors will offer you these things “just to make sure” because they CAN and to protect themselves from liability. Right up until the insurance company says NO. When people hit 40 they start developing lots of minor issues that they can work themselves into a fit of hypochondria over – and spend a lot of money on unnecessary testing and surgeries to try to fix. Like women getting biopsies on breast lumps that are almost certainly harmless cysts. Or people getting hip replacements when they could get better with physical therapy. When it doesn’t matter what anything costs, people will blow a LOT of money out of paranoia and a desire to recapture their 20s.
Fair point. I don’t have a good estimate of which is what percent of the problem, but I think you’re right that the employer-provided aspect is a bigger one than the tax-favored part. And tax-favoritism does provide a nice carrot to make the move away from employer-provided insurance more palatable.
Most employers plans have significant deductibles and copays. People are emphatically NOT insulated from the cost of healthcare. Your arguments, Hazel are years or decades obsolete.
You guys should all read my new book; Big Cucks, Small Cocks: A Year in the Marginal Revolution Comment Section
Anyone have a can of Troll-B-Gone handy? I forgot mine today.
I think the Republican problem is that Obamacare may “collapse,” but not this year, and probably not even this Presidential term. And so, if they have an uncontrollable momentum to “repeal and replace,” it becomes “Trumpcare,” and their plan, before “collapse.” Anyone who loses coverage will be “kicked out” by the change, by “Trumpcare.”
Now, they might do a real Republican plan centered on more market solutions. If they don’t want to drop millions from coverage, they will need subsidies. It will cost money.
So do the plan and pay the money?
The Republican problem is Obamacare will take as long as the disasterous failing collapsing Social Security system to collapse.
When I was 10, my parents were being told Social Security would not be there when he retired. Thus I grew up every day once I could “understand” political economy theory rhetoric hearing that Social Security will collapse long before I got old and retired. My parents got Social Security benefits from age 65 on until they died. I am getting Social Security benefits now that I’m old and retired.
Clearly Republicans are totally incapable of predicting the people future.
The irony is Social Security was periodically in crisis while I grew up which required Congress to, in today’s rhetoric, bail it out every couple of years. Then conservatives Reagan and Greenspan saved Social Security from politics in 1983 so that Republicans had no way to create a crisis over the collapsing disasterous destroying America Social Security system because not a single action by Congress was required to bailout the failing disastrous Social Security system. Thank you President Reagan.
My guess is we will look back on President Trump in a decade, maybe two if I’m lucky (at age 89) and I will be able to say, thank you “President Trump for saving Obamacare which is still in effect, just like Social Security.” Note President Bush saved Social Security from privatization by arguing private pension funds cost less and pay more, pointing to the Texas town and Calpers, plus the claimed over 10% returns on 401Ks and IRAs year after year, only to have the 2008 crash.
Note that while Wall Street indexes have increased past past record highs, lots of retirement funds, whether 401Ks or Calpers, et al, are worse off than in 2000. Ie, if Social Security had been privatized by Bush and Republicans, both individuals and Congress would be facing a huge old age funding crisis.
Simply eliminating taxes and payments by government will not both eliminate the cost of the old and the sick, AND ALSO PAY FOR GDP SERVING THE OLD AND SICK. Obamacare has added significantly to the gdp of Kentucky and added jobs in Kentucky because of Medicaid. Slashing Medicaid spending in Kentucky will cause a big cut in Kentucky gdp and massive job cuts. Ditto for most of the 30 Obamacare States.
Zero sum. TANSTAAFL. You can’t take credit for gdp that you stop paying for.
Social Security is not collapsing. That’s pure rightwing delusional crack.
The food in this place is terrible. And such small portions.
The question I have is who is paying Levin’s salary? Reportedly, most of the loudmouths demanding repeal of ObamaCare are on the payroll of a billionaire who stands to make even more billions with the repeal. There’s no question that the GOP had their donors craft the bill. Those same donors, presumably, are paying “policy wonks” to promote it. At the same time, different billionaires are paying different wonks to hate this bill.
I looked up Ethics and Public Policy Center and I’m guessing that’s where Levin makes the bulk of his income. Who bankrolls Ethics and Public Policy Center?
The entire right wing media (and social media) machine made “Obamacare is the devil!” their meat for years. They never did the explainers, within their silos, for why healthcare was hard. And so, they actually got a President elected on repeal, got repeal in motion *before* that President said:
‘Nobody Knew Health Care Could Be So Complicated’
Viewed this way it is a self-inflicted wound. There are many, many, bankrolls involved with that.
The only people who think Trump won because he promised to repeal ObamaCare are you and people who don’t live on earth.
Further, it is has nothing to do with complexity. It’s bribery. The same people who bribed the Democrats are now buying up Republicans. Health care in America is a massive skimming racket. The way to *fix* this is to focus on who is writing checks to whom in Washington.
“Who bankrolls Ethics and Public Policy Center?”
An ethical person, of course. It is right there in the name.
I poked around a bit – it’s a “conservative” organization with many recognizable names and a religious bent. Generally, not too well-disposed toward Trump.
You might be able to file a FOIA request with the DC department of taxation to get their filing.
You can look up their 990 here: https://projects.propublica.org/nonprofits/
These “charities” do not have to disclose their donors, which is a big problem. What you can see is the people in charge pay themselves very well. They also will sit on the board of other “charities” and get money that way. The other scam is that when Yuval Levin writes a book no one reads, the ‘charities” buy up copies. Pretty much all of the think tanks, Left and Right, are just fronts for rich guys to keep their media advocates. These guys turn up on TV and radio peddling whatever their owner tells them.
Aren’t you a big fan of Trump and wasn’t one of his few policy positions, in addition to the wall that Mexico would pay for, the repeal of Obamacare? Now, I get that people voted for Trump for all sorts of reasons, some with their nose pinched as hard as they could. But this is really rich.
If Trump is awesome because he’s doing exactly what he said he would, then bye-bye Obamacare!!!!
I voted for Trump. I’m a big fan of Kanye. I would not want Trump performing on stage and I sure as heck do not want Kanye in the White House.
The problem guys like you have is you think everyone shares your hive mindedness. You think the only choices are passionate support and angry hatred. There’s a vast middle ground where normal people live. Normal people can like Trump over Clinton, but recognize that Trump is terrible on some things, great on some things and somewhere in between on most things.
I think too many people are willing to pat you on the hand and say “you thought you were doing good when you voted for a lying, pussy grabbing, casino owner for President of the United States .. of course you did.”
What’s really rich though is that you want to be proud of that, while washing off all responsibility, because “Trump is terrible on some things” and that has nothing to do with you.
It is strange that you cannot accept that your side lost, even though months have passed, and stranger still that you cannot fathom that good decent people could have weighed things and decided that, on balance, living with a coarse loudmouth with thin skin in the White House is better than the also-mediocre Hillary (whose husband didn’t get permission to grab pussies which at least Trump did: “they let you ” etc).
Well, if today’s trajectory (that Trump’s health care plan takes away coverage from Trump’s supporters) comes to pass, how cute will it be to say “your side lost!”?
That’s a reasonable answer, though based on your previous posts, you came off as a big, big fan of Trump, and not just Kanye…. Okay. I actually had no idea how you felt about Kanye.
EPCC used to be a social conservative think tank focused on abortion and funded by midwestern, Christian industrialists. Over the years the funding has switched to sources like Donors Trust, basically a front group for hedge funds and the Kochs. Not surprisingly, EPCC has stopped talking about abortion and Levin wrote a book that can be summed up as, let’s stop fighting the culture war and focus on coaching Little League teams. So basically EPPC represents a classic example of O’Sullivan’s law.
The one that says that not everyone cares about your obsessions?
The Redskins are all over the news, so everyone does care about my obsessions, apparently.
Not everyone, just people who care about bad football teams.
No billionaire profiting from killing Obamacare is in health care, and the only way to benefit is by not pay a 3% of income tax. Ie, if a billionaire gets $100 million in good as cash income, he saves $3 million in taxes. Few billionaires agree to get $100 million in income in a year.
Because you can choose any two of these: A) repeal Obamacare, B) maintain coverage, C) cut spending
I’ve read Yuval Levin based on recommendations, but I didn’t get any tingling down my leg.
This bill was designed to fail, and it will fail, allowing Trump to blame the cuckservatives and demcrats for the problem. Can’t believe you guys don’t see it.
Yes, the establishment Republicans who wrote the bill designed it to fail so that they could be blamed for that.
And they would have got away with this if it weren’t for meddling economic blogs commenters.
I guess it would be a dream solution if Trump blamed “partisans” and then demanded a bi-partisan bill. But likely?
I seriously think there is some sort of Yuval Levin payola scheme where bloggers are paid to promote Levin’s platitudes.
” And in any case, momentum depends on a strong, successful push at the start. This could have started better, and it needs to end smarter.”
This could apply to literally any government program. In fact, it could apply to literally any human endeavor.
This will not get a single dem vote. More than half the population would like a single payer system. Flawed as it may be it’s still more comprehensive and simpler than any corrupt market based health care.- http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcare-system.aspx
“Momentum”? Is Levin trying to become a sports commentator?
Everyone knows that the best strategy to deal with health policy is defense, defense.
“This would mean that people could get catastrophic coverage for extreme expenses for the same price they now pay to be uninsured—i.e., nothing. ”
This is a HUGE selling point, if Republicans can get over their “just another entitlement” hangups. It defangs a lot of criticism from the left.
The compromise is clear: accept more redistribution, a clear minimum level of health insurance coverage, in exchange for a robust free market.
From a purely political self-interest standpoint, anything the Republicans do that makes it to where they fully “own” the outcome isn’t a great idea, since it isn’t going to be something where everyone wins. So I would think that they would want to offer a plan that won’t ever become reality, but that seems acceptable to certain interested members of their coalition and makes it look like they tried, and then hash out a bipartisan deal that gets them some of what they want, while allowing them to still share blame with Democrats if things go badly.
“…and then hash out a bipartisan deal that gets them some of what they want, while allowing them to still share blame with Democrats if things go badly.”
A bi-partisan deal is the only way to make the system politically stable. Otherwise, we’re going to see the health care issue see-saw back in forth in a giant blame game.
Agreed. I think the problem is that Democrats saw the blame game work for Republicans before, so they are more apt to say no to any deal, and try to force Republicans to take ownership. Especially if they can frame it in any way as resisting Trump.
To get the conditions for a bi-partisan deal, the current system may need to be allowed to continue on without any tweaking until Democrats are convinced that they are about to get blamed for some sort of big, identifiable, and noticeable failure. Maybe we’re already close enough to that for that deal to happen, but it doesn’t quite seem like it.
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