I’ve been predicting this

Republican presidential hopeful Mitt Romney, who promised early in his campaign to repeal President Barack Obama’s health care overhaul, says he would keep several important parts of the overhaul.

“Of course there are a number of things that I like in health care reform that I’m going to put in place,” he said in an interview broadcast Sunday on NBC’s “Meet the Press.” ”One is to make sure that those with pre-existing conditions can get coverage.”

…”I say we’re going to replace Obamacare. And I’m replacing it with my own plan,” Romney said. “And even in Massachusetts when I was governor, our plan there deals with pre-existing conditions and with young people.”

I would say he is preparing for a major fold on the issue.  I’ve been predicting a Romney administration would block grant Medicaid, undo some or all of the Medicare savings in ACA, but essentially keep the mandate under a different label and then claim to have “repealed and replaced.”  The story is here.


Etch A Sketch

Or try this on for size: let's scrap the election and just toss a coin to decide its outcome:


I don't mind the mandate so much, just the base level of coverage (maternity, conctraception, etc.) seems innefieicent and raises the price floor too high. Just make sure everyone has a high deductible, basic policy and move on.

You can say that again!

'maternity, conctraception'
And yet, strangely, one of those prevents the other. Must be too complex for some people to grasp - or could it be that both mentioned examples concern women, a group that seems to be notably lacking among the commenters here.

Please. Like Wikipedia, anybody can comment on Marginal Revolution. Maybe certain demographics are less interested - or informed - about economics and policy minutiae.

Anyway, you seem to be conceding that some people find contraception too complex to procure without free birth control pills and IUDs being helicopter dropped on their heads.

So, we should pay for contraception to subsidize non-maternity. Bizarre stuff.

No - health insurance should cover maternity (the process by which we all arrived, after all), and if one feels that maternity is too expensive (which is a fairly unique American view in comparison to other countries which actually provide universal health care), then one should support contraception as a much more cost effective alternative.

Since without contraception, maternity is quite predictable. But as the vast majority of posters here seem to be male, maybe they should ask their girlfriend/wife or sister(s) (if available), or their mothers. Because as noted, maternity is a process which has involved all of us. It just appears some people posting here forget that reality - and saying maybe that is because the posters are too concerned with economics (leaving unspoken the assumption behind such a silly statement) seems, well, like positing a can opener to handle a real world situation, as one classic summation of economics notes.

Prior - I notice that liberals tend to treat maternity as a problem to be managed. The logic appears to be something like - welfare and food stamps for single moms are expensive, so let's go ahead and spend some more to provide free contraception so that we aren't forced to fork over more welfare to kids they have out of wedlock.

If one pays for health insurance and then one pays a co-pay for prescriptions, how is one getting "free" contraception?

Ranjit, it is unplanned pregnancies that are the issue. Liberals aren't on some crusade to stop all pregnancy because it leads to welfare. Actually, one would think promoting slowdown in the growth of the welfare population would be a very right wing approach to this issue. I mean, you said it.

The marginal cost of contraception is minimal compared to health care overall. And it is so obviously a significant component of health care it seems funny indeed to assert that including it among a basic benefit package is "free contraception."

Jan, Margaret Sanger was quite explicit about the 'eugenic benefits' of Planned Parenthood. This was several decades before Ranjit's comment.

"No – health insurance should cover maternity (the process by which we all arrived, after all),"

Wrong again, on even the most basic logical level. The funny thing is I don't even think you guys understand your parroting of these nonsense talking points.

Plenty of people, in fact everyone not long ago, and a large number even today don't use the "traditional' (read non-traditional) medical system for birth.

If you want to force people to pay for emergency care because you are incapable of coming up with ideas on how to internalize the costs, fine. "We can't possibly think of any way to not have free riders!" Fine, uncreative bureaucrat. What would that really cost? I'm thinking pennies.

Skip Intro September 9, 2012 at 12:59 pm

If one pays for health insurance and then one pays a co-pay for prescriptions, how is one getting “free” contraception?

It is free to the extent that other members of the risk pool are compelled to be in the pool that pays for things they don't want covered.

For example. Let's say I signed a contract for a high-deductible plan. Then they come along and say "oh, by the way, we are going to cover contraception (this was not the lady's point before Congress btw, which was about the other health uses of hormone pills). You are subsidizing contraception at the expense of the things you are not subsidizing by forcing me to pay for it.

What is so scandalous to me about this is that you could very easily have a program that people could voluntarily enter to pay for insurance for these things. Except there wouldn't be much of a point would there? If everyone were paying their own way without tapping into someone a little wealthier to free ride on their premiums for your birth control. This is why confusing insurance with a wealth transfer kind of works for elections. It's just plausible enough that people don't feel the shame of free riding.

The point of any conversation about diversity is not usually about whether people from absent groups are *able* to participate: it's about why they don't, and how the absence of balancing points of view works to the detriment of the social unit in question.

"Not interested" is a popular trope to explain the absence of women. It pops up a lot in the software world. In reality, plenty of women are interested, but don't feel like it's worth dealing with the rampant chauvinism--for example, the kind of chauvinism that leads us to assume that women aren't interested, rather than noting and examining the fact that men act like ignorant asshats. =)

Interesting...would you also say that female-dominated fields and subjects are female-dominated because the men who might be interested are scared off by "rampant misandry"?

As we with many things, it's the same gender that shames you. Men are less likely to be nurses because they're afraid of what other men will think.

Or perhaps men and women tend to gravitate towards different interests because evolution has caused their brains to be wired differently. Have you ever considered that?

Chris D:

That is simply not true. Study after study have been done, over a period of decades. The fact is that women (or "girls" may be more appropriate in many cases) simply do not choose to enter that career path, and pick something else. As far back as high school. And that applies to many tech fields, not just software.

It is NOT a matter of getting a degree and then finding the work conditions are not to their liking. That is a myth. I am sure it happens but it happens to men, too. Women simply choose not to go there in the first place. Before they get their degrees or even choose a major. Before they even enter college.

There is a huge amount of scientific evidence to back this up, over a very long period of time.

May be, but mentors and seeing yourself in a profession are important. I have been shocked at the pervasiveness of "girls can't do math"...I've heard it from second graders to econ PhD students. Now there's no way "can't" is the right term for girls. It might harder on average, fine. So there's plenty of technical fields that require math...if you decide in second grade that's not your thing then of course you won't choose it. And how many people men or women choose to enter a profession where there's few of their gender? People don't generally embrace being an outsider. They want to be a part of the in group. Men don't have to be jerks for women to feel unwelcome, but the dominant group in numbers is often going to set the tone and will recycle itself.

Ranjit, I assure you that an IUD dropped on my head wouldn't be money well spent, but hey as a woman what do I know about women's health, economics or policy details? (Psst I do know what helicopter drops are, but you deserved that response for such a goofy characterization of the policy.) On the under representation of women here (which seems a little off topic to me)...now let's think, would people who care deeply about policy solutions hang out en masse on a libertarian-ish blog? I enjoy the exposure to different ways of thinking, but it's not for everyone. Also I know far more female economists who focus on health policy issues than male economists (not the case in my field of macro). So carry on but this thread already contains more than a few examples of why it's a boys mostly conversation here. (And that's fine. Just don't infer much about the non-commenters or non-readers.)

What you're advocating is not equal rights and gender parity. It's endless, self-justifying entitlement.

Women wants to sleep around but doesn't want to get knocked up. We have to pay for her contraception. Women gets knocked up. We need to support Planned Parenthood and an abortion. On second thought, she decides to have the baby. The man has to pay child support even if she told him she was on the pill. The state has to give her welfare, food stamps, health care, and child care. If anyone simply opposes an expansion of this gravy train of entitlements they're demonized as anti-woman. Instead of shaming loose women who have children out of wedlock - which is a disincentive that actually works - we shame the men and women who still have values.

Somehow it's become not just the right but the duty of every woman to spend her young adulthood carousing for tough guys before settling with a guy she can divorce later and for the state to subsidize this dissolute behavior. No.

I like how Ranjit characterizes it as loose women instead of loose men. I thought it took two to tango, but I guess I was wrong! Dumb sluts are out of control!

Ranjit, your viewpoint is so misaligned with modern U.S. values that is doesn't warrant much of a response. You're entitled to that viewpoint, but you and the handful of Americans who share it with you are a miniscule proportion of the population and shrinking every day. Welcome to irrelevance.

I was wondering why in your comments you link to you a blog that hasn't been updated since 2009.

Thanks for helping Obama rack up a huge edge in the female vote, Ranjit!

I do not fully agree but I think if any healthcare would be subsidized it would be maternity care, care for infants and children. These seem to be the most effective care but as things are now elder care which is the least effective care is the most subsidized.

Does everyone really not get it? You don't need insurance for contraception because contraception is not a rare, high cost item. Forcing a situation where your insurance buys your contraception for you INCREASES your total cost! That cannot help but be true. It's not doing anyone a favor but the insurance companies. Certainly it isn't doing women any favors.

Maternity is sort of rare and high cost, but 99.9% under your control, so it is another good candidate for not being REQUIRED. What if someone is confident in their ability to take a pill every day and doesn't want maternity coverage? Why can't they have that option? What if they want to self-insure?

Pregnancy is generally foreseen so can be saved for, or financing offered if it is unexpected. Insurance is the wrong product.

Nah, they get it. The point is to try to turn an internality it into an externality. This is what governments are for. To help groups externalize their costs.

So, what you guys are saying is that we here demand free condoms and free abortions because we are dudes...

I don't mind the mandate so much, just the base level of coverage (maternity, conctraception, etc.) seems innefieicent and raises the price floor too high. Just make sure everyone has a high deductible, basic policy and move on. D

Well, if he can say it again, so can I -
‘maternity, conctraception’
And yet, strangely, one of those prevents the other. Must be too complex for some people to grasp – or could it be that both mentioned examples concern women, a group that seems to be notably lacking among the commenters here.

What is too complex? Maternity is something that can be planned for and planned against. Contraception is trivial. If you can't afford contraception you have a non-medical problem.

If you want to subsidize contraception for social engineering purposes then you may have a non-medical problem.

What your statement evidences is that you simply see this as a wealth transfer socialist move while pretending it is medical and risk market (insurance) related.

My statement posits that both contraception and maternity as issues that -

a. Involve at one level every single human being, where a healthy society attempts to ensure that maternity leads to the best possible outcome for all involved. Sadly, the U.S. has a hard time breaking into the top 30 in this area, though its teenage pregnancy rate remains amazing compared to other industrial societies.

b. Well, that U.S. teenage pregnancy rate already pretty much demonstrates the point. With contraception available, the U.S. would likely be able to lower its health care costs, as maternity is expensive, and teenage pregnancy is generally not an optimal outcome for anyone.

You could ask a woman - they seem pretty well informed on the subject of maternity and its effects on their lives, generally. And who knows? You might even discover that they aren't all socialists, either.

Teenage pregnancy is rational in a society that:

1. Provides subsidies to poor mothers - TANF, SNAP, WIC, etc.
2. Mandates that men provide child support and alimony
3. Has withdrawn the obligatory ostracism once given to women who have children out of wedlock

Of course, you're in favor of all these things and then come up with the conclusion that the answer is more money being plowed towards irresponsible women.

1. You just described most of Europe.

2. The US is less generous than Europe.

3. Teen pregnancy is much higher in the US.

4. Ergo, your explanation is clear, simple, and wrong.

Comparing the US and say, Denmark, directly isn't valid because of the different demographics and cultural makeup.

A better comparison would be to look at teen preganancy rates in the US before and after the implementation of subsidies to single mothers, then do the same for Denmark. More of an apples to apples comparison.


Is the maternal care ranking a valid comparison? Or is it like neonatal care, where the U.S. by far leads the rest of the world but is condemned to a low ranking due to differing international standards (preemie deaths not counted as live births)?


That much-vaunted safety net provides bare subsistence and no more. Ask yourself if you'd want to drop out of the workforce and live off welfare instead.
And by the right alimony is rather rare these days since it's only awarded when one of the spouses has no means of support. In the days of two income couples that does not happen all that often. I've known any number of people who divorced-- and not one instance of alimony. Child support however is another matter, and if you want to gripe about the inequities of our child support system I may agree more often than not.

And yes,. maternity is one of the core benefits for any rational healthcare system, period. Contraception can be argued over-- but not maternity. Leaving that out would be like leaving out coverage for infectious disease or broken bones. It makes zero sense.

@the Original D
"The US is less generous than Europe."
You are incorrect. Europe just front-weighs the benefits more. US tax benefits to having a child are /enormous/ and can exceed your income tax bill, causing your tax burden to go negative.

'The US is less generous than Europe. '
Nope - even the most expensive European health care systems, like Germany's, provide free maternity coverage - along with insuring all children for free, to boot. For a cost that is a third less as measured by GDP ratio of health care expenditure. That isn't generous, it is just practical. If various European health systems started to cost as much and offer as little as the U.S.'s amazingly inefficient system does to its citizen, then we could talk about 'generous' - as it is, Europeans simply enjoy much better health insurance for a lower cost.

No need to be generous creating reality - it is there for anyone to pay attention to.

I'm in favor of teen pregnancy. We certainly don't need the government to be involved.

After all, they are doing a bang up job of preventing it.

Yes – no one except the father and mother, the acting agents, are affected by childbirth.

Abortion of unwanted children – MURDER!

Death or injuries to a child due to insufficient medical expertise at childbirth – perfectly acceptable.

Girls might be bad at math, but boys are fu***** terrible at logic.

I agree with Gonzo. Unless Mitt wants to open his term at war with the House he will have to dump the mandate or drop the floor to very low base level. That would be palatable if it was paired with tort reform and opened all state markets up for competition. Hitting the low base would entail goring many sacred health care cows, I'm not sure he has the stomach for that fight.

The tort reform and interstate competition...Are you bringing those up because you think the House would require those to be part of the debate, or because you personally like them? Personally, I think too many people have a vastly inflated sense of what tort reform will do and not enough imagination about what will happen if you allow all insurance companies to flock to the "lowest common denominator" state. If you're talking about the House...you may be right. They may require them as part of any discussion, but I don't know if they'll help much.

If the lowest common denominator state is still limited by a coverage floor, what's the problem? States compete on wages but they can't go below the federal minimum wage.

"Unless Mitt wants to open his term at war with the House "

Not really, the house structure is such that all the power is at the top. The sitting president can do whatever he wants if his party is in power and the speaker is in his pocket.

Are we also going to see a post on the new Obama plan to implement vouchers for Medicare? Because that's something he's actively campaigning against, and doing at the same time.



So Americans can choose between Obama ... and Obama-Lite (Romney) in November.

Why bother with elections when there is no real choice ?

The Ruling-Party ALWAYS wins.

Republicans & Democrats are merely factions of that same Ruling-Party;
they take turns at the wheel every few years, but the nation's course remains the same.

Nothing of substance will change after the election. The only slight benefit to citizens is the frictional cost of changing specific personnel in the "new" administration -- it slows'em down a bit on their standard mischief; kinda like rival Mafia families fighting & altering control of their 'territory'. Things will look the same (that is - ever worse) to Joe-6Pack.

No need for paranoid rantings.
Most cases where Repubs and Dems offer basically the same position is because the voters severely punish any deviation.

Old people vote. Old people like Medicare. Which is why Romney and Obama are both campaigning on being the true savior on Medicare.

Of course, the public statements are irrelevant. The reality is Obama is taking money away from old white people (Medicare) to hand to younger non-whites (Obamacare). This is because Obama, like most Democrats, hates white people.

Most of Medicaid is spent on care for seniors and the disabled. The reality is Romney is taking money away from old white people (cutting Medicaid) to hand it to much richer people (Romney's policies generally). This is because Romney, like most Republican politicians, hates everyone other than people at the top 1% of income.

"Obama, like most Democrats, hates white people."

Do you really believe that?

RINO teabaggers like jose do believe that.

Um, patients aren't the ones getting any money from Medicare: doctors and other providers are. So it isn't old white people losing money (nota bene: their actual benefits are unchanged), it's the doctors and other providers.

By the way, there are old black people on Medicare too, and plenty of young white people who will benefit under the ACA. I can see the argument about age here, but race is meaningless since the ACA is completely color-blind.

And your final statement leads me to wonder if this was done in satire.

Take your own advice from that first sentence.

"Old people like Medicare."

Actually, the old are the demographic that are most in favor of medicare cuts.


My mom is an old-school Democrat. She is appalled at the opportunism, waste, and squandering of resources associated with delivering her Medicare benefits.

My dad is similarly outraged, but he left the Democratic party in the '70s when they lost their sense of humor.

Anecdotal yes, but I'd be surprised if this were atypical.

Welcome to the Median Voter Theorem and the resulting convergence of successful candidates on similar policies.

I don't think the Mccain/Palin ticket overlapped much with Obama/Biden but I do wonder if overtime parties converged (possibly due to media intensification and sounbite politics on steroids) or has this been always the case?

American democracy has been going on for hundreds of years, with many dozens of presidential election cycles. As much as the public voices a desire for change, when it comes down to it, the basic policy framework they want is in place. No radical policy change is wanted, and what is considered radical, is a single new major policy, such as Obamacare, NOT major overhauls of multiple parts of the system. Equilibriums of choice across the social spectrum are in place.

And how'd that election turn out?

Block grant of medicaid could be a social insurance disaster.

Here's why. Think of this as a game and figure out the end of the game.

State A, with a high proportion of seniors from another state, call it Florida or Arizona, currently is at risk for attracting seniors by offering low income taxes. Great place to retire. Live half time someplace else up north half of the year, and pay no taxes their to be close to family members.

Block grant comes to State A. State A has a problem: it has all these seniors who now need nursing home care, and it has full time citizens (low wage earners) who are employed in local businesses. State A has a big idea: Block grant gives it the option as to what kinds of services it wants to offer. Here's the idea: let's get rid of this nursing home exposure. Maybe those folks who came down from up north will go back to where they came from. Yeah, let's do that.

Meanwhile, in State B, up north, it is seeing an influx of former medicaid nursing home recipients in state A coming back home to live near the children. State B, fearing the influx, cuts back on nursing home care.

Race to the bottom unless benefits are uniform across states.

Tell me where I'm wrong.

If for no other reason, the elderly vote with great regularity. A policy platform of, "Grandma Go Home" is likely to be politically risky at best.

Besides, seniors also bring with them social security, savings, and private pensions that will get funneled into state and local coffers through sales and property taxes even if there's no state income tax. Even more than that, the elderly don't put a lot of demand on local public education, police or prison systems when compared to younger couples who have or want children.


Then why is the medicaid eligibility requirement so low in Arizona and Florida currently if seniors have so much power? These are states which are opting out of the ACCA because medicaid eligibility standards are raised.

Your hypothesis of senior power in these states re nursing home and medicaid eligibility is NOT consistent with the facts.

Have another hypothesis. Mine is that they set the threshhold low so that people move back. Block grant, which would enable them to eliminate categories of eligible care, just facilitate what is already happening.


From Kaiser Health News:

"Because Medicaid is an entitlement program, everyone who is eligible is guaranteed a spot. The federal government, which pays for nearly 60 percent of the cost, has an open-ended commitment to help states cover costs; in return, it requires them to cover certain groups of people and to provide specific benefits. For example, children, pregnant women who meet specific income criteria and parents with dependent children must be covered.

A block grant would effectively end this open-ended approach and provide states with annual lump sums. States would be freer to run the program as they wanted. But states would also be responsible for covering costs beyond the federal allotment."

The only reason for the mandate is that just having a ban on refusing coverage for pre-existing conditions doesn't work. Many people would delay buying insurance until they really needed it, at which point they couldn't be denied. This would raise the cost of insurance for everyone else.

That's the reason Republicans have always favored a mandate, up until Obama proposed one. Anyone else remember the Replican plan in the 1990s (as an alternative to Clinton's proposal), how Mass. works, etc.?

You mean some Republicans. Maybe they realized it is illegal and unconstitiontional and thought better of it.

Yes, one government mandate often results in the need to band-aid the government failure with another mandate if y you are completely uncreative.

A ban on rejecting paying for someone's pre-existing condition is not insurance, it is wealth transfer. You could create a government program paying people for their unfair diseases without f-ing up insurance while you are at it.

"Yes, one government mandate often results in the need to band-aid the government failure with another mandate"

Theory of the second best!

"A ban on rejecting paying for someone’s pre-existing condition is not insurance, it is wealth transfer."

OK, in that case, both Obama and Romney are in favor of "wealth transfer." Given that there is a political consensus in favor of this sort of "wealth transfer," we move on to the issue of what the most efficient way of accomplishing this transfer is. A mandate is certainly one way of doing it. Another way would be what Singapore does: namely, impose heavy restrictions on private insurance and strongly encourage people to buy into a state-run health insurance program so that you attain a broad risk pool.

Just because douche and doucher agree on something, as if Romney's marbles making contact occasionally rattling around his skull counts as agreement, doesn't mean (1) there is political consensus or that (2) a political consensus trumps reality (see below).

Reality = insurance, i.e. risk markets, should be handled by insurance. Wealth transfer should not be handled through the insurance market.

It destroys the market. That is what we are talking about. That's why you need a mandate, a mandate which incidentally is also known as "destroying a market."

A rather fact-free, vulgar and tasteless response from you. A CBS opinion poll showed 85% support for a law mandating that insurance companies cover people with pre-existing conditions. As for "reality," no developed country relies entirely on markets to deliver health services to the people or to insure people against catastrophic health risk. That's reality -- what you write above is unsubstantiated assertion that is divorced not just from the reality of policy in most of the world but also from the literature on health economics.

The 25 year olds now on a family policy, those with pre-existing conditions, and those who have fought rescission cases in the past...they probably don't want to lose those things. Same for Medicare seniors for whom the ACA lowers some co-pays or helps with the doughnut hole. For the most part, the things that are controversial are dwarfed in numbers by those that aren't. Birth control, mandate, etc. But can you get rid of the mandate and keep the aspects on pre-existing conditions and rescission? The private insurance companies will likely tell you the answer is no, that's not financially viable. I they're telling the truth, what then is the public's preference? I don't think the polls answer that. I don't think everyone understand how intertwined these things are (cf. the three legged stool analogy).

There are a few comments here about the basic plan being too high. I sympathize with that. My insurance premiums went up to meet new Obamacare standards (I talked in depth about all this with our company's insurance coordinator). My new insurance is so much better than last years...vastly better...but it is more money, quite a bit more. As I'm going through surgery/recovery, the much better but more expensive insurance is actually my preference. I started using it day 1 and they've written thousands of checks on my behalf to deal with my injury, and they've gotten 1 month's premium thus far from me. Quite a deal on my part. But, if I were healthy, I may have preferred the older, crappier, but cheaper pre-Obamacare insurance.

Personally, I like it! My new benefits are huge benefits given my circumstances, but I can understand why others may gripe.

But you always had the choice of a more expensive plan, right? With an individual policy if not through your company, although companies frequently offer multiple options.

Saying that people always had the option of more expensive plans through individual policies begs the question. In fact, many people in the real world could not find a company willing to sell them individual policies. That is why many states created high-risk pools and why several of these plans were over-subscribed and had waiting lists for coverage.

"In fact, many people in the real world could not find a company willing to sell them individual policies. "

This is due to government premium (price) caps. (They are usually a multiple of the premium of the least risky person on that plan.)

I just want him to dramatically shrink the minimum mandatory coverage. Let's get mandatory catastrophic coverage and ditch the rest.

This only works for moderate to high wealth individuals. Anyone in a family situation with a median income (e.g., $50K/year) quickly runs into financial problems if there are multiple health care problems in the family. A $10K copay with the catastrophic coverage is 1/5 of their gross income! Do the math.

The whole concept of the ACA is subsidized coverage based on income. Why would you think the copay will be the same for a family making 50k/year and a family making 500k/year?

But I was responding to your previous comment about ditching everything EXCEPT for catastrophic coverage. Most of the folks that I know who have gone this route have $10K deductible policies and are high wage earners. My point is that this does not work for the median family (and all those who are below). Look at what your pharmacy costs would be if you are paying out of pocket. I did this math a couple of years ago when my daughter, a mild asthmatic, graduated from college and went on her own health plan with a decent drug benefit program. Her out of pocket expenses alone for Rx was $1300/year on an income of $24K (entry level job). When you start adding in the MD appointments to that you start seeing the money go out of your pocket. this doesn't even cover a hospitalization event which can run up the bill quite fast. Anyone in the hospital for more than a couple of days hits the $10K deductible very fast.

Cash prices for prescriptions are typically on par with prices through insurance if not even lower. Yes, you have to ask for the cash price.

$10k deductible is not the norm. There are plans with $4k deductible, which is not crazy for a $50k income.

People with low assets also have the option of declaring bankruptcy and getting free care.

Of course the meaning of "catastrophic" will vary somewhat with income, which is why deductibles vary. Also premiums will go way down, which helps counteract the increased deductible.

Orange, apparently you don't know me. There is nothing in math that forces "catastrophic" to mean only catastrophic to a high-paid lawyer or consultant. Catastrophic is whatever is catastrophic for you at the time.

If you anecdotally only know people for whom this works because they are wealthy (and again, you apparently don't know me because this plan worked fine for me for years), all that means is that the market hasn't moved into the lower deductible zones.

I believe our deductible was in the $1000-$2000 range. Funnily enough, it still is even though I've since been forced into an old-style plan.

If the 10k copay for the 50k/yr family is a big problem then they can certainly purchase additional insurance beyond the "mandatory catastrophic coverage" that becon advocates for. If they aren't doing that already who is the state to say that they aren't spending their money correctly?

Nobody mentioned the elimination of the lifetime cap under the ACA. One of the more poignant moments at the Democratic Convention was the speech about the young girl facing her third open heart surgery sometime next year that would not be possible without the cap removal. When you add this in with the things already mentioned, the insurance companies cannot successfully underwrite without an expanded pool of insurees that comes in under the ACA. Romneycare in MA accomplishes this. I would love to hear in plain English what he and the Republicans plan to replace the ACA with. Repeal does not work if there is no replace and the average citizen who is already benefiting under the ACA knows this.

Contraception! Dumb sluts! Repeal!

There, now you've heard the Republican plan.

Pretty much explains why my two daughters are Democrats. :-)

So, what you are saying is that there are infinite numbers of open-heart surgeries.

As I've said every time I get the chance, under my plan you could donate your life-time cap space to your kids.

You guys really don't get why some people are uncomfortable with lumping subsidizing people's fornication with emergency care and heart transplants?

There is something a lot cheaper than babies and even contraception...not f----ing.

As it is now, Medicare and private insurance are obligated to pay for expensive and questionable medical procedures.

Heart Surgeons Kill First Man on the Moon: Neil Armstrong

Do you think Armstrong was incapable of weighing risks/benefits?

Just becuase there is a bad outcome does not support your claim.

The point I was trying to make is that third parties end up paying for questionable medical procedures, causing insurance premiums to be higher. What's needed is for Medicare or some branch of government to start drawing quality-adjusted life year (QALY) lines based on comparative effectiveness research. If the cost of a medical procedure exceeds its QALY, the insurance provider is not obligated to pay for the treatment. Big pharma in particular is fighting this. Could it be that they are afraid of a head to head comparison of aspirin vs. Plavix; or maybe doxazosin vs.Flomax? The opposition for this approach is disproportionally coming from Republicans. Could it be that the Republican party of today is in bed with big pharma?

Ha! Who supported ACA? The entire health care industry.

Yet every time efforts are taken to boost research into what works and what doesn't the Republicans are the first ones out of the gate complaining that this will only lead to rationing of care!

Yes. This has bugged me for a long time. Somehow, through the magic of markets, we are supposed to know which treatments work best and are more cost effective. Does not happen. We end up guessing and going with whatever treatment is in vogue or the one that the prettiest rep pushes. I cant sort this out w/o adequate research and my patients dont stand a chance of figuring it out. You usually only get one chance at a big procedure, chemo or series of tests.


Right, because all the research we do has nothing to do with what works and what doesn't work...

It usually depends on who is proposing the research. Say that an insurance company should be able to say your procedure isn't covered and see what Democrats do.

I've definitely been yelled at by Republicans for mentioning effectiveness research, too.

We really do need to stop doing things that don't work, but we are as determined to make that step as hard as possible for all of us.

So everything the Republican Party has been saying about the ACA has been lies and bullshit.

Why is anyone even considering voting for those dorks.

Romney =/= All Republicans

You didn't catch that the entire Republican primary process was saying this?

I would say he is preparing for a major fold on the issue.

But if he is saying this now, it means the campaign thinks that he can get swing voters by saying stuff like this.

Or else it means that he can't control himself.

There seems to be a common acceptance here that the primary cause of unwanted/unplanned pregnancy is that contraception is not affordable . I disagree strongly with this idea . It seems to me that ignorance and stupidity are far more common causes ,plus the idea that government will support your illegitimate child if you have one (or 6) . Paying people to do something is almost never a very effective way to get them to stop doing it .

So what you are saying is that if contraception were unaffordable and if there were no safety nets for starving children, then unwanted or unplanned pregnancy would decline? Yes, well the evidence bears that out. After all Ireland had so few unplanned pregnancies 150 years ago when there were no contraceptives or safety nets. Then with all the safety nets and free contraceptives, Ireland's unplanned pregnancies skyrocketed (correlated with rising birthrates overall).

Have you ever, in your entire life, even heard of someone who got pregnant because they could not afford contraception? The idea is absolutely bizarre.

Of course I have. Haven't you?

At 6 bucks a month?
(yes thats the price of generic, oral, hormonal contraceptives at Target)

You can buy those without a prescription? In what state?

"You can buy those without a prescription? In what state?"
(1) Prescriptions are a huge prohibitive cost?
(2) This is somehow our fault that the state requires permission for something it wants to give away for free?
(3) Who cannot get condoms in the bathroom without a prescription?

Maybe 50 cents is too much to ask for the cost avoidance of pregnancy and ruining a kid's life, but I cannot grasp why I should feel any compassion whatsoever for such people. So, work the implied eugenics angle a little harder.

(1) Prescriptions are a huge prohibitive cost?

Not sure if serious or just trolling?

(2) This is somehow our fault that the state requires permission for something it wants to give away for free?

Did I say that? Maybe this is a troll after all?

(3) Who cannot get condoms in the bathroom without a prescription?

Shifting goalposts! I'll wager you are just trolling. Goodbye

dirck, actually the only cause of a pregnancy is a sperm from a man fertilizing an egg from woman. Contraceptives reduce the odds of this fertilization. So yes, better access to more effective contraceptives would likely reduce the number of pregnancies (regardless of the modifying adjective). I don't want to make light of the behavioral responses to increased access to contraceptives or paint this as a cure all, but I also don't think calling people names is going to get them to stop having sex. But when you've got a pill that cures ignorance and stupidity (in all of us) then maybe I'll change my mind.

Don't you think unplanned pregnancies mostly result from choosing not to use contraception, not a lack of "availability" of contraceptives?

No Cliff, I don't. How many women have you heard of who pop their IUDs out before having sex? I am not saying that men and women don't sometimes make poor decisions regarding sex...only that better (read easier to use, more effective) contraceptives could help mitigate one of consequences.

The other aspect of the issue is that just like some people are too lazy to be bothered to look for a job, some women are too lax to consistently and correctly use birth control.

The issue is the same: short time horizons, low impulse control, and poor planning abilities.

At some level I sympathize for cognitive deficiencies like this. Nobody has control over what neurological equipment she's inherited. But we should call a spade a spade: unplanned pregnancies among unmarried women are inversely correlated with IQ. Put more bluntly - one of the strongest arguments for free contraception is that there's a whole lot of dumb people in America.

But I believe that this observation actually supports the values position. People of low intelligence and weak self-discipline can understand very simple moral principles like - no children out of wedlock - as long as there are social consequences to back them up. Instead we have political conventions from both parties praising single mothers and pretending that a widow or abandoned wife is the moral equivalent of a single woman with children from multiple men.

So, is it about compassion or eugenics?

My kid was unplanned because of a choice not to use contraceptives. So, for me it's 100%.

That's it you've crossed the line, Andrew'. How dare you use the "C" word in the comment section of this blog!

You know I actually put "compassion" in urban dictionary to make sure it hadn't sprouted a new sinister meaning. I was pleased to see it still means what I think it does. Don't get me wrong I think personal responsibility is important...more like a privilege in a lot of ways. But I simply don't get how it can exist in the world (with people) without some compassion. I am not asking for a sing-a-long here, but the "they-aren't-as-clever-as-me-so-they're-crap" barbs get old.

Well, duh. That would be like killing his own baby.

We need a Republican Congress first to prevent any shenanigans no matter who is in the WH.

The two main issues are pre-existing condition coverage and portablity of employer insurance. We don't need a health care industry takeover to accomplish that.

The ability to change jobs without losing health insurance coverage was guaranteed by HIPAA back in 1996-- if the new employer offers healthcare coverage which takes effect less than 60 days after employment. (There are employers who cheat on HIPAA by requiring a 90 day or longer wait for benefits for new employees)

By the way I don't see where the "takeover" come in under the ACA. That's just vacuous Republican rhetoric.

"That’s just vacuous Republican rhetoric."

So was "death panels" until Democrats (e.g. Krugman) started saying "well, of course we need death panels, who ever thought we wouldn't need death panels, silly?"

I'll make you a deal. When Democrats do anything that is not entirely conducive to a takeover of an industry, then I'll give them the benefit of the doubt.

"The two main issues are pre-existing condition coverage and portablity of employer insurance."

Actually, these are the same thing. If you buy insurance before your condition is known, you could own that option on care for that condition. Currently, the (government created and maintained) connection of insurance to employment makes it so that when you change jobs you reboot your care, losing that initial option you had with your last insurer.

It will be a while until my "medical procedure futures market" comes into being, but remember that the government screwed it up to begin with.

For many in the work force, there is no insurance available through their employer. For many others the insurance available is offered at a cost the employee can not afford with the wages paid. For other workers, wages and hours are set by the employer to insure the employee is covered by state Medicaid and the employee qualifies for SNAP. Fast food employees are offered inexpensive insurance coverage - but the insurance covers basicly nothing.

While states are doing their best to decrease the numbers on their Medicaid.

These are the people who end up in emergency rooms after waiting to long to seek medical care due to affordability, and who can not pay the emergency room bills.

He didn't say "people with pre-existing conditions can get any policy they want, any time they want, at the community price. He said people "with pre-existing conditions can get coverage".

Mittens has Flipped... Surprise !!!

"Romney Says He Supports Popular Obamacare Provisions On NBC, Quietly Reverses Hours Later On Conservative Website"

For a while Mitt will be trying to "run to the middle" and "fire up the base" at the same time. But that can't last for ever.
AS the race goes on he will concentrate on the base. By the last debate he will spout every lunatic Tea party/ neo con talking point there is. Just like McCain did.

Sorry Tyler Cowen, you are wrong. The game has not been played that way any more.

Predicting Romney would say something that he thought would win him an election? You should take those sharp precognitive powers to Vegas and clean up!

Here are more interesting questions that I don't know the answer to: Assuming a Romney win means Republican control of the senate, how much damage can they do to Obamacare on day one? Does the House leadership have enough control of the tea party to pass a substitute mandate? Would Democrats form a loyal opposition as they did under the early W years? Or would they embrace the Republican scorched earth tactics? How would either of those options affect the eventual policy?

That's only half of it. TC is saying that Romney is going to fully embrace ACA.

I hope he does. Libertarians in 4.

And may I remind you, I predicted Paul Ryan would be president. I wonder if a VP has ever run against the incumbent...

Thomas Jefferson ran against John Adams in 1800, but that was under the old, pre 12th Amendment electoral system where the runner up in the election became the VP. A Vice President has never run against the person who picked him or her to be Vice President.

Also, there is only one instance of a Vice Presidential candidate on a losing ticket going on later to become President (FDR, for the curious).

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