politics

Comey Memo: Jan 6.

691 Comments

The other comment thread is in the multiple hundreds. So, I thought I’d take notes on Comey’s memo to try and clarify things for myself.

As many of you know, I wouldn’t mind at all if Trump stepped down from office. DC seems to be a three or more ring circus right now with with potential villains in each ring. But the Comey memo and testimony is in the main righ right now. So I want to comment on that. This is not really any sort of analysis of what it all means. But I think it’s worth discussing what the claimed ‘facts’ are, and how they are presented. For now, I will just make some comments on the “Jan 6” meeting.

When commenting, I am keenly aware this a document Comey wrote; presumably he went over it carefully. So I think it’s worth nothing what he chooses to tells us, where what he does not tell us, and comment on structural aspect that might lead the reader to take a particular view of what the facts mean.

I will interlace comments; some points that strike me as important do so in context of things we learn or hear after the memo was published. Feel free to discuss.

January 6 Briefing
I first met then-President-Elect Trump on Friday, January 6 in a conference room at Trump Tower in New York. I was there with other Intelligence Community (IC) leaders to brief him and his new national security team on the findings of an IC assessment concerning Russian efforts to interfere in the election. At the conclusion of that briefing, I remained alone with the President- Elect to brief him on some personally sensitive aspects of the information assembled during the assessment.

Comey initiated a one on one meeting with the President to brief Trump, then President Elect.

The IC leadership thought it important, for a variety of reasons, to alert the incoming President to the existence of this material, even though it was salacious and unverified. Among those reasons were: (1) we knew the media was about to publicly report the material and we believed the IC should not keep knowledge of the material and its imminent release from the President-Elect; and (2) to the extent there was some effort to compromise an incoming President, we could blunt any such effort with a defensive briefing.

The Intelligence Community leadership thought the President Elect should be briefed about something.

The Director of National Intelligence asked that I personally do this portion of the briefing because I was staying in my position and because the material implicated the FBI’s counter-intelligence responsibilities. We also agreed I would do it alone to minimize potential embarrassment to the President-Elect. Although we agreed it made sense for me to do the briefing, the FBI’s leadership and I were concerned that the briefing might create a situation where a new President came into office uncertain about whether the FBI was conducting a counter-intelligence investigation of his personal conduct.

The Director of National Intelligence thought it appropriate and advisable for the Comey to meet one-on-one with the President Elect. Also, the “We” (which includes at least Comey and the Director of National Intelligence) appear to believe “minimiz[ing] potential embarrassment to the President-Elect” is good reason to have arrange one-on-one meetings between Comey acting as Head of the FBI and the President Elect.

Comment: One might imagine Trump would infer that since Comey initiated one-on-one meeting for a reason that seems good to Comey and the Director of National intelligince, there is nothing inherently wrong or inappropriate about one-on-one meetings between the head of the FBI and the President. In fact, as the briefing was attended by at least several members of the Intelligence Community, Trump, naif that he is said to be, might very well think that one-on-one meetings to discuss delicate matters were Comey and the FBI’s preference.

I’ll skip a paragraph describing how counter intelligence works which doesn’t seem relevant to the question of whether Trump did anything wrong.

This one may contain a relevant bit:

Because the nature of the hostile foreign nation is well known, counterintelligence investigations tend to be centered on individuals the FBI suspects to be witting or unwitting agents of that foreign power. When the FBI develops reason to believe an American has been targeted for recruitment by a foreign power or is covertly acting as an agent of the foreign power, the FBI will “open an investigation” on that American and use legal authorities to try to learn more about the nature of any relationship with the foreign power so it can be disrupted.

It’s worth nothing that this suggest that a person being under investigation by the FBI does not mean they are suspected of any crime or wrong doing. They might simply be a target for recruitment. So, one cannot assume that, Flynn, for example was suspected of a crime or wrong doing merely on the basis of being under investigation as a person. (Of course, he might be.)

Back to more specifically Trump-Comey stuff.

In that context, prior to the January 6 meeting, I discussed with the FBI’s leadership team whether I should be prepared to assure President-Elect Trump that we were not investigating him personally. That was true; we did not have an open counter-intelligence case on him. We agreed I should do so if circumstances warranted. During our one-on-one meeting at Trump Tower, based on President- Elect Trump’s reaction to the briefing and without him directly asking the question, I offered that assurance

People at the FBI thought it was important for Trump to know he was not under investigation. Comey proactively volunteered this information based on his interpretation of Trump’s reaction to the news about the salacious material. (We are not told what that reaction was.)

I felt compelled to document my first conversation with the President-Elect in a memo. To ensure accuracy, I began to type it on a laptop in an FBI vehicle outside Trump Tower the moment I walked out of the meeting. Creating written records immediately after one-on-one conversations with Mr. Trump was my practice from that point forward. This had not been my practice in the past. I spoke alone with President Obama twice in person (and never on the phone) – once in 2015 to discuss law enforcement policy issues and a second time, briefly, for him to say goodbye in late 2016. In neither of those circumstances did I memorialize the discussions. I can recall nine one-on-one conversations with President Trump in four months – three in person and six on the phone.

At this point, Comey tells us felt compelled to document the one-on-one conversation which he initiated. Mind you: this is a feeling and Comey said compelled rather inclined or something gentler.

Interestingly, if we look at the paragraph, Comey omits any explanation of why he felt compelled. Ordinarily one might infer that what follows is the explanation; that’s how people normally communicate. But that it does not appear to be an explanation. Here’s what follows:

  • Comey explains that documenting these conversations with Presidents was a new thing for him. So his feeling of compulsion was not just feeling compelled to follow his usual practices; this was a deviation.
  • Comey’s explanation about how unusual it was to have one-on-one conversations, his explanation that he’d had many one-on-ones with Trump that with other presidents.
  • It’s impossible to believe that the fact that the one-on-one meeting was unusual would be the reason Comey felt compelled to document it since Comey and the intelligence community set out to have this meeting in this way, and Comey initiated.

What we can learn from this bit of discussion is that Comey’s document gives the impression he started documenting for reasons that could not have been reasons for his feeling of compulsion. (He later gives a reason. I’m mostly looking at this document which I assume was crafted with some care. However, I am noticing this precisely because he does later provide a reason.)

Closing this comment on the Jan 6 meeting, I want to say something that’s important context of later discussions about “leaks”. Comey tells us he typed up the document while still in an FBI vehicle. It’s about a meeting he and the Director of National Intelligence (and possibly others) planned and agreed to. We know this went into a file at the FBI and written to have documentation that those at the FBI could see. The document would seem “work related” to me.

691 thoughts on “Comey Memo: Jan 6.”

  1. No memos of Obama meetings. How about when Lynch told him to call it a ‘matter’ and not an ‘investigation’?

  2. Did Lynch tell him that in a meeting with Obama? I haven’t read that. We aren’t given details describing other circumstances when Comey decided to take notes and what distinguishes the ones where he doesn’t. We know that in testimony, the apparent reason why Comey took notes is he thinks Trump was likely to lie.

    That may well be the reason Comey wrote memos.

    We don’t know why Comey thought Trump would lie about this meeting which Comey initiated. In fact, we don’t even know when Comey made the decision he would be writing memos to file. For all we know, he “felt” the compulsion before the Jan 6 meeting, and had made the decision to do so the moment the Intelligence Community decided Comey would be meeting with Trump alone.

    Given Trumps ehrmmm… communication style, I could well imagine that many people would want to take notes of one-on-one meetings and decide to do so before meeting with them. The “feeling” Comey had might be based behavior every single person in the world has seen and nothing to do with anything Trump did during these meetings. It certainly can’t be because the meetings are “one on one” or anything like that.

  4. MikeN,
    I don’t know if Comey wrote up this troubling incident. Comey hasn’t told the world. You’ll have to ask Comey, wait for the Justice department to find out, or wait for the special prosecutor report. We can’t be sure they’ll ask those questions so we may never know.

  5. It is the overall literary style of Comey’s cya memos that stand out as red flags to me. We know he is a leaker. We know he rolled over multiple times to do inappropriate things that helped democrats. And we know that he set out to get an indie counsel appointed for personal reasons. His toying with the President over the Russian (actually domestic spying and illegal leaks)issue was deliberate per his own words. No wonder he would like to avoid the judiciary committee.

  6. hunter,
    Yes. The issue of “literary style” will become more evident as I move discussion of later days.
    We see a little of the tendentious style here. Consider this:
    He placed the discussion of the frequency of one-on-one meetings IN the paragraph where he tells the reader he “felt compelled” to take notes. But that frequency could not have had anything to do with his feeling of compulsion.

    In terms of “explaining” what happened, it would make more sense to put the discussion of the frequency of one-on-one meetings near the discussion of the decision by the intelligence community, Comey and the director of national security to have a one-on-one meeting on January 6. He could then explain why everyone thought they should do this despite the fact that everyone thought it violated protocol. (In fact, I suspect everyone did not think it violates protocol.)

    He might also tell the reader whether he told Trump that one-on-one meetings were the exception rather than the rule during that first meeting.

    But instead, the organization is such that it makes it sound like somehow Trump is the one pushing for all these one-on-one meetings despite the great reluctance of Comey and the (evidently somehow obvious) violation of protocol involved. Worse, Comey evidently assumes nefarious motives when Trump arranges one on one meeting on Jan 27. But Comey didn’t seem to think he or intelligence community or so on had nefarious motives when they sheduled similar meetings. So it seems odd for Comey to think one-on-one meeting suggests “nefarious motive”.

    I’m not convinced Comey really thinks there is anything wrong about such meetings. He clearly thinks its fine when he arranges them. Sure, they may be infrequent. But likely as not because there is no reason for them. For example: I bet Trump will never schedule a one-on-one meeting with me. Why not: Because neither of us has any business or personal reason for any meetings at all, and certainly no one-on-one meetings. So, it won’t happen. Yet, if something happened where suddenly there was a legitimate reason, there might be such meetings.

  7. Lucia, I agree that Comey evaded specifiying the reason for starting the notes with the meeting he arranged (if he is being honest about the timing). He is avoiding stating the obvious: he either distrusted Trump or he was actively working against Trump, or both. The distrust would be that Trump would later characterized something in the meeting as a reason to fire him and thus making CYA attempts. But as Comey stated publicly after being fired, the President can fire the FBI director without a reason. And the Dems had already called for his firing. So Comey was serving completely at the pleasure of Trump.
    .
    So the meeting Trump set up was to feel out Comey. Was he loyal? Trump may have had his suspicions from the fact that no leakers had been caught and the leaking was unabated. Also, Comey had neglected to mention if Trump was under investigation. I think when Trump found he was not, and that Comey was allowing the press and the country to believe he was, that was the straw that broke it. Trump counted the three times he got that answer. At that point he knew that Comey was not loyal. Trump would have been pretty dumb then to ask Comey a favor on Flynn. What is Comey agreed? Trump wanted to fire him but then couldn’t without expecting retaliation for ingratitude.
    .
    Trump may have not been smart enough to tape the conversation. And, he may have even let Comey know to ease up on Flynn would be a demonstration of loyalty, but not if Trump had no doubts about getting rid of a already known to be disloyal subordinate. It doesn’t make sense.
    .
    I am hoping that when Priebus popped his head in to see if he could come back in, it was really a cover to slip in his cell phone on record mode. –just a good vision to drift to sleep by.

  10. Ron,
    Generally, I wouldn’t consider the President taping wise. Under the specific circumstances that have arisen, taping conversations with Comey might have been wise. However, it’s not generally wise for the US President to be routinely recording conversations.

    I don’t so much wish them to exist because I think it would have been smart for Trump to make them. I hope the exist because… well… I want the “bug under the table” view of this conversation.

    There are an awful lot of things in Comey’s version of the Jan 27 meeting that are favorable to Trump. For example: Trump requested an escalation of the investigation into Russian. Comey counseled against it and Trump suggested he’d think about Comey’s view and suggested Comey continue to think about it.

    This suggests Trump didn’t want to cut the Russian investigation. His disagreement with Comey was that Comey wanted to go slow and let it continue over a long time.

    Another thing is that if we look at the order of statements:

    1. Trump enquires whether Comey wants job.
    2. Comey says yes, and simultaneously (a) reminds Trump it’s a 10 year appointment, and (b) volunteers he is “unreliable” and “not on Trumps side”.
    3. Trump says he needs loyalty.

    Now Comey tells us his motive for 2. It’s based on his assumption about Trumps motive for (1).

    But there could be many motives for Trump’s 1 ranging from “innocent” and even to “not so innocent”. I can think of around 5 plausible ones. If Trump had any of the motives I thought of, Comey’s suddenly announcing he is not “reliable” and that he is not on Trump’s side would likely have taken Trump aback.

    It seems to me Comey seems pretty bad at reading Trumps reactions to information but is also in the habit of assuming he is good at reading people, including Trump.

    But if Trump was taken aback by Comey — his subordinate when it comes down to it– telling him he was “unreliable” and “not on his side”, Trump’s bringing up his need for “loyalty” takes a bit of a different slant. It’s not so much of a request for an “oath” as it is a counter statement to a person who has just practically told him he has no intention of being “reliable”!

    And bear in mind: Comey tells us this is the order. Yes, he tells us what he interpreted all this to mean. But that order of statements is subject to other interpretations. Comey’s interpretation does not strike me as the most natural one. It’s just Comey’s.

    Given Comey’s behavior in 2016, and the fact that Comey is the one who initiated one on one conversations and the fact that he’s doing all sorts of leaking and so on… Well…. I’m just not very prone to assuming Comey’s reactions– which seem to amount to be to things he reads between the lines– things which may not even be there– are the most reasonable ones. I’m not even sure they are in the vicinity of reasonable.

    If I heard the tape, I might change my mind. Or not.

  11. I suspect Comey made no blatant lies since he was warned there could be a tape. But my reading is that Trump was suggesting that if it were the case that he was not personally under investigation then it would be really appreciated if Comey would let that out, and that point was repeated on several occasions. Of course, Comey’s rationale for not stating that, when the media was assuming it so, is very weak. Comey’s logic for not pursuing that origin of the false dossier is also weak. Trump has to know Comey is undermining him. He may have tried to use logic that if Comey himself had worked with Flynn and new he was a patriotic man of good character why in the world would he want to support and prolong the media defaming of Flynn as a colluding with Russians?

  12. I sure wish a Senator asked Comey point blank if he had ever before leaked information to the press. Almost certainly he did, but his inevitable “no” response would be grounds for prosecution for perjury when his earlier leaks become known.

  13. “… if he [Comey] had ever before leaked information to the press.”
    Add: Or, encouraged anyone else to leak.
    .
    The NYT logic for sticking by their story of Feb 14 is that it’s well known that Russia uses persons in all professions and positions in the government to work for their IC, (as likely does the USA and many countries). This means that any contact with a Russian is suspect as a potential for recruitment. So under this definition every administration that had back-channels of communication set up with an adversary should have been suspect for recruitment. I think the NYT reporters and editors should know better. And I think Trump was trying to make the point to Comey that he should know better as well in regards to Flynn.

  14. Here is Newsweek’s Jeff Stein’s reporting. It’s like he saw a completely different hearing and was out of the room when Comey said the NYT Feb 14 article was almost completely untrue. Stein is still full steam ahead on the theory that Trump colluded with Russians to hack our democracy.
    .
    It’s telling that none of the MSM ever theorize that we might expect to see Trump helping Russian interests, as their theory would logically predict. I don’t have any other explanation for their reporting then other than intentional dishonest propaganda. And, if that is the case they are indistinguishable from a party organ. If that is the case then it is they, posing as an independent press, who are hacking our democracy.

  15. Did Comey leak his first memo of meeting with Trump, in January? It looks like only the one where Trump asked for loyalty. It is reasonable for Comey to make notes, after being pressured to drop an investigation. What led him to make the first memo? He just assumed Trump is a liar and he needs to write it down, or he’s been doing it all along, and lied about it to the Senate, or something else?

  16. SteveF,
    Comey has testified under oath he has never leaked anything. This occurred in the just the past few months, but I believe it was before he leaked the memo.

  17. Ron Graf,
    If the Russians attempt to contact the Democrats, Russians are bad and need investigated. If the Russians attempt to contact Republicans, Republicans are bad and need investigated.

  18. Lucia,
    “Worse, Comey evidently assumes nefarious motives when Trump arranges one on one meeting on Jan 27. But Comey didn’t seem to think he or intelligence community or so on had nefarious motives when they sheduled similar meetings.”
    .
    This is a very interesting point. Comey/media tried to paint a picture that ANY one on one meetings were suspect and inappropriate.
    .
    Comey was obviously wary of being in the orbit of Trump as this can end badly and be career damaging regardless of if you are a boy scout or not. And it did end badly and will likely be career damaging. So he did some CYA and I don’t find the fact he wrote stuff down to be unreasonable due to the “Trump Factor”.
    .
    But the Trump Factor cuts both ways. If Trump reasonably suspects many people, friend and foe, are CYA’ing to get condemning information on him, it is reasonable to query about loyalty and get a feeling whether he can trust them to not knife him in the back.
    .
    It was evident to everyone with the lead up to inauguration that many government bureaucrats were going to actively work against Trump and wear it on their sleeve as a badge of honor. We can call this another self inflicted wound of Trump, but only partially. If you don’t like your boss or company’s direction you can resign. Unilaterally sabotaging an effort is simply dishonorable. The electorate chose their somewhat irrational path forward and that needs to be respected, period.

  19. Tom Scharf:

    Comey has testified under oath he has never leaked anything. This occurred in the just the past few months, but I believe it was before he leaked the memo.

    I think you’re referring to the testimony on May 3. I went back and looked. Here’s the full transcript.

    I believe this is the passage people are referring to:

    SEN. CHUCK GRASSLEY: Director Comey, have you ever been an anonymous source in news reports about matters relating to the Trump investigation or the Clinton investigation?

    JAMES COMEY: Never.

    GRASSLEY: Question two, relatively related, have you ever authorized someone else at the FBI to be an anonymous source in news reports about the Trump investigation or the Clinton investigation?

    COMEY: No.

    GRASSLEY: Has any classified information relating to President Trump or his association — associates been declassified and shared with the media?

    COMEY: Not to my knowledge.

    The question is whether he had been an “anonymous source”. Assuming there aren’t other occasions where he leaked information, that answer was completely truthful.

  20. Tom Scharf:

    If the Russians attempt to contact the Democrats, Russians are bad and need investigated. If the Russians attempt to contact Republicans, Republicans are bad and need investigated.

    That’s from the left-wing media. From the right-wing media, it’s even worse:

    “If the Russians attempt to contact the Democrats, the Democrats are bad and need to be investigated for collusion. If the Russians attempt to contact Republicans, the Democrats are bad and need to be investigated for leaks.”

  21. Carrick,
    I’m sure there is truth in their somewhere, ha ha. If the Russians are trying to sow discord in the US, they are doing a great job.

  22. With respect to dumping on Comey, it is entirely possible he knows some things we don’t, so his Trump paranoia may be more founded than we realize. Time will tell.
    .
    The other side is how fantastical it is that the Russians would contact team Trump and they would effectively respond “Sounds like a great idea, they are trustworthy, how could this possibly go wrong?”.
    .
    I could envision the remote possibility that Russia told Trump they would give him some money to run for President at the start (I don’t think this is even illegal amazingly enough) and Trump thinking he had no chance and could use the opportunity to have a little bit a fun, said “why not?”.

  23. Carrick, that line of questioning doesn’t eliminate the leak that Comey made, since he went thru someone not at the FBI.

  24. MikeN—Exactly. My point was just that the question to Comey was quite narrow in scope.

  26. The question now is if Comey shared any work info with his Columbia professor friend Daniel Richman before May 3. And, if Richman is brought to testify and takes the 5th on any of the leak questions Comey and he are toast — comeytoast.

  27. Carrick

    Interesting. If we are going to do parsonomics about what *literally* is true lets have fun!

    SEN. CHUCK GRASSLEY: Director Comey, have you ever been an anonymous source in news reports about matters relating to the Trump investigation or the Clinton investigation?

    JAMES COMEY: Never.

    In the later leak we know of, he used his friend as a go-between. So one might say COMEY was not the anonymous source of the information of the news report. His friend was.

    Someone else might say, bunk. Comey wsas the source. Here what is true depends on how we define who precisely is the “source” of materials for the news story. Is it the person who gives it to the news media (and who might, in fact, have forged it)? Or is it the person who gave it to his friend who gave it to the news media? I actually don’t quite know. I think if we end up having to parse stuff like that we are going to go back to “what the meaning of is, is” territory.

    GRASSLEY: Question two, relatively related, have you ever authorized someone else at the FBI to be an anonymous source in news reports about the Trump investigation or the Clinton investigation?

    COMEY: No.

    In the leak we know of, Comey did not authorize anyone at the FBI to be an anonymous source.

    GRASSLEY: Has any classified information relating to President Trump or his association — associates been declassified and shared with the media?

    COMEY: Not to my knowledge.

    The material that got to the media through Comey’s friend was not classified.

  28. Lucia, I agree with your points—I was responding to Tom Scharf’s comment “Comey has testified under oath he has never leaked anything” that what he testified to was much more ambiguous than this.

    Also, there have been reports on right-wing media (which I generally monitor) which claim that Comey perjured himself. I think that would be a very tough case to make here.

  29. Carrick, from what I’m hearing in the media is “if the Russians are paying democrats for favors it obviously the Republican partisans who need to be investigated. If the Russians approach any Republican then Trump needs to be impeached. By the way in at least part of his testimony Comey is documented as deceptive. He did take notes of meetings with other Presidents, apparently.

  30. OK, another post from the gutter. I apologize in advance. This is pretty funny. Student wears a Trump MAGA shirt to photo day, somebody Photoshop’s it out for the yearbook. (and a couple other edits). Teacher gets suspended.
    http://www.cnn.com/2017/06/11/us/trump-high-school-yearbook/index.html
    .
    Amazingly this one went viral. CNN / NYT / WP / ABC. This is small potatoes in the grand scheme and people probably ought to turn the outrage meters down from 11.

  31. Hunter—I’d be really surprised if you considered the media who you perceive as saying those things as either reliable or as your primary source of information.

    if you corresponded with some of the journalists (in a respectful manner), I think you might be surprised how often your reading of them is more shrill than their intended meaning. I mean for this time apply to any person viewing articles from an opposing “camp ” and not just you personally.

    Comey created memos when he was Deputy Attorney General. There’s the memo in the Ashcroft meeting for example. I believe memos are a standard practice in fact, and not just for Comey for preserving conversations when no other recording is present.

    It could be on the limited meetings with the other presidents, that generally the meeting were being taped as a matter of course. Either way, I don’t think it’s necessary to view the creation of memos in this case in some ominous fashion, like the leftwing media are doing—different circumstances warrant different methods.

  32. Carrick
    I wasn’t meaning to agree or disagree. I saw the quote and things struck me.

    Also, there have been reports on right-wing media (which I generally monitor) which claim that Comey perjured himself. I think that would be a very tough case to make here.

    I agree. I haven’t seen any evidence of he perjured himself.
    Going forward, I doubt we are going to find evidence he perjured himself. (Or at least nothing that counts as evidence unless you look at it seven ways to Sunday to find an interpretation that’s a lie. But the other 6 ways won’t be lies. That makes it pathetic evidence.)

  33. Tom,
    I’m not entirely surprised that went viral. It’s got lots of things people yap about:

    1) Freedom of speech
    2) Dress codes.
    3) Teacher’s arbitrary rule making.
    4) Administration treatment of teacher.
    5) Trump.

    The only thing missing is “common core” or “charter schools”!

  34. Carrick

    I don’t think it’s necessary to view the creation of memos in this case in some ominous fashion, like the leftwing media are doing—different circumstances warrant different methods.

    In fairness to hunter, the main thing that makes the creation of these memos to file sound ominous is the way Comey presents it with all the discussion of his “feelings”.

  35. lucia:

    In fairness to hunter, the main thing that makes the creation of these memos to file sound ominous is the way Comey presents it with all the discussion of his “feelings”.

    Yes, I came away that Comey was framing the memo writing activity itself as being somewhat ominous. There is absolutely nothing that I’ve seen that suggests that actually is so.

    hunter suggests that Comey was “documented as being deceptive”. Honestly, I think he’s at a meta-layer above simply “deceptive”. It’d be hard for me to put my finger on it, other than saying “he’s being a sleazy little weasel.”

  36. Carrick,
    I don’t think I agree ” Comey was “documented as being deceptive” “.
    I do agree with “sleazy [] weasel”. At 6’8″ he’s perhaps a very large weasel.

  37. From Wikipedia, “Weasels vary in length from 173 to 217 mm (6.8 to 8.5 in).” Comey is therefore an order of magnitude larger than a typical weasel.

  39. Lucia,
    “At 6’8″ he’s perhaps a very large weasel.”
    .
    That much is clear. If a high Federal government employee, like Comey, clearly disagrees with his/her boss (AKA Trump), then the reasonable thing to do is resign. What makes Comey a worm is the hystrionics absent resignation. Let it go dude. Trump is elected, and you are not. If Comey is caught in any earlier ‘leaks’ then the guy is toast (in a criminal sense)… as well he should be.

  40. Lucia, HaroldW… you are both correct.

    I should have said that Comey is a Weasel Of Unusual Size (WOUS, pronounced “wuss”). I’ll strive to be more careful. :-/

  41. Carrick and lucia, thanks for the insights. Yes Comey is much more than deceptive. We are witnessing a carefully orchestrated show trial American style. First the public trial and conviction, then the investigation, then the “discovery” of the crime.

  42. Carrick –
    If Comey is a WOUS, does that imply that Trump is trying to drain the Fire Swamp?

  43. The true lesson of Comey: Demand the resignation of every political appointee on January 20, effective immediately, no exceptions.

  45. NBC is taking heat for a Megyn Kelly interview of Alex Jones to be aired. I am guessing the point was to expose Jones as a conspiracy nut since he apparently is. According to reports Jones not only believes that 9/11 was an inside job, he also says Sandy Hook was staged. But NBC did not consider the families of the dead children and there is a backlash against NBC, which there should be. The question is who is worse, Jones, or NBC who is trying to cause a backlash against the far right by attacking their most extreme pundit’s most extreme theory?
    .
    My feeling is that Megyn Kelly could have been put to better use. Jones is like the National Inquirer. There is no need to put a microscope on it. It smacks of Lewandowsky. The story they are trying to tell is that all conservatives are conspiracy nuts.

  46. Mueller employing investigatory staff with ties to Democrats is an absolute joke. See http://www.lifezette.com/polizette/robert-mueller-stocks-staff-democrat-donors/ One of the worst hires is Jeannie Rhee, who was a lawyer for the Clinton foundation. In this highly charged environment none of the staff lawyers should have either Democratic or Republican ties. Simply amazing brazenness to hire someone who worked for the Clinton foundation and effectively Hillary Clinton. If this is going to be a clean investigation devoid of politics, Mueller can’t find nonpartisan lawyers or investigators. Just ridiculous.

    He apparently is so arrogant that he doesn’t even make an effort to appear fair.

    JD

  47. Ron Graf,
    It is standard partisan protocol to always interview the biggest bozo you can find on the opposing side. “To see what Trump supporters think, we interviewed Jethro (wearing a Confederate flag shirt) at a WV Walmart”, “To see what Clinton supporters think, We interviewed Dr. KnowsEverything (wearing a bowtie) at Harvard”.

  48. I am kind of fed up with the perpetual outrage by both sides about how one mustn’t be exposed to Alex Jones, Trump murdered as Julius Caesar, Kathy Griffin, etc. The answer is to let everyone speak freely and let the market decide. It’s all fun and games to hold the left to their own “tolerance rule book” but I don’t like that rule book.
    .
    It’s a bit more complicated of course, there needs to be social boundaries, but people should be given the benefit of the doubt when challenging those boundaries. Every time someone does something a little bit edgy there is no need to call for national boycotts and have corporations start making social decisions every ten minutes. We end up with the lowest common denominator of acceptable discourse.
    .
    I favor a very wide Overton window, not a very narrow one.

  49. Tom, our lefty friends are systematically seeking to silence all on the right by defending the advertising revenue and imposing so-called “net neutrality”. If a play had been made showing a truth commission trial of Obama showing his cynical lies and deliberate dismantling of American defense and support of Islamic terror that ended with him being marched to say a scaffold how would that go over? Yet killing Trump as Caeser is great art. ]

  50. The right does not want to enter the victimhood Olympics with the left, it only feeds that insanity. The left are professional victims, the right are amateurs.

  51. Ron, I was watching a broadcast channel, RT(Russia Today?), and had Alex Jones hosting a show. I thought I’d watch and see what the fuss was about. Seemed kind of outlandish with the defenses of Trump. What was really surprising is it turns out the host was Ed Schultz who was an Air America host, not known for having on both sides.

  52. JD, perhaps Trump is taking a page from The West Wing, and got his investigators to be as biased as possible to make them easy to attack?

  53. MikeN, if I were Jones I would get a clue when the far left is interested in offering a spotlight.
    .
    Tom, I agree the way to determine the value of ideas is the free marketplace. There is no need to ban the National Inquirer or tabloids. I suppose the worry is that conspiracy theories can be a form of hate speach like Holocaust denial theories. Rudolph Hess, the deputy fuhrer, believed that the Jews had supernatural powers to hypnotize (mass mind control) until his death in 1987. If the speach goes so far as to directly incite violence then yes it should be censored. Anything less should be met by counter speach. But I suppose in today’s propensity for compartmentalized information exposure people block out hearing the other side.
    .
    Schools could do a better job of prioritizing making student skeptical and able to vet information and viewpoints. Unfortunately, I think they are going the opposite direction.

  55. Tom,
    The great thing about greens is that they are utterly disconnected from reality and immune to learning. Eg… the world’s greenest and weirdest country, Germany, decommissioned its nuclear reactors and (shockingly) its CO2 emissions are rising. California (the greenest and weirdest state in the nation) is doing their best to follow suit. Does Germany’s experience make them think a bit? Heck no and ‘lights out’… unless CO2 emissions increase, of course.

  56. SteveF, for religious environmentalists the goal isn’t lower CO2 emissions with cleaner energy, but less energy.

  57. MikeN,
    Yes, I know that, but some really are shocked (shocked!) when they discover people expect the lights to stay on.
    .
    The ultimate goal of the truly religious environmentalists is a dramatic reduction in total human population; I have read claims of “sustainable” population ranging from not more than a hundred million to not more than 1 billion worldwide. IOW, a reduction of >85% to >98% compared to today. They really don’t like people very much.

  58. Curiously the people who asked the most probing questions to Sessions about Russia were Republicans. The Democrats seemed to want to know about Comey. Russia is looking more and more like it is going to go out with a whimper as far as Trump collusion goes.

  59. Off Topic Chemistry Question: My 11-year-old daughter loves to make slime (clear Elmer’s Glue and Starch — Something like silly putty). She had some left over watery slime and put it in the bathroom sink. I ran water in the sink and the bathtub for about 10 minutes. Doesn’t seem like anything is clogged. Should I worry about the glue hardening? Is there anything else, I should do to make sure the glue doesn’t clog my pipes?

    Thanks for any help that can be given.

    JD

  60. JD,

    Sounds to me like you did the right thing. My guess is that you’ll be OK.

    If there is a problem, I think that acid would dissolve the slime by breaking the cross links and turning it back it polyvinylacetate (Elmer’s glue) and boric acid. Vinegar might be strong enough; you could try it on a small sample of slime. I’d be reluctant to put a stronger acid down pipes.

  61. JD Ohio,
    Elmer’s glue is an ’emulsion’ of polyvinyl acetate, a polymer that is insoluble in water (the generic term is a PVA glue). The individual particles are separated by water, and repel each other due to surface active materials on the particle surfaces, the most common of which is a water soluble polymer called polyvinyl alcohol. Adding borax (or water soluble starch) causes the formation of weak bonds between polyvinyl alcohol molecules, so the whole emulsion ‘gels’ (becomes a semi-solid). When you add some water to Elmer’s glue the particles become much further apart and the viscosity falls rapidly. The hardening process with this kind of glue is due to evaportion of water… when the water is gone the particles can’t avoid each other and stick (irreversibly) together, forming a solid. so long as your drain pipes don’t dry out (they don’t!) you are in no danger of clogging your pipes. It is the same as cleaning paint brushes used with water based (latex) paints… also polymer emulsions. 😀

  62. Mike M,
    If the drain pipes are PVC, even very strong acid (eg 20% HCl) would be OK. I’ve done it lots of times to clear calcium carbonate and calcium soap scum from drain pipes. If they are metal the strong acid could cause damage…. but metal pipes haven’t been used for waste water for a very long time.

  63. Mike M & Steve F — Thanks for the insights on the glue. Originally almost used Liquid Plumr, but I checked on Elmers Glue and when I noticed that it bonded only when dry, I decided to run the water.
    JD

  64. SteveF: “but metal pipes haven’t been used for waste water for a very long time.”

    That is a dangerous assumption. Many building codes still have restrictions on plastic pipe, especially in multistory buildings. There is also a lot of legacy piping in use. Just because you look under the sink and see plastic does not mean that there is no metal further down.

  65. They sell concentrated sulfuric acid at the local hardware store for cleaning drains. That seems overkill to me, not to mention the danger. The heat of dilution for sulfuric acid is pretty high.

  66. Mike M,
    Yes, there are still a few states where there are restrictions for buildings more than 2 stories tall… many of these regs fall in the general category of “plumber’s protection rules”. When I built a house in Pennsylvania in 1978/79, the local inspector (a retired plumber) started out insisting everything in the house be done in metal ‘by a licensed plumber’. It was only when I produced a copy of the state regulations (plastic was allowed, and do-it-yourselfers exempted from licensing rules) that he relented… but was obviously unhappy about it.
    .
    I suspect JD can look at his pipes and figure out if they are metal or PVC. Unless he lives in a very old house or a high-rise building, I would guess a 95% chance they are PVC.

  67. I saw a documentary that stated a big part of the problem in Flint was that the water wasn’t properly balanced and it was effectively dissolving built up deposits in the small lead pipes from the water main to the houses. The water wasn’t leaving the water plant with lead.
    .
    It appears there was a pissing match with academics about the proper way to test the water. If you ran the water for several minutes as the first test protocol stated (thus flushing the small pipes) the concentrations were much lower. An activist water academic from VT did most of the work uncovering the scandal. He appears to be very biased, but may have been quite right.
    .
    Ultimately there is an additive to the water that maintains the chemical pipe build up and when Detroit switched water supplies it didn’t add this in. If it is not clear enough, I’m not a chemical engineer, ha ha.

  68. GOP baseball shooter James T. Hodgkinson Facebook:
    “Trump is a Traitor. Trump Has Destroyed Our Democracy. It’s Time to Destroy Trump & Co.”
    https://www.washingtonpost.com/local/public-safety/law-enforcement-officials-identify-shooter-at-congressional-ballgame-as-illinois-man/2017/06/14/ba6439f4-510f-11e7-91eb-9611861a988f_story.html
    .
    The media is going to have an absolute field day with this one. I only hope they take time to look in the mirror.

  69. Tom Scharf,
    ” I only hope they take time to look in the mirror.”
    .
    They don’t own that kind of mirror.

  70. Tom Scharf,
    “..water wasn’t properly balanced and it was effectively dissolving built up deposits in the small lead pipes from the water main to the houses. The water wasn’t leaving the water plant with lead.”
    .
    The missing additive was phosphate, which was added to the Detroit treated water Flint had been using for many years, but not added when Flint switched to its own water supply (they didn’t want to pay for Detroit’s water). Phosphate deposits on many metals and reduces/eliminates corrosion. Without phosphate, lead in the pipes began dissolving into the drinking water. See: https://www.acs.org/content/acs/en/pressroom/presspacs/2016/acs-presspac-february-17-2016/the-chemistry-behind-flints-water-crisis.html

  71. Tom Scharf: “The media is going to have an absolute field day with this one.”

    If it had been some right wing kook shooting Democrats, the media would have enthusiastically blamed it on Trump and the Republicans. Since it was a lefty shooting Republicans, they will have to shift gears and blame it on Trump and the Republicans, but with rather more effort as to why.

  72. Hilariously The Atlantic describes the above FB post as: “In one, Trump is described as a “traitor” who “has destroyed our democracy.”
    .
    Then it doesn’t even mention the “It’s Time to Destroy Trump & Co.”. Words fail me.
    .
    Sanders is already doing damage control, this guy was a big Sanders fan.
    .
    The combination of free speech, easy access to guns, and a very volatile and toxic political atmosphere combine to push some crazy people near the edge over the edge. Similar to terrorism it’s the price we pay sometimes for a free and open society. I propose we change nothing, but that seems to be the least popular opinion at the moment. It’s a good thing this guy was a poor shot.

  73. Mike M,
    One could become quite cynical when comparing reactions of the media and sometimes the same authors with this and the Giffords shooting. The left is going to forget all about hate speech and the right is not even going to acknowledge a gun was used (except by the police, ha ha). Rinse. Cycle. Repeat. There will be 12 seconds of unity and then everyone will run to their side and load up on grenades. 12 seconds of unity is better than nothing.

  74. Tom,
    “Then it doesn’t even mention the “It’s Time to Destroy Trump & Co.”. Words fail me.”
    .
    Not me… they are utterly dishonest.

  75. It’s not even subtle anymore. Our lefty friends have created the climate of hatred over Republicans in general and Trump in particular. They have fabricated the Trump is a spy bs. They have worked to delegpitimize this election. Now mentally ill fringers are taking to deadly violence and targeting Republicans. Eff them.

  76. Putin must be more powerful than I thought if he can elect the American President, despite all the American three letter agencies listening in. LOL.
    .
    Lucia, “I wouldn’t mind at all if Trump stepped down”
    Be careful what you wish for. The war mongers are keen to see Pence take over.

  77. Trump stepping down due to pressure from this coup attempt guarantees much worse outcomes in the future. Sadly we gave to fight this.

  78. Adrian

    Be careful what you wish for. The war mongers are keen to see Pence take over.

    I continue to not mind if Trump stepped down.

  79. The Democrats and the FBI have formed investigative committees to link today’s shootings to THE RUSSIANS. Among the evidence they cited is repeated denials that this had anything to do with the Russians, and assertions there is no evidence to support Russian involvement, which they believe sounded very suspicious. Clearly everyone distancing themselves from this linkage points to a widespread conspiracy and a cover up. The big question is what did Trump know and when did he know it? They cited false flag operations are common and the shooter was so evidently anti-Trump that it is laughable this propaganda could be authentic. Russian white supremacy is more likely the cause based on the indisputable fact that the assailant was white and he thought the victims were black because the sun probably got in his eyes. Several people who disputed these allegations were immediately labelled racists and sent voluntarily to cultural sensitivity training camps in handcuffs and leg irons. They also stated that any other theories weren’t worth investigating because the assailant is “conveniently” dead. Several members of congress have justifiably called for impeachment because….well just because. In other news Hillary Clinton is now stating this shooting is why she lost the election.

  80. If Trump is impeached, then are Democrats a lock for winning the next election, or is it more favorable for Republicans?

  82. MikeN,
    He is not going to be impeached.
    .
    There are lots of practical reasons having to do with the makeup of Congress. But there is even a simpler reason: he didn’t commit high crimes and misdemeanors… save for in the fevered imaginations of crazies who want to shoot conservatives….. along with all the folks at CNN and the NYT. But I repeat myself.

  83. Mike M.: Since it was a lefty shooting Republicans, they will have to shift gears and blame it on Trump and the Republicans, but with rather more effort as to why.
    .
    If it’s a leftwing nut then the MSM blames GOP for their insensitive policies. If it’s a rightwing shooter then it proves rightwing = insane. If it’s Islamic then it’s denied to be Islamic motivated until it can’t be, and then it’s GOP insensitivity. All shootings are because GOP supports NRA. If shooter was anti-second amendment it proves that guns turn peacenics into maniacs.

  84. If Trump is impeached for trivial reasons and it is seen as unjustified, then the emotional energy will shift back to the right. If Trump does something legitimately awful, then the left will retain the emotional advantage.
    .
    Seeing as how it takes 2/3 of the Senate to convict and 2018 is unfavorable to the left, Congress removing him from office seems remote unless Trump starts smoking crack during press conferences.
    .
    It’s pretty clear the left will overplay whatever cards they have possibly resulting in self sabotage such as what happened today.

  86. Trump impeachment means Republicans are on board. So either he did something very bad, and Republican image is hurt and Dems win, or Republican officeholders abandoned Trump and Trump voters will feel betrayed and Dems win. In the latter case, there is the possibility that Trump runs again and wins again.

  87. It was good to see AT Sessions stand up for himself yesterday. But again it’s not over.
    .
    When Comey testified he knew Sessions would need to recuse himself and thus he reasoned there was no use in approaching Sessions about Trump queasiness. But look at the Timeline:
    Feb 14 — Meeting where Trump brings up Flynn.

    Feb 15 — Comey discusses his deputies whether they should ease up on Flynn and decide not to.

    We concluded it made little sense to report it[Trump’s comment that Flynn was a good man] to Attorney General Sessions, who we expected would likely recuse himself from involvement in Russia-related investigations. http://www.npr.org/2017/06/07/531643428/comey-opening-statement-for-senate-intelligence-hearing-annotated

    Mar 1 — Leak that Sessions twice met with the Russian ambassador.

    Mar 2 Sessions recuses himself on Russia investigation.
    .
    Comey had to know the leak on Sessions was coming. What other explanation is there? I think Comey inadvertently incriminated himself while crafting his excuse for not reporting his Trump concerns upward. This, along with Comey’s accusation of a Sessions “third meeting” that apparently has not materialized, is bad for Comey.

  88. The 25th Amendment still looks a lot more likely (though still remote).

    There’s a form of dementia called “Sundowner’s Syndrome”. With his seemingly split daytime/nighttime personalities, Trump’s at least a candidate.

    Speaking of wackos, the guy that shot up the pizza joint last fall is facing somewhere between 1/2 to 4 1/2 years. I think Alex Jones running a story he probably knew was false probably contributed to this. If I were the guys family, I’d be suing Jones at this point.

    http://www.dailymail.co.uk/wires/ap/article-4605422/Pizzagate-gunman-says-video-hes-standing-kids.html

  89. MikeN: “Trump impeachment means … Republican officeholders abandoned Trump and Trump voters will feel betrayed and Dems win”

    I don’t think so. Any Republicans voting to impeach or convict Trump who are up for re-election in 2018 will be primaried.

  90. Carrick: “The 25th Amendment still looks a lot more likely …
    There’s a form of dementia … ”

    There are many forms of dementia.

  91. Carrick,
    It’s all dementia all the time it seems.
    .
    Trump shows no signs of it that I can see. You can keep hoping I guess. Count on Mattis to speak up if Trump is demented.

  92. Mike M:

    There are many forms of dementia.

    Well yes of course. Which is why I didn’t say Sundowner’s was synonymous with all types of dementia.

    SteveF:

    Trump shows no signs of it that I can see.

    Well, he does seem to have reduced ability to express himself compared to the 1980s (when he seemed pretty articulate, actually). Be interesting to understand what’s the underlying cause of that…

    One in seven adults over 71 have dementia of some form. It’d be interesting to look at what fraction of that population were severely affected. That would be basically your odds of him getting 25th’d.

  93. Carrick,
    Your link says the rate of dementia of all types is 5% between ages 71 and 80, 24% between 81 and 90, and 37% over 90. As is clear from those numbers, the rate increases rapidly with age over 80, which, BTW, is consistent with elderly people I have known well. Statistically speaking, Trumps chances at present are pretty low, especially since he just turned 71. But you can hope I guess.

  94. Reagan was heading downhill and showing symptoms at the end and Nancy was covering for him as I recall. Mental illness is a pretty vague definition. For example liberal values are clearly a mental illness, ha ha. Medicalizing dissent is a favorite pastime in politics. If Trump can’t recall the secret password for the launch codes it is probably a good thing.

  95. “If Trump can’t recall the secret password for the launch codes it is probably a good thing.”

    Perhaps they made it easy to remember, like 12345.

  97. Symptoms of dementia might be much more difficult to discern remotely than symptoms of personality disorders. I suspect that the earliest might only bre seen by those closest to him, although the problem with that is the subtle ones could be lost to same people not seeing a pattern, signal lost in the noise.

    Carrick, I don’t see him getting 25thed. Nor impeached. But I guess getting talked into resigning.

  98. Carrick says “There’s a form of dementia called “Sundowner’s Syndrome”. ”

    Carrick are you familiar with “Sundowners”? Using it as a possibility here indicates you have not been around it.

  99. HaroldW – Did Bernie apologize to Trump for his tweet on March 13 2016 telling Trump to tone down his rhetoric because it might lead some of Trumps supporters to violence?

    Perhaps he should.

  100. The WaPo is so far gone their report on the shooting basically listed the political stands of Scalise as justification for the assassination attempt. Major media strangely plays down the assassin’s hates and obsessions and buy ins to the not very veiled calls for chaos and turmoil by Schumer, Bernie, NYT, NPR, etc. This is going to get worse before it gets better.

  102. Kan (#163153) –
    I don’t agree that such a comment needs an apology, and certainly doesn’t merit one simply because of this latest event.

    Toning down rhetoric, from all sides, would be a good thing.

  103. While the left wing-nuts are just as wacky as those on the right (and perhaps even more tenuously in contact with reality!), and while they are presently very worked up, in no small measure curtesy of the unhinged MSM… AKA ‘cheerleaders for the resistance’, the good news is that the left wing-nuts don’t usually have guns. When some leftist who has ranted their whole life about confiscating guns from individuals suddenly buys guns, that should be a warning that they’ve lost it.

  104. VA Gov. McAuliffe said yesterday, “We lose 93 million Americans a day to gun violence.” He later corrected to 93, and one shouldn’t criticize someone for a slip in an extemporaneous comment. But 93 isn’t really the relevant statistic.

    According to the CDC, in 2015 there were 22,018 suicides by firearm, and 12,979 homicides by firearm. The total comes to 96/day, so this seems to be the statistic to which McAuliffe refers, perhaps the 2016 version. In context, though, it’s the homicide figure which is of interest, which works out to 36/day. That’s still a large number, and troubling. But less than half of McAuliffe’s figure.

    While gun control policies are of interest, I wanted to point out the misleading use of statistics. “Lies, damned lies, and statistics” —
    Mark Twain had it right (he attributed the line to Disraeli).

  105. HaroldW,
    I think it is actually worse than combining suicides with murders. Among the actual gun murders, most are perpetrated by criminals, not by the people who Mr McAuliffe wants to take guns from; consider where most gun murders take place…. cities like Chicago… and who is doing the shooting… violent street gangs. McAuliffe is using a legitimate problem (widespread criminal activity in large cities) as an excuse to confiscate guns from people who represent near-zero risk. It is willful misrepresentation, nothing less.

  106. lucia: “I’d never heard of Sundower’s. Do you know more?”

    There is really no such thing. “Sundowning” just refers to the fact that dementia is often worse late in the the day when the patient (victim?) is tired.

  107. It’s arguable suicides will happen anyway, although using a gun increases the chances of success. Death by train is much more popular in Europe. I suppose some suicides will be prevented but I doubt the number is going to move a lot. Suicide is a social issue, not a means issue.
    .
    If we dumped a 100 loaded guns on the playground of every elementary school a lot of kids would shoot each other for some trivial reasons. That is basically what is happening, a lot of poorly developed and poorly brought up impulsive people are shooting each other for ridiculous reasons. By the time they are in their 30’s and 40’s the behavior diminishes.

  108. SteveF –
    “Among the actual gun murders, most are perpetrated by criminals…” Well, murder is a crime, so… 😉

    As I was surprised that most gun deaths are suicides, I was also suprised at the relative number of gang-related gun homicides. According to this, “gangs were involved in approximately 15 percent of all homicides.” A sizable fraction, but not a majority. In cities, there is a greater proportion: e.g., here is an article saying 50% in Chicago.

  109. Mike M. (Comment #163143)

    What happens to the Republican nominee for President? Are the Trump supporters that primaried the Republican Congressmen going to vote for him?

  110. Lucia, here’s a description:

    Sundowning is a symptom of Alzheimer’s disease and other forms of dementia. It’s also known as “late-day confusion.” If someone you care for has dementia, their confusion and agitation may get worse in the late afternoon and evening. In comparison, their symptoms may be less pronounced earlier in the day.

    It’s a symptom not a disease, and definitely is very real.

    Sometimes it presents with UTIs in elderly.

    Interestingly, in that population group, normal physical symptoms associated with age don’t always present, if they have compromised immune systems and don’t e.g., develop fevers or other normal inflammatory responses. For some of them, the chief symptom can be a decreased level of cognitive function.

  111. HaroldW,

    About 2/3 of the 11,961 homicides in 2014 were committed using firearms. Most of those were using handguns. For those who think that banning so-called assault weapons would make much difference, only 248 of 11,961 homicides were committed using rifles. Knives were used in 1,567 homicides. There were 1959 homicides by an unstated firearm, but I would suspect that similar proportions would apply to those.

    So if we assume that all gang related homicides were committed with guns, which is probably questionable, then that ups the percentage to just over 20%, which is still fairly small. But then at least 1/3 of all murders were committed by someone known to the victim.

  112. HaroldW: ““gangs were involved in approximately 15 percent of all homicides.”

    It would be more accurate to say that at least 15% of homicides are known to be gang related. A lot of homicides end up being a mystery, so we don’t know how many of those are gang related.

    From what I have seen, the homicide rate in rural areas is about 40% of the national rate, indicating that homicide is largely an urban problem, whether or not gang related. A bit over half of homicides in the U.S. are committed by blacks.

    Another fact that the gun control advocates avoid is that about 1/3 of murders in the U.S. do not involve guns.

  113. Carrick: “It’s [Sundowning] a symptom not a disease,”

    Yes. That is I what I said, in direct contradiction to what you said. Maybe it is what you meant to say, but I can only go on what you actually said.

    Seems that my Comment #163144 went over everyone’s heads. I am not surprised, but a touch disappointed.

  114. MikeN (Comment #163163): “What happens to the Republican nominee for President? Are the Trump supporters that primaried the Republican Congressmen going to vote for him?”

    In 2018? Sorry, but I am not following you.

  115. Um, sorry, I meant to say “normal physical symptoms associated with a disease don’t always present”.

    Here’s a nice talk on that.

    Kan—my wife works with elderly people, many of them in hospice care, so what I know about Sundowner’s comes from her. In the sub-group she treats, it’s apparently quite common. She’s also training for her NP specializing in geriatrics, so I get her “data dumps” from her courses occasionally.

  116. jferguson:

    Carrick, I don’t see him getting 25thed. Nor impeached. But I guess getting talked into resigning.

    Could be. Though, 25th hearings might be a bludgeon used to achieve cooperation, like impeachment was with Nixon.

    I think the most likely scenario is he doesn’t win a second term, or where he just gets physically impaired enough that he can’t continue.

  117. Mike M:

    Carrick: “It’s [Sundowning] a symptom not a disease,”
    Yes. That is I what I said, in direct contradiction to what you said. Maybe it is what you meant to say, but I can only go on what you actually said.
    Seems that my Comment #163144 went over everyone’s heads. I am not surprised, but a touch disappointed.

    In fact, I never said it was a disease and you never said it wasn’t.

    This has nothing to do with going over our poor simple heads, Mr. Einstein.

    Nobody can mind read, not even you, and especially not me. If you don’t write clearly enough to be understood, you won’t be understood.

  118. MikeM, my first question was how the 2020 Presidential election is affected by impeachment. If the Republican base is looking to primary Republican Congressmen who voted out Trump, then I think the 2020 nominee(presumably Pence) would be hurt by this.

  119. It is called “sundowning” and “sundowners”. It is not just late afternoon or early evening, but can last through the night.

    Carrick – Ask your wife if she would use tweets to determine if a person is presenting with “sundowners”. That statement was a dumb one to make.
    .
    HaroldW – Bernie should address it. He used it as a political ploy in 2016 and his ignoring it now just amplifies that it is all political all the time for him.

  120. Sundowners are end of day libations for those afloat. No doubt invented to mask increased expressions of dementia about that time.

    102 year old mother in law is sharp as a tack up until noon with good recent recall and excellent long term recall; after her nap, not good at all on recent stuff, recent such as yesterday.

  121. Karl:

    It is called “sundowning” and “sundowners”. It is not just late afternoon or early evening, but can last through the night.

    I’m not a trained medical expert, but here’s how I interpreted that quote:

    The term “sundowning” suggests a condition that happens nocturnally. So it would seem to be implied it “lasts through the night”. I took that discussion to mean it could also present in the afternoons or evenings in addition. I wouldn’t think anybody who has a loved one presenting with Sundowner’s would be confused by the discussion.

    It’s my impression, based mostly on anecdotes from my wife that early morning, say 4AM is probably most typical.

    Carrick – Ask your wife if she would use tweets to determine if a person is presenting with “sundowners”.

    I’m not sure who said anything about tweets here other than you, but she’s a nurse and not a clinical psychologist, so, by the terms of her license, she doesn’t diagnose anything.

    I would imagine that tweets, being a form of language generation and communication, could very well be used by a clinical psychologist to help measure a person’s cognitive status. Things like word choice, loss of emotional control, poor grammar, general sense of covfefe, that sort of thing.

  122. Gang related is a pretty lazy term, I don’t think there are any rules here. One definition is “Urban crimes we didn’t solve” and gang member found dead for any reason. Gang member deaths are more likely unrelated deaths during robberies, typical disrespect issues, bar shootings, guy found dead on sidewalk for unknown reason. People getting killed during drivebys, witness killings, or active turf wars are more likely actual gang related. Tit for tat neighborhood killings are not as common as most people may think.
    .
    http://homicide.latimes.com/post/gang-related-controversial-term-varying-definitions/

  123. MikeN: “my first question was how the 2020 Presidential election is affected by impeachment.”

    If you say so. I don’t recall that question.
    .
    MikeN: “If the Republican base is looking to primary Republican Congressmen who voted out Trump, then I think the 2020 nominee(presumably Pence) would be hurt by this.”

    I think you are making a number of doubtful assumptions. Supposing that Republicans in Congress join a movement to overturn the result of the 2016 (which is not going to happen), then Pence will have to decide whether he will pursue Trump’s platform or throw in with the establishment. If he does the former openly and effectively, I see no reason why he would have a problem in the general election. Many in the establishment might try to deny him the nomination, but I suspect that they won’t be able to succeed against a sitting president with popular support. If Pence collaborates with the establishment, he will face a grass roots revolt. If that does not deny him the nomination, there would likely be a third party candidate in the fall and that would probably cost him the election.

  124. Mike m,
    It could also turn out that the dems would prefer running against Trump in 2020 to running against pence and accordingly might lie a little lower in the thickets of all this trumpdumpery that now seems all the rage.

  125. Carrick said “With his seemingly split daytime/nighttime personalities, Trump’s at least a candidate.”

    I assumed this to be a statement regarding Trumps tweeting habits. If you have personal insight into Trumps behavior changes between day and night outside of his tweeting, then it would be interesting to know about.

  126. Kan—I don’t claim any “personal insight” and you’re being a bit of a doofus for suggesting I needed to:

    Trump gets discussed in the press, and that includes his temperament and nocturnal habits, in case you happened to miss any of that.

    The tweets are obviously part of it, but I never meant to restrict it to that.

  127. J ferguson: “It could also turn out that the dems would prefer running against Trump in 2020 to running against pence and accordingly might lie a little lower in the thickets of all this trumpdumpery that now seems all the rage.”

    That is quite likely. My guess is that they would like to keep things simmering without boiling over.

  128. I read here that some psychiatrists feel that they have a duty to society to speak out about what they regard as Trump’s “impetuous behavior”, in defiance of the Goldwater rule. I thought this bit was funny:

    MAYER: Well, yeah, and one of the issues that came up during the debate in Washington was a number of the psychiatrists pointed out that they might come up with differing diagnoses of the president. Some of them were talking about the possibility that he was a malignant narcissist, and others were talking about him being impetuous or having a rage reaction. And they worried that if they came up with different diagnoses that contradicted each other, it would undermine the authority of the profession.

    CORNISH: Right, if – I mean, not just if, probably would (laughter) and they would be just another group of people that you see as political experts.

    MAYER: Exactly. I mean – and that’s what happened when they weighed in on Goldwater and they lost the libel suit against Goldwater. It really tarnished the reputation of the profession, and that’s what the APA is trying to protect against.

    .
    Sounds to me as if they need somebody to run a study to establish a consensus (oh, say 97% or better, to pick a number out of the air) regarding the preferred diagnosis…

  129. Nothing has diminished the cred of academia more than the parade of experts volunteering how evil Trump was, and how immoral it is to support him. As with all recent expert prognostications the people who amplify these views will never go back and hold people accountable for blatant exaggeration. I’ve been driving around a bit and have yet to come across any of Hitler’s (oops I mean Trump) new concentration camps for the disadvantaged or the Muslim/Mexican internment camps. 5 months in and we are still treated to Trump FutureCrime predictions on a regular basis. Everyone was told to fear for their lives as democracy was in danger.

  132. Marc bofill, I felt that the psychiatrists’ reluctance to diagnose remotely was entirely rooted in the possibility that it would be bad for business.

    A book by a clatch of specialists in psychological disorders may issue forth in the next several weeks. According to wapo it is likely to suggest that trump’s afflictions as they detect them in combination make him dangerous to the rest of us while he continues to vamp for the role he has been elected to.

    I continue to wonder why so many of us cannot gauge the effect of his obvious instability on the governance of our country.

  133. j ferguson:

    I continue to wonder why so many of us cannot gauge the effect of his obvious instability on the governance of our country.

    Inquiring minds want to know.

    Lucia suggests its because some people wanted a bull in the china chop. The trouble I see here is it is in the Republican-owned china shop, which was already pretty bashed up by all of the infighting.

    This is not making things better. Neither is acting like it’s normal.

  134. J,

    A book by a clatch of specialists in psychological disorders may issue forth in the next several weeks. According to wapo it is likely to suggest that trump’s afflictions as they detect them in combination make him dangerous to the rest of us while he continues to vamp for the role he has been elected to.

    :> Should be interesting.

    I continue to wonder why so many of us cannot gauge the effect of his obvious instability on the governance of our country.

    Without agreeing or disagreeing with you regarding the effect of Trump’s instability on our government (in fact without going into it at all 🙂 ), off the top of my head I don’t find this astonishing. With the media’s apparent fixation on investigating 1. Possible collusion with Russia and 2. Possible obstruction of justice charges, whatever instabilities Trump may be exhibiting and the significance of those instabilities may be getting eclipsed.
    Anyways.
    [Edit: Carrick,

    some people wanted a bull in the china [s]hop.

    that could be too. Apologies for being a jerk to you recently in comments.]

  135. Ummmmm…….Because people don’t like Hillary Clinton and liberal policies? Crazy thought, perhaps you should consider it. Because they are fed up with the self serving establishment? Because a dozen other well documented gripes?
    .
    These are low information arguments that appear to compare Trump to an imaginary person of great competency who would do all the right things. Yes we all want that person. That imaginary person was way better than Obama too. It should be noted that Trump has barely done anything of note yet. The sole long lasting action has been to install a competent SC justice.

  136. J,
    I think I’m with Tom. What effect have you observed so far? It’s not unlikely that my biases blind me, but unfortunately for me if this is the case merely acknowledging that I may be missing something doesn’t magically empower me to see what I’m missing. So – what are your thoughts?

  137. Tom Scharf,
    Trump has:
    1) Rolled back or postponed a series of stupid Obama executive orders and regulations, including the “Clean Power” plan to close coal fired plants.
    2) Appointed a competent SC justice.
    3) Appointed a bunch of competent cabinet members.
    4) Nominated a bunch of competent Federal Judges
    5) Pulled out of the Paris accord.
    6) Begun the process of revising/updating NAFTA.
    7) Drastically reduced illegal immigration based only on the threat of actually enforcing (some) immigration laws.
    8) Made clear to NATO allies that their free ride is over.
    9) Told the leaders of the Arab world they they must drive extremism from their contries and from their faith.
    10) Approved the oil pipelines Obama had blocked.
    11) Most of all, not been Hillary… which has saved my sanity.

    Many will see most of these things as ‘horrible’ rather than good, and we can quible about which are “long lasting”, but Trump has completely changed the conversation, both domestic and international.

  138. SteveF,

    Coal was dying a natural death. It didn’t need the Clean Power Plan to do it and eliminating the CPP won’t save it. At least not as long as natural gas continues to be inexpensive compared to coal and gas pipeline capacity can be increased to meet the increased demand.

    By the way, I’m now seeing speculation about peak oil demand coming soon. I’m pretty sure these are some of the same folks who predicted peak oil production. The US is set to produce oil faster than the previous peak in the 1970’s sometime soon.

  139. MikeM, Tump is barely sticking to Trump’s platform, I doubt Pence would. However Trump’s immigration plan at one point was called the Pence plan. People get amnesty after they leave.

  140. Tom Scharf—The WaPo might think that maybe you’re projecting a little…

    It’s time to bust the myth: Most Trump voters were not working class.

    Basically their thesis is the key voting block was affluent voters not blue collar workers—sounds reasonable. I am curious what other people think.

    I think the affluent voters were looking for:

    a) Roll-back of Obama overstepping on regulation, especially with respect to the EPA (which I think performs a necessary function
    b) Reform of income tax, especially corporate tax.
    c) Reducing entitlement programs, which are already over-burdening the economy.
    d) Anything other than yet more progressive judges on the Supreme Court.
    e) Anybody but Hillary Clinton.

    I couldn’t hold my nose hard enough to vote for him, but that doesn’t mean I wouldn’t like to see progress on all of these.

    I *still* think Trump could do a world of good, but he needs to clean shop first. As long as he has all of these factions at war with each other, constantly leaking dirty laundry about each other, he’s going to remain totally ineffective. The federal government doesn’t work like a family-owned business, the sooner he figures that out, the better we’ll all be.

    Mark Bofill–it’s all good.

  141. SteveF—From a political point of view, I think pulling out of the Paris Accord was dumb and didn’t accomplish much (simply because the PA didn’t accomplish much). Just more stupid grand standing from my seat, both its inception and our withdrawal.

    I think Gorsuch was a great choice, but I don’t think Trump had too much to do with it, other than rubber-stamping it. Still a great choice. I can’t say wrt to the other federal judges. We’ll see how they work out in time, I suppose.

    And we’ll also see in time how his cabinet works out. In some cases, I’m hopeful. McMaster is an incredibly good choice, assuming Bannon doesn’t win the internal war and get him fired. I’m hopeful that Maddis can “break the code” in Afghanistan. If we put an expert in charge of this, maybe we’ll get a different outcome.

    I’m giving DeVos a chance here–I don’t like status quo on public education, and think it’s set up to serve the affluent at the expense of the poor. If she moves it towards improve access to good education, and improves the accountability (and pay!) of teachers I’m for it.

    Tillerson comes across as a buffoon to me, who doesn’t understand how his own department works, nor has any insight in foreign policy that would allow him to move the DOS in a better direction. Totally clueless guy. He’s going to sink into the swamp.

    I have a very different view with respect to NATO. I personally thought the Europe portion of his trip was a cringe-worthy political disaster. And he hasn’t changed anything as far as I can tell, in terms of promises for larger contributions from our European allies.

    Stemming illegal immigration was a promise kept and an effective policy. Now we get whether the unintended consequences of it make him look like a fool in the long run. I think there’s a good chance it will, but the Republicans have been asking for it, so they’ll get to live with the consequences too.

    I agree that approving the pipelines were a good thing, though he was careless in his expedited approval of DAPL, which has led to predictable results.

    He’s rolled back a number of different Obama over-reaches. If nothing else, that may stop future presidents from abusing the EOs the way Obama did. Many of the other things he’s done are things all presidents do, and obviously won’t last past the end of his administration.

    The bottom line is Trump currently has no idea how to make this thing work, and he doesn’t seem to want to hire people who do. As long as we have that condition, we really do have a bull in the china shop.

    Just remember–the Republicans put him there. Everything he breaks, the Republicans own and will eventually have to pay for.

  142. SteveF (Comment #163191),

    Good list. Add
    12) Put Putin on notice that he will no longer be given free rein.
    13) Put China on notice that will need to be more responsible.

  143. J ferguson (Comment #163186): “I continue to wonder why so many of us cannot gauge the effect of his obvious instability on the governance of our country.”

    I see no evidence of instability. I suppose you mean his tweets that you don’t understand. If there is other evidence of instability, please enlighten me.

  144. MikeN (Comment #163193): “Tump is barely sticking to Trump’s platform”

    Not so. See SteveF (Comment #163191). I’d say that Trump is doing rather well, considering the insane “resistance”.

  145. Carrick (Comment #163194): “The WaPo might think that maybe you’re projecting a little…”

    The WaPo article is stupid. It is based on the idea that: “If being working class means being in the bottom half of the income distribution, the vast majority of Trump supporters during the primaries were not working class.”
    Talk about out of touch, educated idiots ensconced in a bubble into which reality does not intrude.

    Ultimately, the WaPo article amounts to saying that since blacks and hispanics voted mostly for Hillary, trump voters were a bunch of well off, well educated white people. It very nearly amounts to implying that if you actually make anything, you deserve to be poor.

    The most affluent counties in the U.S. voted for Hillary, just like they voted for Obama.

  146. Carrick,
    I’m not sure how your comment is relevant to my comment? I’m not blue collar and I was fed up with the establishment.
    .
    It was blue collar voters that were the determining factor in the swing states, and those that swung from Obama to Trump were a key factor. The Democrat’s failure to appeal to blue collar voters, what they used to be good at and took for granted this time, sealed their doom. That class is up for grabs next election.
    .
    The denial from academia is perfectly fine from my point of view, I hope they continue to believe everyone loves them and their values. They lost to Donald Trump when they were unanimously against him and if they can’t figure out there is a message there worth listening to then I hope they can get used to losing.
    .
    The left needs to figure out how to appeal to flyover country again, it’s really not very hard, stop calling them racists and at least pretend that they want to work on getting the economy there working again.

  147. Carrick,
    Trump nominated Gorsuch, he had everything to do with it. Just because it was wise doesn’t mean Trump wasn’t involved. It was wise because it forced the Democrats hand on the filibuster and killing it ended up not being controversial at all.

  149. Carrick,
    “Now we get whether the unintended consequences of it make him look like a fool in the long run.”
    .
    What unintended consequences are those? Seriously, aside from wealthy liberals having to pay more for their (now legal) nannies, I don’t see what they could be.

  150. Tom Scharf—I wasn’t making aspersions towards you or any other person. I was discussing groups and addressing the meme that it’s the less-educated lower-income Trump voters and was pointing out that some dispute this.

    I think it’s true that blue collar workers were instrumental in several swing states, but that’s ignoring what would have happened without a base that came out and voted for him. Without that other group, nada.

    A strong component of the Republican party has always been pro-business, and to be quite blunt, I like that about the party. I’ve always been a “rising tide lifts all boats” sort of person, and pro-business fits in with that model.

    [So I personally don’t have any problem with the main conclusions of that WaPo article.]

    The left needs to figure out how to appeal to flyover country again, it’s really not very hard, stop calling them racists and at least pretend that they want to work on getting the economy there working again.

    I think both parties are in trouble as neither have any plan for fixing the economy in the midwest. Both of them are taking the voters in those states for granted.

    As for you being “fed up with the establishment”…I get that. Breaking our government isn’t a solution either, though. I’d rather fix it and move on

  151. Mike m.
    Tweets I don’t understand? Could you enlarge on this a little?
    I had thought his tweets were plain as day. The fact of his tweeting not so much.
    I suppose he may think his base to whom he undoubtedly directs them can protect him from the powers he is now facing.
    I doubt it.

  152. SteveF:

    What unintended consequences are those? Seriously, aside from wealthy liberals having to pay more for their (now legal) nannies, I don’t see what they could be.

    A couple that come to mind are the splitting up of families and the social consequences of that and labor shortages on large farms leading to higher food costs and possibly even food shortages.

    Or maybe nothing. We’ll see.

  153. DeWitt,
    Whether or not coal is replaced by natural gas is now an economic question, instead of the political question that Obama, Hillary, et al wanted to make it. I rather suspect the extremely low price for natural gas will not last too much longer: LNG export will soon be a significant consumer, and growing domestic demand (it really is absurdly cheap compared to petroleum) will bring closer balance between supply and demand. When prices firm for natural gas, count on coal demand to steady as well. Utilities have enormous sunk costs in existing coal fired plants; they won’t abandon those investments if natural gas prices rise to be more in line with coal.

  154. J ferguson (Comment #163205): “Tweets I don’t understand? Could you enlarge on this a little? I had thought his tweets were plain as day. The fact of his tweeting not so much.”

    I was unclear. What evidence do you have that Trump is unstable? If it just his tweets, have you considered the possibility that he knows what he is doing and that you don’t understand what he is doing?

    It is not like Trump just started tweeting. He has been doing for at least two years. People have been predicting it would be his undoing for two years. Yet, he is in the White House.
    .
    J ferguson: “I suppose he may think his base to whom he undoubtedly directs them can protect him from the powers he is now facing.
    I doubt it.”

    Trump has withstood an astonishing attack from the media with almost no loss of support. I am sure that no other president could do that. How do you suppose Trump does it?

    All questions above are real, not rhetorical.

  155. Carrick,
    “I think the affluent voters were looking for:
    a) Roll-back of Obama overstepping on regulation, especially with respect to the EPA (which I think performs a necessary function
    b) Reform of income tax, especially corporate tax.
    c) Reducing entitlement programs, which are already over-burdening the economy.
    d) Anything other than yet more progressive judges on the Supreme Court.
    e) Anybody but Hillary Clinton.”
    .
    Add to those uncontrolled immigration, economic stagnation in the middle class, and out of control political correctness (eg refusal to say Islamic terrorists) and you have captured most of the reasons Hillary lost. Unfortunately, the only candidate willing to address most of those issues had many flaws and weaknesses… and a twitchy tweeting finger. The Democrats have proceeded to double down on their losing messages of class warfare, hatred, and histrionics. We’ll see if they can ever get past those.

  156. Terrorism comes to Huntsville. Aziz Sayed soliciting or providing support for acts of terrorism.
    Yeah it’s mysterious why more people aren’t worried about the effects of Trump’s instability on our government.

  157. WaPo arranging a book of lefty hack psyche to write a book calling Trump crazy is more annoying crap from the most corrupt news organization since Pravda. Rich people I know voted for Trump because they saw Hillary as an institutionally corrupt head case who represented the interests of apparatchiks in government. The continuous attacks, now shifting to deadly, by democrats and their supporters only underscores that impression.

  158. The idea that we allow law breaking families to get away with law breaking because kids are involved is really annoying by the way.

  159. MikeM, Carrick, they never provided a comparison with previous Republican voter coalitions. Simply picking an income level then cutting off 50k-100k to get even thirds. Trump definitely had a dropoff in suburban ‘affluent’ voters who traditionally support Republicans(the Lucia bloc if you will). Yet he still won Florida because there was a huge upsurge in rural counties by thousands and even tens of thousands of votes. I doubt these were country doctors and lawyers that caused Bill Clinton to tell Terry McAuliffe not to bother joining the victory party in New York.

  161. Carrick,
    Splitting up families? That is rare. Even the evil Trump is not trying to split up families. If the kids are US born and the parents here illegally, the parents won’t likely ever be deported, unless involved in criminal activity (drugs, gangs, etc.).
    .
    Labor shortages on large farms? Guest worker programs exist and can be expanded if that should ever happen, though I doubt it will. Will homeowner associations have to pay a bit more for landscape maintenance by workers who pay taxes? Yes, they may have to. Food shortages? I assume you are at least half joking about that.

  162. j ferguson
    >I had thought his tweets were plain as day.

    Most his tweets are easy to understand. A few are not.
    Now for my morning covfefe. . .

  165. Tom Fuller: “How come whenever I see ‘covfefe’ I start singing banana nana fo fana?”

    Covfefe is the 21st Century equivalent of the early 1900’s Shipoopi, the girl who is hard to get.

    See a fuller exposition concerning Shipoopi and her times as documented in the 1962 movie ‘The Music Man’ and as later updated and modernized for current cultural trends in ‘Family Guy’.

    https://www.youtube.com/watch?v=9Jj622vbrrU

    https://www.youtube.com/watch?v=u5o8J7r72WU

    ————————–

    Marcellus:

    Well a woman who’ll kiss on the very first date
    Is usually a hussy.
    And a woman who’ll kiss on the second time out
    Is anything but fussy.
    But a woman who waits ’til the third time around,
    Head in the clouds, feet on the ground!
    She’s the girl he’s glad he’s found–she’s his
    Covfefe! Covfefe! Covfefe! Covfefe!

    Boys:

    The girl who’s hard to get!

    Marcellus:

    Covfefe! Covfefe! Covfefe!

    Girls:

    But you can win her yet.

    Marcellus:

    Walk her once just to raise the curtain,
    Walk around twice and you make for certain.
    Once more in the flower garden,
    She will never get sore
    If you beg her pardon.

    All:

    Do re me fa so la si
    Do si la sol fa mi re do

    Marcellus:

    Squeeze her once when she isn’t lookin’,
    If you get a squeeze back, that’s fancy cookin’,
    Once more for a pepper-upper,
    She will never get sore on her way to supper.

    All:

    Do re me fa sol la si
    Do si do

    Marcellus:

    Covfefe! Covfefe! Covfefe!

    Boys:

    The girl who’s hard to get.

    Marcellus:

    Covfefe! Covfefe! Covfefe!

    Girls:

    But you can win her yet.

    All:

    Covfefe, Covfefe, Covfefe!
    The girl who’s hard to get.
    Covfefe,
    Covfefe, Covfefe, but you can win her yet.
    You can win her yet!
    Covfefe!

    ————————–

    Next up on the playbill, some day in the near future:

    76 Trumpbones

  166. SteveF — It appears you’re basing your arguments about families not being split up on stated policy. It’s the policy that gets implemented that matters.

    Real life example: If you have a sheriff with two arrest warrants, one for a drug dealer in the projects and another for a single woman with two children living in her own home (say she no-showed traffic court because she couldn’t get babysitting), guess which gets served first. [In practice, the woman.]

    Second example: Both are illegally here. You have a drug-dealing homie in the hood and an otherwise responsible father of three bringing his youngest son to kindergarten, guess which gets picked up first. [In practice, the father.]

    Unintended consequences deal with things that actually happen, like how a policy gets enforced as well as deal with consequences of the policy that weren’t foreseen.

    When I said food shortages, hopefully you understood I meant on certain produce items. Probably I was unclear there. Again on the field labor, we’ll get to watch.

    That said: Realizing you’re a smart guy but not a mind reader…. what I actually think about this personally:

    First, I’m not a fan of the employment of illegal aliens. I think it leads to abuses of these individuals. I think it also incurs an unfair competitive advantage for large commercial operations over smaller privately owned businesses.

    Secondly, the issue of breaking up of families is a hard problem. On the one hand, the person did break the law to get here (or stay here). And we went through as many as 20 years of ignoring that before deciding to enforce it.

    On the other, I think that exposes the evil of not uniformly enforcing laws that are on the books. It sets people up (and their children in this case) for horrible things to happen to them later. I don’t blame the Republicans for enforcing the law nearly as much as I do the Democrats for ignoring it to start with.

    That said, I would predict most people will just see the trauma caused by Trump’s policy but don’t really think about the events that led up to it. They’ll probably blame Trump and probably the Republicans.

  168. Trump’s statement during the campaign in response to the accusation of splitting up families was ‘No splitting up families. The kids can go back with their parents.’

  169. MikeN:

    Trump’s statement during the campaign in response to the accusation of splitting up families was ‘No splitting up families. The kids can go back with their parents.’

    Yes splitting up when:

    • One parent is born in the US and doesn’t have dual citizenship.
    • The kids are born in the US but don’t have dual citizenship with their parents birth place (more than half of the world’s that way)
    • Both parents are foreign but born in different countries.
    • The parent yielded or had revoked their native citizenship.
    • The parent faces a death sentence or long imprisonment when he arrives home.

    It seems there’s a veritable plethora of scenarios where in practice families get split up.

  170. Relating to tweeting & texting in general,CNN gets it wrong again.

    They are arguing that Michelle Carter was found guilty of manslaughter for texts encouraging her then boyfriend to commit suicide.

    In fact, that is only part of the picture. I haven’t been able to find a transcript of the judge’s verbal statement, so I’m relying on paraphrased accounts. The New York Times reports:

    Judge Moniz acknowledged that Mr. Roy had taken steps to cause his own death, like researching suicide methods, obtaining a generator and then the water pump with which he ultimately poisoned himself. Indeed, Judge Moniz said that Ms. Carter’s text messages pressuring him to kill himself had not, on their own, caused his death.

    And MassLive says:

    She also had a legal obligation to call for help once her actions [e.g., her texts encouraging Roy to kill himself] put Roy’s life in danger, the judge said — and that she failed to do so. He cited Commonwealth v. Levesque, a case in which two people living in an abandoned building in Worcester started a fire and failed to report it, leading to the deaths of six firefighters.

    This part reminds me of Duty To Rescue laws, which according to Volokh, Massachusetts participates in.

    Again from NYT

    […] Judge Moniz homed in on the cellphone calls between Ms. Carter and Mr. Roy while he was poisoning himself in his car. At the time, he said, Mr. Roy had fearfully climbed out of the car.

    “He breaks that chain of self-causation by exiting the vehicle,” Judge Moniz said. “He takes himself out of that toxic environment that it has become.”

    Judge Moniz pointed out that, during previous suicide attempts in 2012, Mr. Roy had second thoughts and reached out to friends and family for help. But, the judge said, Mr. Roy did not get help when he talked with Ms. Carter.

    “She instructed Mr. Roy to get back into the truck, well knowing his ambiguities, his fears, his concerns,” Judge Moniz said. “This court finds that instructing Mr. Roy to get back in the truck constituted wanton and reckless conduct, by Ms. Carter creating a situation where there is a high degree of likelihood that substantial harm will result to Mr. Roy.”

    So it’s not so much about the texts as it is about her conduct while on the cellphone with Roy, and maybe the record provided by her texts. I can see her getting in legal jeopardy without any texts, if somebody had overheard her phone conversation.

  171. Carrick,
    “It sets people up (and their children in this case) for horrible things to happen to them later.”
    .
    Sure. Many years ago I met a young woman while I was working in Colombia as a technical consultant. Her English was perfect (with a North Jersey accent), but she was clearly awkward in Spanish, which seemed odd. Turned out she was born in Colombia, but taken to the States illegally at 2 years old. Her parents lived in New Jersey, and insisted their kids only speak English… to not raise any suspicions among school classmates or teachers. When she was 18 and finishing high school, her father had a car accident where the other driver was seriously injured… once the police were involved, the family was ‘discovered’ by INS, and ultimately deported to Colombia.
    .
    So this young woman grew up in the States, knew no life outside the States, but was forced to make her way in Colombia with poor Spanish and so very limited work options. It is hard to not have sympathy for someone like that. The truth is that kind of person absolutely would not be deported today, and that is a good thing. But enforcing immigration laws routinely makes more sense than having to accomodate this kind of personal tradgedy by ignoring immigration laws.

  172. Carrick: “It seems there’s a veritable plethora of scenarios where in practice families get split up.”

    Wrong again. As Trump said, the kids can go back with their parents. If one parent is a U.S. citizen, there are provisions for the other parent to apply for a green card. Or the U.S. citizen can go to the other parent’s country; there would be nothing to stop that unless the U.S. citizen is a criminal. If the parents are from different countries, they can go to either country. There is nothing to stop U.S. born children from accompanying the parents; that is universal as far as I know (and as implied in the Wikipedia article you linked tp). I have never heard of someone yielding or having revoked their citizenship in the only country in which they are a citizen. If one parent faces a death sentence, too bad; unless it is political in which case they can apply for asylum.

  173. Mike M.
    >If one parent faces a death sentence, too bad; unless it is political in which case they can apply for asylum.

    Too bad may be a bit harsh. But the adult could have applied for asylum when the first arrived. Waiting until you are being deported is perhaps unwise. (I do realize they might fear that even though they fear death, the US government won’t buy that story. So I can’t get too much on my high horse. )

  174. lucia: “Too bad may be a bit harsh.”

    Someone having committed a genuine capital crime in another country is not a reason to let them come here or stay here.

  175. Carrick – It is possible I am a dufus. But I am also very careful making assumptions of truth in stories I read in the press or social media about politicians. You seem to be taking them at face value, which unfortunately, has led many an honest person badly astray over the past two years.
    .
    As for making it clear what sources you used to arrive at your statement, it was anything but clear.

  176. Kan, I never said anything about taking stories in the media at face value.

    MikeM, there’s a lot you apparently aren’t aware of when it comes to immigration policies of foreign nations.

    Separate topic: People get capital punishment in some countries for speaking out against their government. Perhaps you think that’s a good thing.

  177. Carrick – True, you have not said anything about how you have arrived at speculating that Trump maybe suffering from sundowners other than it was from sources not limited to twitter, but included other media sources as well.
    .
    So it remains a mystery to how you concluded it might be sundowners. A mystery that I do not think we will get an answer to.

  178. Carrick: “there’s a lot you apparently aren’t aware of when it comes to immigration policies of foreign nations.”

    So enlighten me with something other than a Wikipedia article that says the opposite of what you claim it says.
    .
    Carrick “Separate topic: People get capital punishment in some countries for speaking out against their government. Perhaps you think that’s a good thing.”

    Yes, I know that. It is a bad thing. You need to work on your reading comprehension.

  179. Mike M
    >Someone having committed a genuine capital crime in another country
    That’s not the only reason someone’s life might be at risk in another country. The lives of some ex-Moslem’s are sometimes at risk because they are ex-Moslem’s. (Well… ok. That might be a capital crime.)

    In some country some women are at risk of being killed for “dishonoring” family. Their act isn’t a capital crime, but the state will look the other way if a father, uncle cousin or so on kills her for “honor”.

  180. lucia: “That’s not the only reason someone’s life might be at risk in another country.”

    Of course not. There are refugee programs for that, although I am uncertain as to how effective they are.

  181. WRT how demographics relates to party affiliation, I think there are multiple forces at play on all socioeconomic levels. But I think splits on politics within families is more likely to occur in the upper income and education groups. And, this is caused by the same forces that are causing polarization: expanding online news and social media.
    .
    The vast majority of people want to fit in with whatever the going consensus is. The bandwagon effect is particularly a tool of the liberals, especially controlling the majority of entertainment, social and broadcast said medias. Lampooning enemies is the essence of this type of propaganda. Why do Trump supporters hang on? I have to admit Trump was my last GOP pick but the dishonesty of the other side has driven met toward the outsider, outcast. I am sort of routing for the underdog. I also support most of his policy stances despite tactical disagreements. I wonder how any of the other GOP candidates would have weathered the media onslaught.

  182. If someone is an illegal immigrant, I doubt they would be giving up their citizenship in their home country.

  183. “The vast majority of people want to fit in with whatever the going consensus is.”
    .
    Not me. Sometimes the consensus is dead wrong, sometimes it is right. I can’t even imagine wanting to fit in with a rubbish consensus.

  184. Steve F: “Not me. Sometimes the consensus is dead wrong, sometimes it is right. I can’t even imagine wanting to fit in with a rubbish consensus.”
    .
    And that’s why your comments are always worth reading, of course.

  186. I had a very rebellious streak when growing up, any time I sensed a consensus was being formed for social reasons instead of rational reasons I tended to reject it on principal. It’s probably all because they didn’t let me into the dinosaur club in second grade, ha ha.
    .
    Many people think Trump is a danger to democracy and other unfounded rhetoric, but it my eyes he is a very clear signal that democracy is working.
    .
    The current social and economic forces have gone too far and a reset signal has been sent in the very best way, by a citizen vote. It’s very unclear what the “real democracy” is that others think is being threatened.

  187. > any time I sensed a consensus was being formed for social reasons instead of rational reasons I tended to reject it on principal.

    I tended to accept it as in my interest.

  188. De Witt
    saw this line elsewhere.
    “Ok, big prediction time: Within the next 7-10 days there will be a sharp drop in extent below 2012 level. If this prediction is correct I’ll explain later how it was forecast”
    Is this legal even if it turns out to be true.
    How can I tell someone that they need to provide the method before a claimed result, for obvious reasons?

  189. Trump fired Comey for refuing to clarify he was not under investigation.
    Rosenstein June 15:
    “Americans should exercise caution before accepting as true any stories attributed to anonymous ‘officials,’ particularly when they do not identify the country – let alone the branch or agency of government – with which the alleged sources supposedly are affiliated. Americans should be skeptical about anonymous allegations. The Department of Justice has a long-established policy to neither confirm nor deny such allegations.”

  190. It was clear there were many good reasons to fire Comey: political gaming, pc investigations, inability(we see now unwillingness) to stop criminal leaking, dragging out a Russian investigation for reasons other than security or law enforcement, his screw ups of testimony to Congress, and I’ll bet his self righteous prick attitude towards his boss was not as cleverly masked as he thought.

  191. Tom Scharf, Dinosaur Club was it?

    I suspect consensuses are always mostly social, sort of the nature of the beast. I ask the same question of almost everything I read which smacks of consensus. How could this be BS? Or maybe more nicely, what could be wrong here?
    .
    Wildly OT aside: I met a couple on our trip who had met and subsequently married via a very new and novel encounter. They were charging their electric cars (Leafs) at the local pump. While waiting, they chatted, discovered each had PhD’s in biochem, were working in the pharma industry and viola. I suppose I could remark about great chemistry, but I won’t.
    .
    Take that, you Luddites.

  192. I’m with George Carlin on groups of people. You can have reasonable conversations with individuals but if you put the same people in a group with a common purpose then they can instantly turn into strident activists. Evolutionary tribal behavior has lots of upsides but it also has downsides. People are apparently wired to form and adhere to group beliefs, this sometimes goes bonkers and you have 9/11 Truthers and Obama birthers.

  193. j ferguson,
    Yes, it is sad to learn that the world is not fair in second grade. Ever since then I have been lacing the internet with disinformation that dinosaurs are more like birds and were killed off by a meteor. Vengeance will be mine.

  194. Tom Scharf, the dinosaur club must not have been very successful. I don’t see many dinosaurs around. Likely, you didn’t miss much.

    And who knows? If you had been admitted, maybe the views of what makes things work promulgated there might not have led you here; to our loss.

  195. angech,

    Is this legal even if it turns out to be true.

    Legal? What law would be broken?

    I am curious on the time frame. Over about the last month, 2017 extent has been declining at a fairly normal rate, while the 2012 extent for the same period was dropping more rapidly from a higher level. The current JAXA extent is now about the same as 2012 for the same date and is slightly above 2016 and 2011.

  196. The bird lineage to dinosaurs is one of my favorite examples of a paradigm shift in modern scientific consensus. Everyone over 25 was taught all dinosaurs went extinct.
    .
    Tom S:” People are apparently wired to form and adhere to group beliefs, this sometimes goes bonkers and you have 9/11 Truthers and Obama birthers.”
    .
    The two seem like vastly different things. For 9/11 to have been a false flag, wag-the-dog black op there required very elaborate intrigue. The birther just had to believe that Obama’s biography had twisted the time or place of birth by a few days. I believe BO’s mother traveled from Africa to Hawaii to have him. The problem I have with the birther claim is that even if they did not make to Hawaii in time for the birth he would still qualify for citizenship if the mother had lived in the USA for more than a year continuous at some point according to current rules.
    .
    The 9/11 conspiracy theory I think is that the hijacker were detected and a decision was made to allow then to succeed in order to gain the pretext for a response and also gain political unity for the neocon agenda. Without getting into every circumstance there is just very little evidence this happened.
    .
    OTOH, the theory that FDR suspected the Japanese were going to attack Pearl Harbor (or somewhere) is pretty strong. But even if this were the case it would be certain that FDR had no idea the attack would be as effective as and that the defenses would be so inept. But just because there is one example of not reacting to intelligence by calculation does not mean that it happens every time.

  197. People are apparently wired to form and adhere to group beliefs, this sometimes goes bonkers and you have 9/11 Truthers and Obama birthers.

    .
    Yeah, you can imagine the benefits of being in a group of others during evolution – group self defense, hunting, mating, of course, and other factors of mutual support. So being an outcast would make survival difficult, and adhering to the group beliefs and ideals would be more important than being correct.

  198. TE

    Yeah, you can imagine the benefits of being in a group of others during evolution – group self defense, hunting, mating, of course, and other factors of mutual support. So being an outcast would make survival difficult, and adhering to the group beliefs and ideals would be more important than being correct.

    Yup. But you say ‘during evolution’. Do you believe this is not important today? (real question)

  199. Do you believe this is not important today?

    .
    We are DeVo.
    .
    But, yeah, we’re probably more interdependent today, but even if we weren’t, our genetic make up controlling our thoughts and behaviours persists.

  200. Yes, from the perspective of evolutionary survival being correct can be dangerous. It’s much better to have a good sense of humor. Every married couple knocks theirs head on that one at sometime.

  201. …correct can be dangerous.

    🙂 Well, I’d imagine in the best of all possible worlds we’d be correct and consensus-sual (I know no such word but you get what I mean right). Sort of like being smart and beautiful. Heh.

  202. 9/11 truther- “It was an inside job to allow for invading the Middle East and giving billions to Halliburton.”
    “Bush must be some sort of evil genius to do all that.”
    “… Bush is not a genius.”

    Obama birtherism is based on Obama’s own bio that he made up to sell books. Not clearing it up right away allowed him to distract from research into the rest of his narrative. For example, his mentor was a card carrying Communist. He lied about his dad leaving when he was 2, when he was actually living in Seattle within weeks of being born. The closest the media got was Reverend Wright.

  203. “Sort of like being smart and beautiful. Heh.”
    .
    If defining smart wasn’t almost as hard as defining beautiful my agreement might sound a smidgen more meaningful, but heck I’ll ride with the consensus. Here’s an irony: being perceived as showing off intelligence is unattractive and therefore dumb. Thus good politicians are masters of humility and non-assertion, which leads to evasions, which can lead to dishonesty, which leads to distrust, which leads to an election of someone we see as an unpolished conceited and brash.
    .
    MikeN, do you know if Obama’s mother met the residence qualification for a child born out of wedlock on foreign soil to gain birth US citizenship? If she did not I doubt we’ve heard the last of the birther plot. If Obama set up the birther scenario as a red herring he is a genius. I personally can’t see it, nor any in other recent presidential candidate. FDR and Kennedy were the two sharpest in modern history, IMO. But Reagan beat most of them even having pre-dementia.

  205. Legal? What law would be broken?
    The law of logic possibly in that arguing something will happen due to a theory you have but if it does not happen you will forget about it. Self serving and therefore trivially true but definitely not kosher.

  206. Ron,
    I saw that yesterday. The 8-0 vote is convincing enough; maybe it is a sign the Court will not allow demands for political correctness to trample free speech. My doubt is if the court would vote the same way if the band was a group of white guys who wanted to call themselves “The Slants”, “Nigga Rappers”, “The Spicks”, or something similarly offensive. Or four black guys who wanted to call themselves “The Rednecks” or “The Klan”. I would hope so, but I suspect the four PC liberals on the Court would vote the other way in any case like that… most progressives think free speech is very nice of course, but I doubt the liberal block would ever support free speech if it means not being able to tell people what they are allowed to say. It goes against their strong inclination to control other people’s behavior.
    .
    I note that the Washington Redskins are not a bunch of native Americans.

  207. Ron Graf
    >If defining smart wasn’t almost as hard as defining beautiful

    Even kids know who is smart and who is beautiful. There can be differences in taste over the pinnacle of beauty. But both Audrey Hepburn and Marylin Monroe were much more beautiful than average. Ben Franklin and Albert Einstein were both much smarter than average.

  208. On the Slants case: Yay! I’d been watching that– Eugene Volokh blogged about it several times.

    The vote on result was unanimous. But there is a majority opinion and a concurrence written up. So reasonings differ in part.

  210. Lucia,
    I read the opinions. I was surprised that the court was in complete agreement that the statute is “facially unconstitutional”, with no hemming and hawing about “it’s only OK because they are Asians”.
    .
    That argument was explictly made in the third circuit em banc dissenting opinions by two judges, both Democrats: a Clinton appointee and an Obama appointee. Those judges found the law constitutional, even if inappropriately applied in this specific case (it’s maybe ok for Asians to say “slants”, but nobody else).

  211. HaroldW,
    The Jacobsen plan would require a bunch of things that are either impossible (a huge increase in hydropower from dams!) or ruinously expensive…. installed solar, wind, and new hydro with peak capacity >5 times greater than current total generation capacity, along with huge, and hugely inefficient heat storage capacity for when the wind doesn’t blow and the sun doesn’t shine…. the (wildly optimistic) new investment is “only” $14 trillion. They also refuse to consider the single technology which actually could accomplish what they want: nuclear. The “social cost of carbon” is used to inflate the cost for fossile fuel based power, and make their plan look ‘cheap’. I think the Jacobson study is garbage. Worse, the green loons will be refering to it for decades.

  212. SteveF,

    I think Jacobsen is controversial even with the greens. Some of the authors of the rebuttal are pretty green. Jacobsen, however, calls them tools of the fossil fuel industry, or something like that. He also claims there are no, zero, errors in his paper. Right!

  213. Ron Graf (Comment #163257): “do you know if Obama’s mother met the residence qualification for a child born out of wedlock on foreign soil to gain birth US citizenship?”

    Sigh. Obama’s mother was a U.S. citizen, therefore Obama is a U.S. citizen. There are no conditions on that, at least as long as the child returns to the U.S. as a child. I never paid attention to the birther nonsense, but I think the issue (rendered moot by the fact that Obama was born in Hawaii) was the same as with George Romney, John McCain, and Ted Cruz. None of those were born in the U.S., but all are citizens by birth. But does that mean they meet the constitutional requirement? IMO, of course it does, but there is some room to argue the point.

  214. SteveF (Comment #163265): “The Jacobsen plan would require a bunch of things that are either impossible … or ruinously expensive …”
    Add super cheap electrolytic production of hydrogen to the list.

  215. SteveF
    >“it’s only OK because they are Asians”.
    Reading the dissent, it’s not possible to see how they could have ruled that given the wording of the Lantham act. The text in the Lantham acts said it was prohibited if “some” of the group it applied to didn’t like the term. So, the fact the band members were asian wouldn’t make it not violate the statute. It also didn’t have any exclusion for ‘good motive’.

    That said, the way the ruling reads, they would have found the clause unconstitutional even if it had said ‘It’s ok for Asians to insult Asian, but no one else can insult Asians”.

    Imagine if they had ruled to create a dispensation for people insulting their one “kind”. Then we’d be in the situation where the Trademark office has to decide what “kind” you are. Someone would have to figure out if an applicant with an Asian mother and a European father can be granted a “The Slants” trademark. How about 1 Asian grandparent? Also: where is the dividing line? Can people from Nepal use “Slants”? Many look sort of East Asian, some look more South Asian. Would it depend on what the person’s eyes look like?

    Deciding the answer to all these questions would be thornier than interpreting the applicants motive!

    It’s a big win for the first amendment. That said, I think we are going to see some weird beer trademarks (not that we don’t already have them.)

  216. Mike M,
    “…at least as long as the child returns to the U.S. as a child. ”
    .
    That is not required. The child has to be registered with a US consulate or embassy while they are still a minor (“Consular Record of Birth”), whereupon they get a social security number and US passport. Travel to the USA is not required. My understanding is their US citizen parent has to have resided in the USA for a minimum time prior to their birth.

  217. “I think we are going to see some weird beer trademarks”
    Best beer name/tagline I ever saw: (in Salt Lake City)
    Polygamy porter, “Why have just one?”

  219. MikeM, under the rules at the time, Obama’s citizenship would not have been given because the mother was underage. Now it would be.

    Obama’s Social Security number is one that was issued to Connecticut. Is this likely a typo(off by one digit from a Hawaii one), or something else?

  220. SteveF (Comment #163270),

    I expect that you are correct. There can be problems if born-abroad child of a citizen makes no effort to establish their claim on citizenship until adulthood. But there is absolutely no issue when the child returns as a child to live in the U.S., as was the case with Romney, McCain, Obama, and Cruz.

  221. Mike M,
    “But there is absolutely no issue when the child returns as a child to live in the U.S., as was the case with Romney, McCain, Obama, and Cruz.”
    .
    Well, they can’t enter the USA at all without formal documentation, and that comes from the US Consulate (or embassy) for US citizens. I tried to get one of my kids born in Brazil to the USA before he was registered with the Consulate… nope, impossible. The only way that could happen is if the child had dual citizenship and lived in a country where no visa was needed to enter the States… they could then travel on their other passport. Any request for a visa (in countries where a visa is required) would lead to disclosure of a US parent…. and immediate denial of a visa. But I think if they did enter using a foreign passport, getting them registered here would be complicated. The of State Department REALLY wants foreign births registered outside the States; the issue is (I think) that once someone is physically in the States, they have standing to fight the decisions of the State Department in Federal Court. Outside the States, they have no legal standing or recourse.

  222. >MikeM

    MikeM, under the rules at the time, Obama’s citizenship would not have been given because the mother was underage. Now it would be.

    Except Ann Duhmam was 18 when Barack was born which wasn’t underage.

    But besides that, these appear to have been the rules for kids born to parents who were married:

    For persons born between December 24, 1952 and November 14, 1986, a person is a U.S. citizen if all of the following are true:[11]

    * The person’s parents were married at the time of birth
    * One of the person’s parents was a U.S. citizen when the person was born
    * The citizen parent lived at least ten years in the United States before the child’s birth;
    * A minimum of 5 of these 10 years in the United States were after the citizen parent’s 14th birthday.

    The problem is likely bullet 5. Technically, the mom doesn’t have to be “of age”. But Ann Dunham was 18 years old. That would make years living in the US at most 14,15,16,17 with 18 only a partial year. No one can make that last requirement without reaching their 19th birthday.

    But she was in the US, so the fact that she hadn’t lived 5 years past her 14th birthday didn’t matter.

  223. Lucia, Snopes has it 5 years after age 16.

    …the U.S. because the law in effect at the time he was born specified that “If only one parent was a U.S. citizen at the time of your birth, that parent must have resided in the United States for at least ten years, at least five of which had to be after the age of 16.”

    .
    So it really does hinge on whether Obama was born on US soil, which Hawaii became just two years prior to his birth. Unless evidence arises the birth certificate was forged or there is another one in Kenya for a Barack Obama, or Barack Dunham, the matter rests. But if it does not it certainly didn’t take a massive conspiracy. My grandmother’s birth certificate was wrong by a week since it was made years after the fact.

  224. The Supreme Court shows nothing but signs it will not tolerate messing with the 1st amendment. They are not going to allow rules than can be bent to a partisan’s wishes because they know full well how that ends. The exceptions to the 1st amendment are much narrower than most people believe.
    http://www.latimes.com/opinion/op-ed/la-oe-white-first-amendment-slogans-20170608-story.html
    .
    Hate speech is legal.
    Being a racist is legal.
    Being Islamophobic is legal.
    Being a white supremacist is legal.
    .
    As it should be. If the SJW wing of the liberals were allowed to make the rules, all white men would be in Guantanamo for thought crimes now. One only needs to examine the recent insanity at Evergreen State to see what the desired endpoint is.
    .
    It’s very important to remember this is protection from government action, not the private sector. You can be fired for overtly being any of the above. It doesn’t say anywhere you can’t discriminate against those categories, the government just can’t make them shut up. Thankfully you can’t discriminate against white males for being white and male….yet. Affirmative action is very nearly this codified in law, but the SC has been walking this back more and more. States are allowed to ban it.

  225. >So it really does hinge on whether Obama was born on US soil,

    I don’t see how the birthers could achieve anything by arguing about law at the time when current law says otherwise.

  227. My comment keeps getting caught in moderation.
    In practical terms, makes no difference if Obama not born in America and mother not a citizen.

  228. MikeN
    Something must be weird with moderation. It’s not there.

    >Is there a reason this blog is set to Mountain time?
    Dunno. Maybe something changed when WordPress updated.

  229. Ron Graf
    >My grandmother’s birth certificate was wrong by a week since it was made years after the fact.
    There is a big difference between a clerk misdating by a week which can happen by a slip up and falsely stating a kid was born in the US which requires considerably more than a clerical error.

    Falsifying where the kid was born would have almost certainly required family connections or $$ paid to someone to fill out a false certificate.

  230. I think I tried edit, then as a separate comment.

    Practically speaking, it wouldn’t matter if it was found that Obama was born in Kenya, and his mother was not a US citizen.

  231. One thing that has changed with the WP update is that I now have to enter my name and email address in the text blocks every time. It used to fill those in automatically. It isn’t Firefox, because it still fills them out at Science of Doom. It remembers the contents because I only have to enter the first letter to get the full entry as a selection.

  232. MikeN,

    I still want to see Obama’s college transcripts even if it doesn’t mean anything now.

  233. Ron Graf (Comment #163277): “Snopes has it 5 years after age 16.”

    I think that is the claim Snopes was debunking. The law has changed many times. http://www.americanlaw.com/citabrd.html For people born in 1961, it was 5 years after age 14.

    I was surprised by how restrictive it used to be. What I thought I knew (and got wrong earlier) was based on what other U.S. citizens in Canada told me when I lived there. But that is the post 1986 version of the law, which was not retroactive.

  234. Re: Jacobson
    Yes, with regard to the original paper, it certainly appeared to exaggerate the possibilities of renewables. I’ve been busy today, so I haven’t read the rebuttal & response. Even if Jacobson is off, doesn’t mean that the Clack et al. criticism is apt.

    Paul Mathews and Andrew Montford weighed in.

    There’s also this Twitter exchange for amusement.

  235. DeWitt – I was surprised to hear what others thought of him in college only after 8 years as President. I am still baffled to how this was kept so quiet for so long.

  236. DeWitt,
    “I still want to see Obama’s college transcripts even if it doesn’t mean anything now.”
    .
    Why do you care? He was likely not qualified to get into the schools he did, and CERTAINLY not qualified to edit the Harvard Law Review. But so what… the importance of his intellectual capabilities, or relative lack thereof, has long since past.

  237. Kan,
    “I am still baffled to how this was kept so quiet for so long.”
    .
    Not me. I would be shocked if it were otherwise.

  238. Obviously, the DNC vetted Obama. The MSM is pretty much an arm of the DNC. That left Sean Hannity and a ragtag handful of conservative talk radio people to look into Obama.
    .
    I think it would be a huge story if one of Obama’s half siblings came out and claimed he was born in Kenya. It would prove not only poor vetting but outright collusion since they called anyone who questioned the fact a racist conspiracy buff. Most of the population still rely on the MSM as mostly unbiased fact reporters. This is how opinions on issues like climate are being shaped.

  239. Ron Graf,
    “I think it would be a huge story if one of Obama’s half siblings came out and claimed he was born in Kenya.”
    .
    I doubt that, because it is a non-issue. He served his term in office, and he is not coming back. He has a birth certificate showing he was born in the States. If he responded at all, and I very much doubt he would, he would just say they were mistaken. The MSM would not likely dwell on the story, nor would the public.

  240. Media does not dwell on story of guy claiming to be Chelsea’s half brother.
    The DNC did not vet Obama. At the time, Hillary was their champion, but Chairman Howard Dean was not in her pocket.

  241. Ron Graf,

    We could just as well discuss whether the people executed for Lincoln’s assassination were all actually guilty or not, but it would have roughly the same effect as what Mr Obama’s half sibling remembers about his birth location.

  242. When Trump was being grilled for not disavowing the birther theory fast enough last year a story broke loose that was kept hushed for 8 years.
    .
    On 9-16-16 McClatchy News released that McClatchy Washington Bureau Chief James Asher had been approached by the Clinton campaign and informed Obama was born in Kenya.

    Blumenthal had “told me in person” that Obama was born in Kenya.

    “During the 2008 Democratic primary, Sid Blumenthal visited the Washington Bureau of McClatchy Co.,” Asher said in an email Friday to McClatchy, noting that he was at the time the investigative editor and in charge of Africa coverage.

    “During that meeting, Mr. Blumenthal and I met together in my office and he strongly urged me to investigate the exact place of President Obama’s birth, which he suggested was in Kenya. We assigned a reporter to go to Kenya, and that reporter determined that the allegation was false.

    “At the time of Mr. Blumenthal’s conversation with me, there had been a few news articles published in various outlets reporting on rumors about Obama’s birthplace. While Mr. Blumenthal offered no concrete proof of Obama’s Kenyan birth, I felt that, as journalists, we had a responsibility to determine whether or not those rumors were true. They were not.”

    .
    So after 8 years we were entitled to know that Obama’s natural born citizenship was questioned by the Clinton top brass. But we are not entitled to know of the details of the McClatchy Kenya trip, only that the McClatchy reporter was satisfied there was nothing.

  243. SteveF, I would be immensely interested if there were new and compelling evidence on the Lincoln assassination, or the Lindbergh Kidnapping, or the JFK assassination.

  244. Ron Graf
    I think it would be a huge story if one of Obama’s half siblings came out and claimed he was born in Kenya.

    Well none has made the claim. But I agree with Steve F.
    It might have made a difference if the half sibling had claimed it in Dec 2007. Now? Not so much.

    Ron Graf

    was questioned by the Clinton top brass

    So briefly and privately it doesn’t matter. They heard a story, checked and quickly found it wasn’t true. Big whip.

    This is nothing like Trump or the birthers.

  245. Ron Graf,
    “I would be immensely interested if there were new and compelling evidence on the Lincoln assassination, or the Lindbergh Kidnapping, or the JFK assassination.”
    .
    Serious question: Why?
    .
    There is an outside chance someone “involved in” the Kennedy assassination could still be alive, but Lindberg or Lincoln? I just don’t see those as very relevant. Next we might revisit who killed Julius Caesar in the Roman Senate, and who maybe ‘got away with it’.

  246. The interesting thing is how long team Obama suppressed the Obama written press release where he bragged about being Kenya born. The or was for a minor publishing company as part of an authors profiles piece that is common in the publishing industry. Few if any Presidents have controlled their public persona as well or as long as team Obama. And the way team Obama was able to get the media to in effect shrug their shoulders and just move on was amazing.

  248. They successfully concealed that Obama was born at a very early age as well. It’s really tough to understand what’s going on in the country if you don’t even know if his navel was inny or outy.

  249. J,

    Exactly! That and the seven almond snack. You can’t tell me there’s not something sketchy about that. Not six (6) almonds, not eight (8); certainly not a handful (!).
    Exactly.
    seven (7).
    almonds.
    If the voting public had only known. If they’d only had some small inkling. The mind quails!

  251. JD Ohio,
    “…how did Illinois elect a Republican governor?”
    .
    It may be a little like a consultant: someone from outside you call in at the last minute to blame for all the screwups. 😉

  252. Off topic: Looks like the Republican will win the special election in Georgia for the seat vacated by Tom Price (HHS Secretary). The margin looks like 6%…. or 4% ahead of Trump in that district. My guess is that the locals took some offense at the $30 million in outside money the Democrat received. Didn’t help that he didn’t live in the district either. The Republicans showed up late with about $20 million of outside money. So lemme see… the Democrat got about 105,000 votes and spent about $30 million. He could have treated all the voters in the district to a very nice dinner for less than he spent. There will be renewed histrionics in the MSM tomorrow.

  253. SteveF, The GA district special election cost 50 million. If there were 105K voters that’s almost $500 per voter. One wonders what is so valuable at stake for one House seat. Another sure sign the government needs to be smaller.
    .
    SteveF “There is an outside chance someone “involved in” the Kennedy assassination could still be alive, but Lindberg or Lincoln? I just don’t see those as very relevant. ”
    .
    Steve, some take everything they were taught at face value and some take it as just a starting point. The historical view of all three of these historical crimes are still unfolding over that last 30 years. The Lindbergh Crime looks to have not even have been a kidnapping. Twenty five years ago the Congress, revisiting the JFK assassination for the third time decided that 75 years was a tad too long to keep the last files sealed. They thought 55 years was a more fair amount of time for the public to wait for the files. That happens to be this year. Any bets on whether they get released? Real question.

  254. In case others are having the problem, I think if you edit you need to re-enter your name and email or else it fails.

  255. Lucia: “They heard a story [BO born in Kenya], checked and quickly found it wasn’t true. Big whip. This is nothing like Trump or the birthers.”
    .
    Blumenthal was the Clinton’s intel agent. He likely knew it was false before he told McClatchey. If he suspected it was true he would have sent his own staff to Kenya to get the goods as a later bargaining chip. Of course, Blumenthal denies the whole incident happened.

  256. JD Ohio
    > If you care to answer, what is going on?
    Oy…..

    >Also, how did Illinois elect a Republican governor?
    Well… we had this Democrat named Blagojavich who is in jail. Then his replacement was never popular. So the Republican guy won.

  258. hunter,
    Completely unconvincing.
    I once needed a second passport to travel in some Arab countries (my regular passport had entry stamps for Israel; visas were not then issued when an Israeli stamp was in the passport). The second passport came through with an error in my date of birth. Though a US passport is legal proof of age, I was still the same age. A promotional paragraph about an unknown author is not a credible source.

  259. Ron Graf,
    The total vote was about 230,000.
    “some take everything they were taught at face value and some take it as just a starting point. The historical view of all three of these historical crimes are still unfolding over that last 30 years. The Lindbergh Crime looks to have not even have been a kidnapping. ”
    .
    I hope you have a lot of tinfoil… you could run out.

  260. SteveF, it’s easier to dismiss things that one hasn’t studied. Books that have different historical narratives on a particular event can be equally well researched and have opposite conclusions by the selection of evidence to highlight. Nobody would have believed Linda Trip when she accused Monica Lewinsky and WJC had she not, 1) recorded the conversation with Lewinsky detailing it, 2) kept the blue dress, 3) turned it over to an investigative authority for DNA analysis. The truth comes out rarely this lucky.

  261. Vince Foster may not have been murdered but Linda Trip later told an author that she took all those measures because she believed Foster had been and she feared for Lewisnky’s life.

  262. Arghh. At what age should children have smartphones? Rather than let parents decide, some want to legislate the issue.

    Sigh. I’m sympathetic to the idea that phones aren’t beneficial for kids below a certain age. But what makes people so eager to impose their choices on others? [Sounds rhetorical, but it’s a real question. You’d think that people would think about the implications — what other choices might be enforced by a majority in the future, using this as a precedent.]

  263. SteveF,
    I don’t see the old press release as evidence of Obama being born in Kenya. I see it as evidence that he milked his African heritage cynically. In the 19th century for awhile it was expected that if you were running for political office you would claim to have been born in a log cabin. This is not that different except that Obama likely played that African card to get from his nondescript state school with nondescript grades to get into the Ivy League by way of a highly unusual student transfer. As far as his citizenship, as I understand it if a child us born of an American citizen that child qualifies as a natural born American citizen.

  265. A possible lesson in the 4 straight victories by Republicans in special elections is that the narrative the dems/media are pushing is not as compelling outside their echo chamber as it apparently is on the inside. Another lesson is that most politics is local. Democrats are choosing weak national candidates to run against strong local candidates. But their tinfoil hat ideas about Trump are not going to serve them well in any time frame. They should probably be thinking about the implications of a blowback when the Russian stuff falls apart. But talking sense to people dedicated to believing nonsense is typically a waste of time.

  266. hunter,
    “I see it as evidence that he milked his African heritage cynically.”
    .
    There is no doubt about it. A fair to middling student would never get into Colombia via transfer, and then into Harvard Law, without more than a little ‘special consideration’. There is no doubt Obama got plenty of that. I don’t blame Obama for taking advantage of special treatment, I blame those schools for their terrible, stupid admissions policies.

  267. hunder,
    Rahm Emanual co-wrote a column today arguing exactly what you say: select attractive local candidates who are a close match to the district, fund them, and have them advocate moderate policies.
    .
    Of course, the unstated part is: have them support the unhinged policies of the extreme left once Democrats control the House, starting with an impeachment bill… it might be called the ‘stealth progressives’ plan.

  268. 100% renewables on the cheap! I say wonderful, go ahead and prove it to everyone, just not in my state where I have to pay the bills. Clean cheap reliable energy would be good for everyone, but you can’t just wish it into existence with a white paper. There’s nothing wrong with someone doing a thought experiment of how we could get there, but the people who take it seriously are the ones with a problem. The failure to include nuclear is laughable.

  269. The left lost all the special elections but closed the gap in every single one. The loss in GA might be very bad for them in the sense that it could send them the wrong message that running a moderate in conservative districts is a losing proposition and they need to turn hard left instead. The progressive base wants that. That would likely be disastrous.
    .
    The most likely thing that will prevent a Democrat takeover of the House in 2018 is their own arrogance and incompetence. The media breathlessly covered the GA election and clearly, clearly was anticipating a Democrat win. The NYT had a live blog with 5 reporters commenting all night. The polls showed the Democrat narrowly leading and he got “unexpectedly” beat by 5%. Sound familiar?
    .
    Running someone not named Donald Trump is not enough. They are out of touch with America and people are fed up with being lectured on their morals from on high. They need to get rid of Pelosi.
    .
    It might have been better for Republicans to take a loss here and put a sense of urgency into the party. Complacency will lead to a 2018 wipe out. 1.5 years is a long time, we will see.

  270. My advice to Democrats for 2018/2020: Drive the identity politics wing way out into a desert, drop them off, and make sure it is at least a 4 year walk back to civilization.
    .
    It is ironic that the GA Republican winner was…ahem…a woman, and was the first women in GA to be sent to Congress. Not a hint that misogyny played a role in the election from the media, and the celebration from the media for breaking this glass ceiling was shall we say “subdued”.

  271. Tom Scharf (Comment #163324): “The left lost all the special elections but closed the gap in every single one.”

    Hardly. You could say that if you ignore California 34, where Democrats got 100% of the vote in the runoff. But in the other 4, the margins were pretty similar. Georgia 6 must be especially galling. Trump edged Clinton 48% to 47%. Ossoff led Handel 48% to 20% in the original election, then lost 52% to 48% in the runoff. And that district is much less conservative than the ones in Kansas (7% margin), Montana (6% margin), and South Carolina (3% margin).

    No real trend, but the narrow margins should keep the Republicans from getting complacent.

  272. Mike M,
    Depends on how you compare. There are endless stats in the media that compare the gap from the previous same election (house seat) to this one, and the gap has closed. Over reading elections is probably not wise though.

  273. Steve F, at least Rahm is somewhat rooted in the retail reality of local politics. While his terms in Chicago have been terrible for crime and finance in the city he has kept his grasp on the power structure…keeping opponents off balance and disorganized. The real lessons are for the Republicans: keep focusing on representing the constituencies that you actually face at election. Not the illegals, not some tiny but loud outraged minority group of the day. Trump when not duking it out with the haters does that. That is also why the dems are so dedicated to forcing a change in demographics by way of illegal immigration. Sort of a reverse protection racket: get the criminals in and then promise to legalize them later.

  274. Tom Scharf (Comment #163327): “There are endless stats in the media that compare the gap from the previous same election (house seat) to this one, and the gap has closed.”

    Of course the gap has closed. Incumbents win by wide margins and the Dems have poured huge resources into races they would normally write off.

  275. The Illinois budget mess is actually a very valid fiasco.
    “Illinois has compiled $14.6 billion in unpaid bills. It’s running a deficit of $6 billion, and its pension liability has soared to $130 billion.”
    .
    http://www.politico.com/story/2017/06/10/illinois-debt-deficit-budget-election-239384
    .
    At this point, the biggest problem is they legally cannot declare bankruptcy as a state. The legislature actually passed pension reform a year or two ago but the Illinois Supreme Court declared it unconstitutional due to a state constitutional amendment that guaranteed public sector pensions that was passed in far better times. Even with the recent stock market rise, they are still in a dire situation.
    .
    The state legislature is hopelessly subservient to public sector unions. Their bond ratings are nearly junk level now. It’s going to be an unavoidable slow motion financial splat similar to Greece. They are going to have to ask for federal help eventually, and that’s a very tough ask for other states to finance Illinois’s budget irresponsibility.

  276. SteveF, I’m happy to fight for safe spaces but they should be for the disturbing, for that is what’s in need protecting. University campuses have it backwards, conformance is natural and corrupting.

  277. The problem with Rahm’s message is that there are no moderate Democrats in Congress regardless of what they say during the campaign and voters know it. Ossof, if elected, would have voted exactly how Pelosi told him to vote on anything important.

  278. To put it another way, the Democrats in Congress are herd animals like sheep or cows. The Republicans are cats.

  279. For the House special elections the voter simply was either a “yes” or “no” to resist Trump and the GOP agenda. There is no hope for Dem legislation for at least a year and a half, (3/4 of the House term).

  280. DeWitt,

    …the Democrats in Congress are herd animals…

    Funny. When I think this I usually think more along the lines of ants or wasps rather than cattle.
    I think your imagery is kinder. 🙂

  281. One way to look at the outcome of the two elections yesterday, especially the GA6, is that while Trump only won by 1.5%, Republicans won by about 4% in the face of relentless attacks on Republicans and Trump and 3:1 spending advantage by democrats. The frenzy , obstructive resistance, claiming Republicans want to kill sick people, the accusations and dog whistling of violence has pretty much backfired on the democrats. What will happen when the likely outcome of the Russian affair turns into a nothing burger and then the screw turns on dems and team Obama and obstruction, Iran, etc. To put it nicely there is some pent up anger over the game team Obama the media and the dems gave played regarding the election.

  282. “I think your imagery is kinder.”
    .
    Mammalian comparisons are indeed kinder. Not sure about the accuracy.

  283. Tom Scharf,
    “The failure to include nuclear is laughable.”
    .
    Indeed. If you price nuclear at $5,000 per KW capacity (even though a big fraction of that cost comes from the ‘green resistance’ to nuclear!) then adding the required nuclear capacity, to completely replace fossil fuels, about 700 GW, would cost somewhere near $3.5 trillion…. 25% of the ‘renewables’ investment cost. It is just nutty beyond belief to exclude the most practical option.

  284. Raccoons can cooperate to a pretty amazing extent…..wolves do strong packs….usually raccoon cooperation involves destruction of everything in the attic including the AC ducts. And wolves in packs are ruthless predators….

  285. hunter,
    Hummm… So are climate scientists more like raccoons or wolves? Judith Curry may have some insight.

  286. Hunter,

    It’s subjective of course. I think of insects rather than mammals both because insects are viscerally alien / disturbing and also because such power as they have comes from their hyper-social nature and eerie slavish devotion to the collective. But this is about as meaningful as arguing the merits of our personal favorite color (I don’t have a favorite color, but) – just opinion / personal preference at the end of the day.
    Anyway. 🙂

  287. mark bofill

    arguing the merits of our personal favorite color

    Red is the best color. No point in arguing. It. Just. Is.

  289. Raccoons for me are the worst because they are superficially cute but can do real damage. Wolves are pretty intimidating right off, unless you are Mowgli.
    lucia, the beloved Mrs. hunter agrees with you on red. We have a geranium red front door to prove it.

  290. :> I’m stymied. Do I run with this or argue?
    …
    I’ll argue it!
    NO LUCIA! Look, people see ‘red’ when they’re mad. Red is the color of fire and blood; words of House Targaryen, and everybody knows Targaryens are no durned good. Further, it can’t possibly be an accident that Sith Lords invariable select red lightsaber crystals. The baddest dragons of legend and D&D geekdom were always red. Smaug was red. Pictures of the devil are sometimes red. I don’t like tomatoes, and they are often red. Red lights mean stop and they contribute to road rage. It is been written that the zombie apocalypse will begin amidst a vast sea of red brake lights on some nameless highway. When I occasionally take my mindless rants too far it has happened once or twice that I eventually become embarrassed, and my face turns red. Lest we forget, this is also the color of sunburn!
    .
    It seems like there are deeper, more profound reasons that I’m just not finding yet this early in the morning. Covfefe may help…

    😛

  291. This interlude, silly as it may seem, has inspired me.
    I’m now thinking of inventing a game to play with my kids. I’m going to call it ‘Fallacy’. The game needs to somehow involve generating and attempting to identify logical fallacies – gotta work out the mechanics. I arrived at this because upon reflection I noted that a thorough and methodical appeal to logical fallacies is what my argument above lacked. Maybe I will revise it when I have time. 🙂 But my kids might get a kick out of this.

  293. hunter,
    “Raccoons for me are the worst because they are superficially cute but can do real damage.”
    .
    I once saw a raccoon latch onto the side of a hound-dog’s face… and it wasn’t ever going to let go… that was one very unhappy dog. The dog’s owner ended up bashing the ‘coon in the head to make him let go. Wolverines are said to be much worse, but raccoons are no joke.

  294. mark bofill,
    “Lest we forget, this is also the color of sunburn!”
    .
    And steamed lobsters… so it isn’t all bad.

  295. SteveF,

    I suspect you of corrupt motive. I know you have every right to say that about the color red. What you say is perfectly reasonable. I just don’t think you’re really speaking from a principled position.

    So. What did Lucia promise you, that’d you’d back her outrageous claim about red? How much was it? Was it power, prestige, women?

    / #OfftheDeepEnd

  296. No, I understand now. YOu’re not really SteveF. The Russians have hacked your credentials.
    They used to be identified as the ‘Reds’ you know. Eh? What further proof could anyone require.
    Just saying.

  297. mark bofill,
    “Was it power, prestige, women?”
    .
    I would find only one of them interesting.

  299. I suppose this is a pretty low threshold, but red also used to be better than dead, at least to some people.

  300. Hunter,
    Thanks! I don’t know how to go about it, but. Seems like it might be a worthwhile thing to do for them; if there’s a fun way to get them to understand what the heck a fallacy is and possibly get them good at identifying them. And who knows! The part about getting them good at generating fallacies may be early prep for a stellar political career.
    🙂
    I better quit screwing around here and get to work already. Thanks all.

  301. Mark — Hera promised SteveF power, Athena promised him prestige, and Aphrodite promised him women, but it was that tramp Eris that started it all.

    P.S. – Smaug was “a vast red-golden dragon,” except in the Rankin-Bass cartoon…where he was bright red, and voiced by Richard Boone, who played Paladin from “Have Gun, Will Travel.”

  302. Joseph,

    Thanks for setting me straight on Smaug. 🙂

    Eris is interesting. I didn’t realize there were two of her.

    She stirs up even the shiftless to toil; for a man grows eager to work when he considers his neighbour, a rich man who hastens to plough and plant and put his house in good order; and neighbour vies with his neighbour as he hurries after wealth. This Strife is wholesome for men. And potter is angry with potter, and craftsman with craftsman and beggar is jealous of beggar, and minstrel of minstrel.

    I can’t quite make out if she is the patron saint of capitalism or the patron of punitive taxes on those who are wildly successful. I sort of lean towards the latter, although I’m not sure why yet.
    Thanks!

  303. mark bofill,
    As there are two of them, perhaps one is the patron saint of capitalism and the other patron saint of punitive taxes.

  305. Mark, I suspect SteveF is in the pay of Big Crimson. As a former executive who has driven numerous businesses “into the red” he clearly is shilling for their monochrome agenda.

  306. Earle,

    No doubt. I’m sure we could get to the bottom of this sordid tale of bribery, women, and steamed lobsters if we could get a special prosecutor appointed. Unfortunately interest is likely to shift to Trumpcare in the immediate future, and all of these red handed perpetrators may walk scott free.
    From what I gather so far, Obamacare lite without the mandates.

  307. By chance an important JFK assassination relic went on auction today. One of the surgeons at Parkland Hospital who operated to try to save JFK did a hand sketch. Dr. Robert McClelland’s is one of several by surgeons on hand at the time that show entrance wounds in the front and exit wounds in the back.

    https://thenypost.files.wordpress.com/2017/06/170621-kennedy-assassination-shooters-03.jpg?quality=90&strip=all&w=664&h=441&crop=1

    http://nypost.com/2017/06/21/surgeons-sketch-suggests-2-gunmen-killed-jfk/
    All hospital witnesses reported a small entrance wound in the throat that was surgically modified into a tracheotomy to clear the airway. All at the Bethesda Naval Hospital autopsy wrongly recorded it as a throat exit wound. The brain was never examined as it was removed by someone before the autopsy (but after the pre-autopsy xrays).
    .
    Other forensics showing the official history incorrect:
    1) Zapruder Film showing head react violently backwards from fatal impact of bullet.
    2) Debris from head seen on film exiting the rear of the head and onto the trunk of the Presidential limo, and Mrs. Kennedy climbing out attempting to retrieve the largest piece of skull. It was picked up and turned in by a bystander.
    3) The motorcycle cop to left rear of the limo was showered in blood spatter along with Mrs. Kennedy’s secret service man running behind the car.

  308. I was a bit confused on the previous few weeks of Trumpcare coverage when the same outlets ran articles on how mean and heartless it was along side articles that said how bad it was that it was so secret and nobody knew what was in it. So it turns out that when it came out, it was unsurprisingly instantly branded mean and heartless.
    .
    It turns out Republicans are killing thousands and thousands of people, probably most of them defenseless babies. As it turns out the left isn’t being obstructionist by not cooperating regardless of the plan, but are instead putting up a brave and heroic resistance. Thank goodness the same standards are in play, ha ha.

  309. It appears that Obama is doing his part to help unite people behind Trumpcare by attacking it.

    “a massive transfer of wealth from middle-class and poor families to the richest people in America.”
    .
    “It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else,”

    I love how ‘cutting health care for everybody else’ that everybody else wasn’t actually paying for in the first place is a massive transfer of wealth. How did Vizzini put it in the movie ‘The Princess Bride?’ OH yes – You’re trying to kidnap what I’ve rightfully stolen.
    .
    Tom,
    It’s oh so much worse than killing thousands of defenseless babies. It’s slashing funding to Planned Parenthood…

  310. Corollary to DeWitt’s theorm that irony always increases: tinfoil always increases. See comment 163362; QED.

  311. Earle,
    “I suspect SteveF is in the pay of Big Crimson.”
    .
    Maybe, but I have been waiting a long time, and no checks have arrived. Maybe the problem is a mixup in documentation… the same mixup that stops my monthly check from the Koch brothers.

  313. Tom,
    If you beat someone to death with a baseball bat, that qualifies as hate in my book.

  314. Tom,

    Yes. I think if we go by, say, the FBI definition:

    A hate crime is a traditional offense like murder, arson, or vandalism with an added element of bias. For the purposes of collecting statistics, the FBI has defined a hate crime as a “criminal offense against a person or property motivated in whole or in part by an offender’s bias against a race, religion, disability, sexual orientation, ethnicity, gender, or gender identity.”

    I agree that it is arbitrary in the sense that it is viewed as something ‘special’. What I mean by this is simple. Comes someone to smash my head with a baseball bat, I don’t give a crap if they come because of my race, or because of my politics, or because the moon was in the seventh house, or because they were crazy and the voices told them to, or what. It doesn’t make the slightest darn difference to me or my loved ones why criminals come. The damage they do to innocent lives is what matters. Whatever rationale governs the punishment that government levies in response, be it eye for an eye justice, or punishment to discourage potential criminals, or whatever: bias and discrimination should have little if any bearing in my view. These things do not make crimes any more or less heinous.
    .
    As always, I could be wrong. I’m sure the Blackboard will point it out if I’m overlooking some glaring point here. 🙂

  315. “I’m sure the Blackboard will point it out if I’m overlooking some glaring point here.”
    .
    Mark, I’m not out to do that but I would like to point out that motive is a critical element in the jury’s consideration of a crime as well it should be. It also is of public concern. For example, the last administration seemed to bend over backwards to mislabel Islamic terror as workplace violence in Fort Hood and initially in San Bernadino. It’s important to know motives for crimes (as well as the motives for mis-characterizing them for political gain.)

  316. Does anyone see a parallel between Trump’s justice department hiring a close friend and mentor of the fired FBI director to investigate the administration and the Koch brothers hiring Richard Muller to set up a climate “red team” that quickly capitulated that the “debate is over?”
    .
    Joe Romm blasts DOE Secretary Perry for being a climate skeptic, which is synonymous with being anti-science.

  317. Thanks Ron,

    I would like to point out that motive is a critical element in the jury’s consideration of a crime as well it should be.

    I’m under the impression that what you say is true. However, I am also under the impression that consideration given to motive has historically been in order to ‘make a case’ against someone (motive, means, opportunity). This seems to me to be different, although I can’t quite precisely articulate why yet this morning.
    BTW,

    I’m not out to do that

    I usually (at least I try hard to) consider people pointing out my errors a kindness. Of course you don’t have to do me any kindnesses, but just the same I strive to welcome and appreciate the help.
    Thanks again.

  318. Christina Figueres joins the Lancet Countdown’s advisory board.

    Even with the departure of the USA from the [Paris] Agreement, 196 other countries are united in their commitment to prevent a global climate catastrophe….By providing annual data across a range of indicators, the Lancet Countdown [Tracking Progress on Health and Climate Change] will lead and communicate on health and climate change; demonstrate the health co-benefits of mitigation and adaptation; and monitor global progress in meeting the Paris Agreement.

    I can only imagine that when malaria incidence (over 200 million cases in 2015) doesn’t expand by whatever increase is currently projected, this positive effect will be attributed to the Paris Agreement. Post hoc ergo propter hoc.

  319. Ron,

    I think it’s that the accused needs to have some plausible motive, because people don’t generally act for no reason, especially when risk is involved, as (sometimes? often?) is the case in criminal activities.
    There needs to be a motive to establish guilt. But there’s nothing magical about the nature of the motive. Usually. I think. I don’t really know. Shouldn’t be, maybe would be a better way to put it.
    Heck I don’t know. I think in the back of my mind I suspect there’s something not right about what I’m saying, I just can’t quite sort out where it is.

  320. HaroldW,
    Those folks appear to have too much time and too much (public) funding on their hands. There is one simple solution to this problem..

  321. mark bofill
    >There needs to be a motive to establish guilt.
    Sometimes an act is only a crime if it has a particular motive. It’s not just a matter of evidence, for somethings no motive means an act was not a crime.

    Different types of mens rea are discussed here:
    https://nationalparalegal.edu/public_documents/courseware_asp_files/criminalLaw/basicElements/CommonLawMensRea.asp
    If I understand right:
    Breaking and entering is only “breaking and entering” if all you want to do is enter and then, say, stay warm. But it becomes burglary if your motive (‘intent’) was to commit a felony once inside. You don’t actually have to commit the felony (perhaps a dog gets you and you fail to get the diamonds), but your “intent” (i.e. motive) is what makes it “burglary”. Otherwise, the same act is “breaking and entering” which is a different crime.

    The idea of the hate crime designation is it adds to the underlying act. What would be just “assault” escalates to a crime with more serious consequences if the motive is “because of vicitim’s sex” or “because of victim’s race” and rather than “after argument with girl friend” or “was the next random person to leave the bar” or something.

  322. Thanks Lucia! 🙂
    I was pretty sure I was missing something there. And thank you for the link as well.

  323. There needs to be a motive to establish guilt.
    .
    If someone kills another but is found that they had no other choice but to defend their own life (and they were not otherwise instigating a threat) then it’s not murder.
    .
    Racism is argued by Black Lives Matter to be skewing the perceptions of where that line is for police killings in the line of duty. I find it an interesting question as to whether being dressed like a gang thug or being of a race in a neighborhood with high crime stats should be weighed as a threat. Then after answering that, what about someone in Islamic garb with a bulging midsection entering a synagogue where a bar mitzvah is being celebrated?

  326. SteveF,

    I know, but I thought I’d try.

    Posner has solid answers for all the points raised by Ron and many more.

  327. Ron Graf (Comment #163370): “motive is a critical element in the jury’s consideration of a crime as well it should be.”

    lucia (Comment #163376): “Sometimes an act is only a crime if it has a particular motive. It’s not just a matter of evidence, for some things no motive means an act was not a crime.”

    Motive is not usually an element of a crime (hate crimes or terrorism might be exceptions, I am not sure of the fine distinctions that may apply). Motive is not the same thing as intent, which may be an element of a crime. Motive addresses the question of why someone did a thing, intent addresses what consequences were intended. If a legally insane person kills someone because voices told him to, he had a motive but probably did not have intent, since he may have lacked an understanding of the consequences. If you repeatedly hit someone in the head with a baseball bat (and are not insane) your intent was to kill, no matter your motive. If you kill someone in self defense, what matters is not your motive or intent but whether your action was justified.

    Motive matters in a trial since the lack of a motive will lead to doubt in the minds of the jurors and that may lead to an acquittal, unless the evidence is very strong. But a motive is not required to get a conviction.

  328. Apparently the FBI has decided in only 1week that the attempted assassination of Republicans was not only a lone wolf attack but was also not political, not motivated by political concerns, not targeted at Republicans and was not terroristic. Just a troubled soul down on his luck just move on please.

  329. Somehow I may have wandered off into the weeds trying to dispute that motive ever currently matters in the eyes of the law. Obviously it matters to the FBI in the case of a hate crime; the definition I linked point blank says so.
    I think my original thinking was that in general it shouldn’t matter, although I’ve come to doubt or at least question this notion as well.

  330. mark bofill “I think my original thinking was that in general it shouldn’t matter, although I’ve come to doubt or at least question this notion as well.”

    I am very much of the opinion that motive should not matter since it is impossible to reliably judge what is in the mind/heart of another. In practice, hate crime laws establish a situation where we are all equal in the eyes of the law, but some are more equal than others. Ultimately, that undermines the law.

    Intent, on the other hand, can be reasonably inferred from actions. If you shoot somebody, we can conclude that you intended to kill him. You might argue that you were only trying to rob the guy, the gun was just a prop, and you fired it by accident. But the law will say that the fact that you chose to use a loaded weapon to commit a crime establishes intent to use the weapon, if need be.

    But I do not see how we can reliably do the same with respect to hate crimes.

  331. Mike,

    I like the distinction you draw between intent and motive; this is helpful and is probably part of what I was groping for. I started from the same point (hate crime laws looking at motive seems like it can go wrong in various ways). I just wonder if I wasn’t being too general. Lucia causes me to realize that there are oodles of cases I really haven’t given the slightest bit of thought to, and that makes me think I ought to pause and do a little reading and pondering.
    I think I’ve got the same concerns you do however.

  332. I don’t doubt that “hate crimes” as defined happen, it is unclear to me that they need to be a special designation with mandatory exceptional punishment. I hate my neighbor murder vs hate crime murder seems to be not a big distinction in my mind. I suppose that the thinking is that the murderee in a hate crime murder could not have prevented his targeting. The bystander shot in a convenience store robbery could not either.
    .
    The bigger problem is that the application of the hate crime designation is too arbitrary and allows too much judgment. When 5 cops are murdered in Dallas, not a hate crime. Scalise shooting, not a hate crime. Terrorist incidents, not hate crimes. It forces a prosecutor to crawl into people’s heads and determine extra special intent. It’s all too fuzzy. The jury and judge can still take this into account during a trial regardless of the designation.

  333. Is that the exception becomes a federal matter a good thing? I can make an argument. Here in my neck of the woods there was probably a time it wouldn’t have been far-fetched to think that a racially motivated hate crime might not be resolved in a just manner locally. [Edit: Good ole boys looking out for one another, that sort of thing] If this was the thinking, there might be something to it.

  335. Not having Al Gore to kick around any more has taken all the joy out of being a climate skeptic.

  336. Can someone explain why targeting politicians who you do not know for murder because you disagree with their policies does not qualify as a hate crime, while trying to murder someone you don’t know for some other reason is? I’m just not seeing the logic. The FBI should be ashamed of themselves for claiming the nutcase leftist assassin was in no way motivated by politics… talk about not passing the smell test!

  337. SteveF,

    Par for the course for the FBI. They are political first and criminal investigators second or possibly lower, and not all that good at it either.

    Let me add that I’m sure there are good, competent people in the FBI. I just don’t think they are anywhere near the majority.

  340. Mike M: “I am very much of the opinion that motive should not matter since it is impossible to reliably judge what is in the mind/heart of another.”
    .
    First, wrt your distinction between motive and intent, I am not a lawyer but the common understanding is that intent relates to an the occurrence of an act where motive pertains to considerations relative to one’s circumstance, whether or not if can be proved they acted on them. For example, a large insurance policy provides a motive for spousal murder, but other circumstances would also need to corroborate the establishment of intent of an action that caused the death. I strongly disagree that it is any more difficult to arrive at a degree of certainty of one’s intent than any other non-physical evidence of the crime. A taped confession explaining one’s intent that is later recanted is a good example of what could be strong evidence. An admission in confidence to an friend, family member or accomplice would be just as strong. Most crimes consider intent. The exceptions are where extraordinary care are a requirement, thus providing a low bar for gross negligence, like in handling classified documents.

  341. DeWitt, As I already commented even equally well researched books can come to opposite conclusion. There exists no better example than the JFK assassination. The is not an accident. There are so many pieces of evidence to consider that one can cherry pick and still get a very robust picture of any one of several plots. This is why I would advise reading more than one perspective or not bother at all. It’s also why I stick to the forensic evidence if I dare to speak my opinion. The direction and number of the bullets are sine qua nons.

  342. Ron,

    I strongly disagree that it is any more difficult to arrive at a degree of certainty of one’s intent than any other non-physical evidence of the crime.

    I’m not sure Mike disagrees with this. He did say:

    Intent, on the other hand, can be reasonably inferred from actions. If you shoot somebody, we can conclude that you intended to kill him.

    This could be a misunderstanding.

  343. Ron Graf, they are similar. I know because it took me a long time to figure out what you were talking about, I didn’t notice the name switch.

  344. mark bofill: “I’m not sure Mike disagrees with this.”

    I am not sure if Ron agree with me (everything he said seems to agree with me) or disagrees with me (he sounds like he means to disagree). I am puzzled as to both his motive and intent.

  345. DeWitt: “Let me add that I’m sure there are good, competent people in the FBI. I just don’t think they are anywhere near the majority.”

    My guess is that the good, competent FBI agents are the majority. They just don’t make it to the supervisory and management positions. Those are reserved for the political animals in the agency.

  347. Ron,

    None of the other books on the assassination of JFK provide a clear and convincing scenario. They, as you say, cherry-pick. If you read Posner, the forensic evidence is not as clear cut as you think. Governer Connally’s wound can only be explained if the bullet that hit him had already lost velocity by passing through Kennedy’s neck from back to front. You can even see Kennedy’s tie twitch outward in the Zapruder film when it’s hit by the bullet on the way out. The bullet path through Connally’s chest is exactly what you would expect if he had turned his body to look toward the Book Depository after the first shot, which happened much earlier than the Warren Commission scenario.

    It’s all there. There is simply no consistent, credible evidence that there was any other shooter than Oswald. You are indeed in tinfoil hat territory.

  348. That doesn’t mean the sketch isn’t valuable. It just doesn’t prove what you think it does.

  349. Mike M:

    My guess is that the good, competent FBI agents are the majority. They just don’t make it to the supervisory and management positions. Those are reserved for the political animals in the agency.

    .
    If this were not the case, Mike, the FBI would be different from 95% of the organizations and businesses in the world; surely too much to expect.

  350. j ferguson,
    “…the FBI would be different from 95% of the organizations and businesses in the world; surely too much to expect.”
    .
    I completly agree for large organizations… but the smaller the obrganization, the more actual competence matters. It took me altogether too long (more than a decade!) working for a big company before I realized that proficiency at the task at hand was most definitly not highly correlated with promotion to management, and indeed, seemed too often anti-correlated. Still took me the better part of another decade before I bailed…. I was still “blinking in disbelief” for a long time I guess.

  351. Mike M, I guess I disagree with you definitions and distinctions between motive and intent. One term is often substituted for the other but in the case of a criminal deliberation motive can also mean possible motives, considerations one could have whether or not they acted upon them. When you say: “I am very much of the opinion that motive should not matter since it is impossible to reliably judge what is in the mind/heart of another,” I disagreed and commented as to why.
    .
    I enjoy the discussion since it is indeed weird that killing someone with rage (hot blood) in your heart is a mitigating circumstance, lowering first degree murder to second degree. But if the rage is exacerbated by racial prejudice then the opposite, it’s and aggravating circumstance.

  352. DeWitt: “None of the other books on the assassination of JFK provide a clear and convincing scenario.”
    .
    Are you stating this from firsthand assessment or taking Posner’s word? There are a lot of JFK books. Have you read Anthony Summers or Mark Lane or Dick Russell or Robert Groden or Dr. Cyril Wecht…?
    .
    Just a quick search shows another Parkland doctor going on the historical record that the throat wound was an entrance wound.
    .
    I am glad you are claiming to have some knowledge and look forward to informed comments.

  353. Ron Graf,
    Whether racial prejudice should or should not matter is rather controversial. A argument in favor of making racist motivations a factor in an escalated crime can be seen if we consider a not too implausible hypothetical. Suppose a member of the KKK decides they are going to exterminate or at least intimidate all uppity black people. (Of course, this person decides for himself who is ‘uppity’. I think that’s pretty consistent with their decision to exterminate people anyway.) This KKK member then arms themselves and starts killing black people only.

    This person is doing something more than merely murdering individuals; their intention is extermination or intimidation of a group he considers a class of people. That class is “uppity black people”. In this particular KKK members case it might be that he wants to intimidate them so they stop being “uppity”.

    This is rather different than just ordinary murder which is already illegal.

    That said, it’s not clear that the escalating factor in the murder must be identified as “racism” or ‘member of some historically vulnerable class’. One might be able to identify the ‘intention to kill members of a ‘class’ with the ‘class’ defined as people sharing a trait the perpetrator latched onto. In that case, the escalating factor would exist whether the latched onto “women who go out unescorted”, “uppity black people”, “religiously observant jews”, “red heads who show off their brilliant hair” or any other feature that a deranged person might latch on to.

    Whether this focus on a class should be called “hate” is debatable. But quite likely the person with this focus does “hate” something about the class of people they decide to murder.

    The thing is: defined this way, it would probably be difficult to pin escalating factor on the perp unless they clearly went out focusing on the class. Or failing that, left some specific evidence that their motive actually was to exterminate or intimidate that class (or at least kill plenty of members.)

    We already have other escalating factors with killing people. Some involve intent, some involve brutality. It’s not that big a stretch to deem desire to exterminate or intimidate a class of people as being something somewhat different than just intent to kill an individual (even one picked at random.)

  354. Lucia, I think you are on to it. Racial crimes are akin to crimes against humanity. It has been agreed by civilization that religious and racial attacks are a form of destructive tribalism that comes from a primitive part of are brains not controlled by higher reasoning,
    (although, of course, we would use the cortex to plan how to execute our primitive motivations).

  355. SteveF,
    the revelation of starting my own company was discovering the magnitude of the psychic overhead of working in a larger corporation; which of course I’d left behind. the problem seems to have been the division of effort required for me to do, or cause to be done, the things needed to progress our objectives with the amount of effort to keep ignorant (possibly stupid) management above me off my back. The guy that does Dilbert has a very accurate perception of this situation. I fear it’s endemic.
    .
    having written the above, I was still a victim of choosing a form of business which became obsolete within the 7 years we struggled with it, but I’m grateful i finally figured it out, recognized we didn’t want to do any of the “what’s nexts”, sold out, and are now living happily in retirement amongst highly intelligent friends while we pursue development of interesting, challenging projects which we may or may not succeed at.
    .
    Younger readers here; save your money. Retirement will isolate you from many of the things you hated in employment as well as reduce considerably your exposure to morons. I have a backlog of things to do that I’m unlikely to deal with in the maybe 20 years I have left.

  356. If there is a hate crime law, then the escalation punishment should also apply to people who fake hate crimes.

  357. Lucia — I think your hypothetical crosses the line from “hate crimes” (as they are normally defined in statutes) and terrorism…where the motive is to “(i) intimidate or coerce a civilian population; (ii) influence the policy of a government by intimidation or coercion; or (iii) to affect the conduct of a government by mass destruction, assassination or kidnapping.”

    In your hypothetical, the motive would fall under part (i)….and thus into a whole new realm beyond an ordinary hate crime statute.

  358. Ron Graf (Comment #163407): “I disagree with you definitions and distinctions between motive and intent.”

    Not my definitions. See the Wikipedia articles or the excellent link lucia provided earlier: https://nationalparalegal.edu/public_documents/courseware_asp_files/criminalLaw/basicElements/CommonLawMensRea.asp
    .
    Ron Graf: “I disagreed and commented as to why.”

    If you say so. I did not follow your point.
    .
    Ron Graf: “it is indeed weird that killing someone with rage (hot blood) in your heart is a mitigating circumstance, lowering first degree murder to second degree.”

    Rage is not a mitigating factor. Premeditation is an aggravating factor that turns ordinary murder (second degree) into first degree murder.

  359. MikeN, I absolutely agree with you that faking a hate crime should add to the crime. It shows malice in forethought. I would extend this classification of in-excuseability to all forms of intentional subterfuge against a group, whether it be a political group or racial group.
    .
    The question then becomes what is acceptable for state’s to conduct on their people or of the people of another state? If Russia’s use of online trolls is an act of war what about the CIA’s operations? Personally I think we could do just fine with 16 intelligence agencies (17 minus the CIA).

  360. Mike M, I agree that link has a better distinction of motive and intent than I put forth, whereby intent pertains narrowly to the criminal act being charged and motive refers to motivations. Do you still maintain that motive should not matter to Lady justice?

  361. Mike M, thank you also for clarifying that premeditation (cold blood) is an aggravating circumstance. Let me thus restate my question. What premeditation in a hate crime is worse than any other premeditated motive? I am supposing the answer is that hate crimes are particularly harmful to society.

  362. Ron Graf (Comment #163417): “What premeditation in a hate crime is worse than any other premeditated motive?”

    None, so far as I can tell. Crimes should be based on what you do, not what you think.

  363. Crimes should be based on what you do, not what you think.
    .
    Does that go for both motive and intent? If so, you are saying accidental acts should be punished the same as intentional. I suspect you don’t think that though. I think we all agree, however, that a thought without an action is (rightfully) not punishable.

  364. Ron Graf: “Does that go for both motive and intent?”

    Of course not. As I said earlier, and as described in the link above, intent can be inferred from actions. In many cases, intent must be demonstrated by the prosecution.

  367. The thought crime issue is an interesting one. “Intention” and “intent” have always been acceptable factors in at least some crimes. Intent was applied in the case of Hillary by self declared legislator, judge and jury Comey to unapply a law that specifically avoided intent. Intent to harm, intent to distribute, intent distribute, etc. But intent, while requiring thought is not itself a thought…or emotion. But no one says intent as an aggravating factor is a thought crime. Yet the FBI worked hard to get the baseball practice shooter’s intent as far from politics, and declared him a lone gunman, with blinding speed. And we know in the case of his intentions, against a great deal forensic evidence. What other evidence was carefully edited to make a predetermined result? Then we come to hate crimes. Hate crimes are about thoughts as well. But what is the difference between intent and hate?

  368. Mike M, I don’t believe there is the separation between intent and motive that you are attaching. The way I read the Mens Rea link is that legal “intent” is a narrow subset of intentions demonstrated by motive. Legal intent tells only whether the action itself was intended but tells nothing about the benevolence or malevolence behind the act. The example in the link demonstrates this by citing the case of an assisted suicide having the intent of killing (which is murder). The motive was pure.

  369. So it turns out that during the peak season of the “Trump is a cockholder for Putin’s pistol” the chief Senate cheerleader of the “Trump is a spy”, Senator Schumer, had been specifically told Trump was under no investigation. Now that means Schumer- and the others who knew thus- were intentional in their saying otherwise. That means the WaPo, biggest media cheerleader_and (profiteer of same) were intentional. Now March was a very formative time, apparently, in the devolution if that slimeball baseball shooter. So was Schumer et al, in their intentional lying and deception merely callous, cynical and deceptive, or was their intent to dog whistle disgusting deranged people into committing dramatic acts of “resistance”?

  370. Ron Graf (Comment #163424): “I don’t believe there is the separation between intent and motive that you are attaching.”

    I am not sure what you mean by “separation”. If you only mean that they are different, then you are mistaken. If you mean they are completely unrelated, then that is not what I am saying.
    .
    Ron Graf: “Legal intent tells only whether the action itself was intended but tells nothing about the benevolence or malevolence behind the act.”

    Yes, intent and motive are different things. Intent is somewhat broader than just whether the act itself is intentional. In many cases, intended consequences can be inferred from the act. So if you deliberately shoot someone, the law will conclude not merely that you intended to shoot the person, but that you intended to kill.

    You can not do something analogous with hate crimes without creating a situation where some people are more equal than others. It is obvious to most people that the baseball field shooting was driven by hate of Republicans. But the FBI seems to have concluded otherwise because Republicans are not a protected group.

  371. Mike M, I think we are now in full agreement on intent vs. motive. In your shooting example motive would be looked at to determine the degree of crime intended. The two are linked and that’s why motives are important to justice.
    .
    On applying equality and reciprocity to hate crimes I again agree. If the reasoning behind the unacceptability of hate crime is that it tears at the fabric of society then protecting one class over another does little to repair that tear.

  372. Ron,

    I haven’t read those books, nor do I have any interest in them. The evidence is that the bullets that killed Kennedy and wounded Connally were fired from above and behind the vehicle.

    No one in his right mind would attempt to kill someone in the back seat of a car with multiple passengers by firing from a position in front of and on the wrong side of the car. There’s the windshield, if nothing else.

    The Parkland doctors didn’t turn Kennedy over to look at his back, so their opinion that the wound in the front of his neck was an entrance wound is not evidence. The tracheotomy meant that no one else saw the original wound. The wound in his back was small and consistent with being an entrance wound, not an exit wound.

    That’s all I have to say in this matter. You can go on believing a fantasy.

  373. I don’t know much about the law, but Hate Crime does seem troublingly close to Orwellian Thought Crime.
    .
    When I was younger, I recall that “malice aforethought” punished more than “crimes of passion”.
    .
    But what’s more passionate than hate?
    .
    Similarly, young people’s intolerance of free speech is disturbing. Not only is Hate Speech protected, freedom of speech exists specifically because no government gets to decide what’s truth or not. To have understanding, scientific or other, one must have free inquiry, which means complete freedom of thought and expression.
    .
    Better that odious ideas are negated by public discourse than by governments corruptly stifling speech.

  374. Ron Graf (Comment #163427): “I think we are now in full agreement on intent vs. motive. In your shooting example motive would be looked at to determine the degree of crime intended. The two are linked and that’s why motives are important to justice.”

    I disagree with all three sentences. I am tired of repeating myself.

    p.s. I need to add a clarification. I assumed that by “justice” Ron meant “the judicial system”. Using a broader meaning of justice, I would agree with Ron’s third sentence. But the judicial system is, at most, only marginally concerned with justice in that sense.

  375. DeWitt,
    The great thing about conspiracy theories is that they are immune to reasoned argument and verifiable data. We currently see a rabble of dishonest (or crazy) Representatives and Senators starting ENDLESS theories of Trump treasonously conspiring with ‘the Russians’, utterly absent any evidence. And probably a third of the population who will never accept anything except a confirmation of those theories… all contrary evidence will be claimed part of the same conspiracies, and the absence of any evidence will be claimed to be proof of the success of the conspiracies.
    .
    Every person who expresses doubt about the magnitude of global warming and its consequences is immediately dismissed as part of the vast Koch brothers conspiracy… not to mention anyone who disagreed with Bill Clinton’s policies or behaviors was part of a ‘vast right wing conspiracy’.
    .
    And of course, there are those who claim all climate scientists are part of a vast green conspiracy; read a comment thread or two at WUWT for confirmation. (I do not think there is any conspiracy; they are just mostly very dedicated greens who want one thing: everyone stop burning fossil fuels.)
    .
    I have often wondered what motivates the tinfoil hat community, and have never found a good explanation. The best I can come up with is that it is some kind of weird defense mechanism…. reality is too complicated or too painful, so they substitute an imaginary reality which is more satisfying. What I do know is that conspiracy ‘ideation’ is rampant, immutable, independent of political views, and utterly disconnected from reality. Hence, tinfoil always increases.
    .
    I find it all pretty depressing.

  376. I seem to have succeeded in leaving a lot of sour tastes here so I guess I’ll try to turn lemons into lemonade. Thoughts that are out of the tribal consensus are disturbing. They upset assumptions, present uncertainty where none existed before and threaten order. SteveF, you are absolutely right that there is are natural defense mechanisms to queer ideas or queer behavior. There are defenses against harming of ones feelings, dignity or place of respect. Modern Western society is mostly safe from physical threats day to day, at least more so than in history. But freedoms, multiculturalism and accelerating modernisms threaten our heads every day.
    .
    Everyone here should be able to agree that the climate debate is more about tribal doctrine than is about physical threat. The base of the climate alarm is the fear of mankind, that is reckless, uncontrollable and irredeemable. It’s seems there is a natural tendency to externalize threats, create a “Boogeyman.” I sure I have written accusations generalizing about liberals or dems. I guess they are my boogeymen. But whether it’s a political group, racial group, tin foil hat wearers or reckless mankind, we seem to need to do it.
    .
    What I think many realize in this string is that hate crime laws are an attempt to deal with this issue. But the attempt was hopelessly flawed in that it seems inevitable that a new tribe can instantly form around a new external boogeyman at the drop of a hat. The US founders knew the dangers better than we of trying legislate specific actions for specific groups. Thus is why Lady justice is depicted blindfolded. Laws should be as equally applied as possible (even when everyone in society is not in equal circumstances.)

  377. Ron,

    I’ve got no interest in JFK’s assassination. This said, I have no general issue with conspiracy theories. As I am fond of saying, I may be wrong / often am. Still, I believe that real events often get casually dismissed as conspiracy theory. Had Comey not explicitly said so under oath in his testimony, I believe claims that Loretta Lynch tried to protect Hillary Clinton for political reasons would have been dismissed out of hand as conspiracy theory
    .
    Further, the term ‘conspiracy theorist’ has become synonymous in our modern age with the term ‘nutcase’. Yet in my view a large part of the genius of our founding fathers lay in the fact that not only did they theorize about possible future political conspiracies, they took them seriously enough to explicitly shape our government to guard against them.
    .
    All this said, the readers here are a skeptical bunch with a high bar. I wouldn’t waste their time mostly. .. Not that I haven’t before, but. ~shrug~
    .
    It’s all good in my book anyway.

  378. Thanks for your comment Mark.
    .
    1) People are inventive in ways to conduct crimes.
    .
    2) Conspiracies are a logical innovation since they make complex crimes achievable and harder to solve.
    .
    3) Law enforcement hates conspiracies because they are hard to solve and because it opens them up to ridicule, making them politically vulnerable.
    .
    4) The larger and more complex the conspiracy the harder one would think it would be to keep all parties quiet. Thus people dismiss conspiracies as generally implausible. Yet, there are many known examples of conspiracies that were uncovered but not be a whistle-blower, until the game was up: The Lincoln Assassination, the Tuskegee Experiment, Watergate and Iran-Contra. The 1933 Wall Street Coup was narrowly averted by a refusal of General Smedley Butler, leader of the disaffected WWI bonus marchers, to incite the spontaneous mob uprising. Butler instead called the FBI. The whole affair was covered up and only is known today due to “fringe researchers.”
    .
    5) The existence of conspiracies, or even talk of them is considered harmful to society. This taboo makes catching or prosecuting perpetrators nearly impossible.
    .
    6) The more arcane the conspiracy the more amplified the inhibitions of authorities or potential whistle-blowers.
    .
    7) OTOH, there really are paranoid schizophrenics and others who jump too soon on the conspiracy train.
    .
    8) Because extraordinary claims require extraordinary evidence even forensics that would make an normal case open and shut can be ignored, and with barely any evidence required poorly fitting scenarios (if nonthreatening) will be embraced.
    .
    9) Therefore the more completely the elimination of conspiracies as being worthy of consideration the more viable they become. “The bigger the lie the more people will believe it.” -AH
    .
    Here’s an Interesting poll that shows the percentage of people believing the JFK assassination was a conspiracy has never been below 50% (when asked anonymously).

  379. 1) Yes
    2) Maybe. That’s a matter of opinion. I’m not a criminal mastermind, but I’d lean more towards the ‘keep it simple, stupid’ theory of operations. I get this from my job I think.
    3) I don’t know. I think *everybody* tends to dislike things that open them to ridicule, sure.
    4) Covfefe. I can’t speak to this without covfefe. Brewing now.
    5) talk of conspiracy considered harmful to society by whom?
    6) Yes, if by arcane you mean complicated. Generalizing, the more complicated something is the more opportunity there is for something to go wrong. People know this and it affects their estimation of the likelihood that a theory explaining something may be true. See also Occam’s razor. People don’t like being wrong or putting forward theories that are unlikely to be correct, so sure. I think people have greater inhibitions against putting forward complicated conspiracy theories. Simplicity can be elegant.
    7) Yes, absolutely. Nobody wants to be associated with people who are really nuts; views get marginalized and dismissed.
    8) don’t know about that.
    9) mebbe.

    Thanks Ron.

  380. Okay, got my coffee.

    4) The larger and more complex the conspiracy the harder one would think it would be to keep all parties quiet. Thus people dismiss conspiracies as generally implausible. Yet, there are many known examples of conspiracies that were uncovered but not be a whistle-blower, until the game was up

    Yeah, one would think, because it’s so. It IS more probable. If the probability of one person blabbing is c, the odds of N choose one (or more) persons (K) blabbing is going to be >= c.

    : The Lincoln Assassination, the Tuskegee Experiment, Watergate and Iran-Contra. The 1933 Wall Street Coup was narrowly averted by a refusal of General Smedley Butler, leader of the disaffected WWI bonus marchers, to incite the spontaneous mob uprising. Butler instead called the FBI. The whole affair was covered up and only is known today due to “fringe researchers.”

    But yes. Conspiracies do happen.
    So, I try to adhere to a skeptical methodology of thought. I run with Occam’s razor. I try not to arbitrarily assume things are true without evidence. I do these things because I think that they minimize the number of errors I will make over the long haul. However, I don’t kid myself. Minimize does not mean eliminate. A good methodology helps one better estimate the truth – but it is an estimation, not the real function itself. There will be errors. One of the errors I think I have to accept is that my methodology tends to false reject conspiracy theories. I accept this because I want to minimize my overall errors, but I don’t kid myself about it.
    Anyways.

  381. Ron Graf (Comment #163435): “2) Conspiracies are a logical innovation since they make complex crimes achievable and harder to solve.”

    They make complex crimes achievable, but easier to solve since conspiracies create a paper trail (or an electronic trail, these days) and are vulnerable to a single member being caught.

    .
    Ron Graf: “3) Law enforcement hates conspiracies because they are hard to solve and because it opens them up to ridicule”

    Nonsense. Much, if not most, of law enforcement is directed at conspiracies. There are specific crimes that deal with conspiracy. There is a large body of jurisprudence directed at things like when the testimony of a conspirator can be used against co-conspirators, when the police can tap phones, when the police can access things like bank and phone records. Plea bargains are often used to turn one conspirator against co-conspirators. The witness protection program largely exists as a tool to fight conspiracies.

    Of course, criminal conspiracies are often referred to by more specific names, such as organized crime, street gangs, motorcycle gangs, drug cartels, etc. There is a lot of such discussion of such things in the news.

    And, of course, political discussion over the last six months has been dominated by an alleged conspiracy.

    .
    Ron Graf: “4) The larger and more complex the conspiracy the harder one would think it would be to keep all parties quiet. Thus people dismiss conspiracies as generally implausible.”

    Not at all. People dismiss certain types of conspiracies. Complex conspiracies to accomplish a comparatively simple crime are implausible. Criminal conspiracies involving people with a lot to lose and not so much to gain are implausible. Complex conspiracies that fail to leave a meaningful trace are implausible. When you put two or three of those together, you have a conspiracy theory that deserves scorn.

  382. Mark, societies require the members to have faith in the institutions to thrive. Allowing consideration of conspiracies tends to undermine the trust. The 9/11 truthers and birthers are not only ridiculed for being wrong but also for being irresponsible.
    .
    I absolutely agree that a high degree of skepticism is required, perhaps lifelong. One must keep an open mind in all directions. The best authors on alleged conspiracies are specialists that research over many years and revisit with multiple books. Mark Lane and Anthony Summers are prime examples. Each one always has an author, ususally an “official” historian or ex-federal IC of law enforcement come along with a “case closed” book.

  383. Ron Graf (Comment #163439): “societies require the members to have faith in the institutions to thrive. Allowing consideration of conspiracies tends to undermine the trust. The 9/11 truthers and birthers are not only ridiculed for being wrong but also for being irresponsible.”

    Absolutely true, provided that we are careful to distinguish between mundane conspiracies and fanciful conspiracy theories. The claimed Russia/Trump conspiracy is just as fanciful as many others and just as irresponsible. But it is being pushed by the Dems and the press *because* it undermines faith in institutions. That is guaranteed to eventually bite the proponents in the ass, since they want to increase the power of those institutions.

  384. Mike M: “That is guaranteed to eventually bite the proponents in the &*!#.”
    .
    Yes, it is remarkable that the MSM is pushing the boundaries on this. But after Watergate and Iran-Contra I think the idea is that GOP conspiracies are both plausible and palatable. DNC ones are not (yet,) though for some of us conservatives Benghazi “spontaneous demonstration against a Youtube” counts and IRS political targeting. I think society is actually in a better place and more mature in accepting the plausibility of conspiracies and to address them soberly.

  385. The idea that the social movement centered around the idea that humans are causing a climate crisis, and the evidence claimed for it, are what I call anthropomorphic. As opposed to anthropogenic. The distinction is significant.

  386. Hunter, what the Climategate emails reveal is the degree of casualness (expressed openly, in writing ) regarding political gaming to destroy “irresponsible” journals that clearly have been “infected” by the wrong thinking or bad elements. The war on McIntyre, justified by the presumption (or the hope) that he was an agent of fossil fuel industry is illustrative to how cabals can form and naturally strengthen.
    .
    Judith Curry represents a very rare example of someone leaving a group, the pressures that need to be overcome to do that, as well as the consequences afterward. It is hard to find examples where someone is rewarded in the end for breaking with the “official” consensus. I hope history treats her very well as I think she deserves it.

  387. The fact that the MSM consensus is that Climategate in general was a fake scandal that has been debunked (Mann exonerated, etc…) tell us something as well. I am hoping Steyn v Mann goes to court and is televised. It has the potential for being a “trial of the century.”

  388. Ron,

    Two of the things you mention ((1: History remembering Judith Curry) (2: Steyn v Mann potential ‘trial of the century’)) prompt me to say – don’t forget that we here on the Blackboard are part of a very very small self selected subset of people who give a darn about such things. The vast vast majority of people are oblivious and utterly uncaring about climate science. I doubt history will [strike:not] remember this at all. Maybe an obscure footnote in an obscure tome or two for a short time.
    [Edit: beg pardon, I misspoke. You didn’t say ‘remembering’, you said ‘treats’. Doesn’t really change my point, but. I misquoted you just the same.]

  389. Lightening strikes twice at the NYT:
    For Grieving Parents, Trump Is ‘Speaking for the Dead’ on Immigration
    https://www.nytimes.com/2017/06/25/us/trump-undocumented-victims.html
    .
    1. An article on crimes by illegal immigrants and the parents of the victims.
    2. The closest thing there will ever be to a puff piece in the NYT for Trump, they actually had a couple nice things to say, with the expected qualifiers. It’s an improvement.
    .
    This is truly an exceptional event.

  390. This is a bit off the current track but I wanted to check if I understood something more or less correctly.
    .
    The usual folks are making a big fuss about how 23 million people are going to lose their health insurance coverage through the workings of the proposed new plans.
    .
    I would expect that a significant part of this number will be young people who not continuing to be mandated will take their money and spend it on something else, food and rent maybe. These people are not being denied coverage by the new system, but are more being allowed to choose not to be covered.
    .
    I don’t think this is the same as 23 million losing coverage. maybe the real number is half that or fewer.
    .
    have i misunderstood any of this?

  391. As this week unfolds it seems very likely that the entire Russin scam is going to turn out to be democrat dirty trick. No wonder the NYT is starting to practice something vaguely approaching journalism. Real journalism, like investigating the hate groups the baseball shooter found so much encouragement from, will likely have to wait a wee bit longer. So the question is how much blowback on slimeball Schumer, Bezos, etc., etc., etc….. Schumer should face censoring by the Senate, if not expulsion…

  392. John Ferguson,
    I strongly suspect you are correct. To the extent it was implimented, there should be an excess of young healthy people on the Obamacare roles. Of course, many young and healthy people will be included in the ‘ people who lost health insurance’. Many will rejoice if they can purchace more suitable heath insurance in the future.
    . it
    Obamacare was always little more than the healthy young paying for the health care of the unhealthy old (and middle-aged). It is an economic loser for the young to middle aged.

  393. j ferguson (Comment #163447),

    You are correct that some of the people “losing” coverage will be people choosing to spend there money on other things. Some (a much larger group, I think) are people who do not have coverage now and that the CBO asumes would have, for some reason, decided to get coverage in the future if Obamacare remains unchanged. I think that another big group is due to assumed Medicaid cutbacks by states, but I don’t if those people have coverage now.

    In other words, the calculation is completely bogus.

  394. Scores of millions people were forced off their health plans by the ACA, including anyone with an individual plan, business group of under 50 employees or group plan that did not meet ACA “essential” health benefits. The average cost trend far exceeded the pre-ACA trend. The trends in plan choice and quality fared no better. Still, the current proposed bills will not much help unless the HHS institutes free market reforms after the bill’s passage and their is followup legislation with bipartisan support (60 senate votes).

  395. Ron Graf,
    Could you expand on that a little? I think what I’m reading is that O-Care forced a lot of people into the new plan who already had plans which they were satisfied but didn’t meet the O-Care criteria. Do I have it?

  396. We’re on Medicare. It looks a lot like universal health care at least for the universe of old people. there is discussion of adopting (inflicting?) this system on everyone in the form of a single payer system.

    “Right to Healthcare” seems to me to mean “Right not to pay ala-carte” more to pay a tax, or not if you’re one of the subsidized, and receive whatever you are unfortunate enough to need in terms of treatment.
    .
    If the distributed cost of this were correctly identified as a tax, I’d like to read observations of those who don’t think that we, as a society, should pay for everyone’s healthcare costs collectively. And please cut me a little slack if there is a better way to suggest this than the one I proposed.
    .
    FWIW, it appears that healthcare outside the system is available in the UK, Canada, and certainly here – concierge medical care, where the Docs promise to remember your name for $2,500/year.
    .
    I’m convinced that universal healthcare in the US is on the horizon, but it won’t be in the forms now under consideration. I suppose that such a thing would kill off the health insurer industry.
    .
    comments?

  397. j ferguson,

    I’ll point out again that the Swiss rely completely on private health insurance with subsidized premiums for people with low incomes. It does, however, require that everyone residing in Switzerland purchase this insurance. Since we can’t have such a mandate here without a Constitutional amendment, we won’t be so lucky.

  398. The Russian thing may end, but not obstruction of justice, not with Mueller as the chief investigator inquisitor. His team prosecuted the accounting firm Arthur Anderson for acting corruptly. That conviction was overturned, but too late for the firm.

  399. JF, you are correct that I was referring to all the people that did not have an ACA compliant plan and were force to get one if they wanted to be insured. Some (mostly young) chose to pay a penalty billed by the IRS that was 1% of income the first year but grew in each year following.
    .
    My idea would be to have universal essential care that would be billed at a single rate that each provider would publish. Insurance would be standardized into tiers that would reimburse at a particular amount for each given treatment code, like Medicare does now. Those who self-insured (without a policy) and were unable to pay the bill would be collected upon by the IRS with a forgiveness determined by their last five and next five years of income. This sounds harsh but many people today are losing their life savings to long-term care needs for which Medicare and regular health insurance do not cover. The afflicted typically “spends down” their estate until they are on Medicaid.
    .
    In my plan the Medicaid bureaucracy would not be needed. The money saved from that would be the set-aside for covering the IRS determined forgiveness, for which they would pay the provider. This way there is no cost shifting. All pricing is transparent and the free market rules. Insurance provider networks would evaporate.

  400. Ron, I like your plan. ‘spending down your estate’ until you fall under the medicaid umbrella seems often abused. Relative’s kids got father to give them his estate early except for what he needed to move into the local CCRC. He then qualified for medicaid for the final 10 years of his life. there is a 5 year claw-back but the heirs escaped it. I wasn’t too pleased at sharing the costs of the final years of a guy who had been a millionaire before giving it to his kids – leeches. And guess what political persuasion they both are – very close to communist.
    i’m also not fond of idea of showing up for insurance pregnant as a pre-existing condition, savoring the benefits and then dropping as soon as the baby’s health is assured.

  401. j ferguson: “I’d like to read observations of those who don’t think that we, as a society, should pay for everyone’s healthcare costs collectively.”

    All third party payer systems lead to some combination of poor cost control and poor patient care. That is true whether the system relies on private insurers (Switzerland, Germany, U.S. (partial)) or the government as payer (U.K., Canada, U.S.(partial)). The government can choose to restrict costs, with severe consequences for patient care (U.K., Medicaid) or to give patients and doctors a great deal of control and suffer runaway costs (Canada, Medicare). Also, efforts to control costs in third party payer systems tend to suppress innovation. It would be foolish for the U.S. to go that route rather than finding something that actually works, as Singapore seems to have done.
    .
    j ferguson: “it appears that healthcare outside the system is available in the UK, Canada, …”

    I think that in the U.K. access to the non-government system is severely restricted. In Canada (where I used to live), the government system covers about 70% of healthcare; for things that are covered alternative access is severely restricted. Within Ontario, there is nothing outside the system. I think that Quebec has walk-in clinics that operate outside the system. If you have enough money and you can’t get the care you want or need, you are free to go to the U.S. (or India or Costa Rica, etc.) for treatment. Sometimes when backlogs get bad enough, the government sends people to U.S. hospitals.

  402. People get health care. When someone is dumped off at a hospital with stage 4 cancer or after a car accident and no insurance card, they get treatment. It’s similar to food stamps, how much are they entitled to and who is going to pay for it?
    .
    The discussion of this subject has become so obtuse in the media that it is difficult to even read. They act like the ACA was giving people healthcare for free and now it’s being taken away by the baby killers. Because we already pay for people’s healthcare the hard way, providing services that don’t get paid, and forcing hospitals to overcharge insurance to make up the difference, there should be a way to make it more sane without bankrupting everyone along the way, or having to go full socialist.
    .
    The cost curve has to be fixed. Less services or less expensive services, or both. The pharmaceutical industry’s co-pay (hide the real cost) model needs to be taken out back and shot. The consumer needs to have skin in the game so that shopping around produces benefits.
    .
    Example: Just try to find out how much an operation will cost from a hospital today before its done, the hospitals themselves literally don’t even know the answer. It’s ludicrous.

  403. >Just try to find out how much an operation will cost from a hospital today before its done,

    I thought I had prepaid the full cost, then they sent me another bill for thousands more.

  404. JFerguson, 23 million haven’t gotten coverage under ObamaCare yet. MikeM has it right- CBO is assuming a large level of signups, even though their previous forecasts have been for far higher numbers than actually signed up.

  406. MikeN,
    Yes, it’s like “that’s for anesthesia services which is provided by someone else” as if the hospital isn’t aware that surgery uses this every single time. The incentives just aren’t there for them to do anything different, and that’s why incentives need to change.
    .
    From their perspective they are getting paid from 1100 different medical insurance companies that all have their own fee schedules and it is total chaos to them as well, so they just pass it along.
    .
    The ACA’s standardized coverage levels are a good idea. You should be able to call up a hospital and get a price for a silver level surgery.

  407. WSJ: The Supreme Court will allow most of Donald Trump’s travel ban against some Muslim-majority countries pending a final decision.
    .
    That’s likely a signal it will pass muster. I have always expected them to allow it based on the fact someone in the government must have immigration authority and it isn’t going to be the court system. It’s ridiculous for the court system to exam Twitter like it has the same force as the legal language in an executive order.
    .
    I can take or leave this executive order, I’m ambivalent. There is a huge gap between what the media reports on immigration and what the split in the citizens are. I do find it objectionable that large swaths of law are just ignored and are blatantly not enforced on an important subject like this. If you don’t like the law then you need to get it changed, pretending it doesn’t exist is not an option.

  408. Supreme Court also gives Missouri Church a victory and agrees to take up the bakery who refused a gay wedding cake case. If suffering through Trump leaves a sane Supreme Court that is blind to identity politics it will be well worth it.
    .
    The gay wedding cake case is probably a close call, but I very much detest the specifics in the case. Apparently gay activists called up a bunch of bakeries specifically searching for someone who would refuse with the original intent to sue them from the start. The bakery ended up bankrupt and out of business.

  409. Tom Scharf: “The ACA’s standardized coverage levels are a good idea. You should be able to call up a hospital and get a price for a silver level surgery.”

    I don’t understand what this means. Why are the ACA’s standardized coverage levels are a good idea? I absolutely agree that you should be able to call up a hospital and get a price for a procedure. But the ACA does nothing to encourage that. In practice it discourages that by trying to force everyone to have insurance. There is no such thing as a “silver level surgery”. Could you clarify?

  410. Ron Graf

    This sounds harsh but many people today are losing their life savings to long-term care needs for which Medicare and regular health insurance do not cover. The afflicted typically “spends down” their estate until they are on Medicaid.

    I don’t think people losing their life savings to cover end of life medical expenses is something that requires fixing. The reason I don’t think it’s a problem is I don’t think we need a program to tax others ensure that those who are hoping for inheritances get the inheritances they hope for. It’s ok if their parents die broke.

    Programs to take care of people after they lose all their savings makes more sense than programs to preserve life saving so they can be passed on to the next generation.

    Those who self-insured (without a policy) and were unable to pay the bill would be collected upon by the IRS with a forgiveness determined by their last five and next five years of income.

    If anything remotely like your idea existed, the “forgiveness” should also include their capital wealth. If they have assets those should be used to cover the expenses. Of course one needs to pro-rate the fraction of capital for the surviving spouse. But there is no reason to preserve anything in an estate of a single person who dies.

  411. Mike M,
    Have you ever tried to compare coverage between two health insurance companies with their 72 randomized coverage levels and limits? It’s impossible.
    .
    Imagine if car inusrance had separate limits and levels for every possible thing that could happen to a car and every repair shop sent you a separate bill after the fix for the painter, the bumper, the engine guy, and you couldn’t even get an estimate beforehand. That’s our health insurance industry.
    .
    A silver level surgery means they are compensated at silver levels, they compensate everyone else associated at these levels, and are thus hopefully able to know their own costs and the cost to a consumer without a level 10 accounting audit. I acknowledge it is really more complicated than this and “silver level surgery” is a bad analogy, but I think standardized coverage allows the byzantine cost structures to be simplified.

  412. Tom Scharf,
    I don’t think there are separate prices, there is one very high price, but they will accept a lower payment level based on the insurance the patient has. I recently had to get an expensive prescription filled. The starting price at the pharmacy was $300. After some discussion about insurance (I have none for prescriptions), I ended up actually paying about $120 cash. Insurance has health care so screwed up that it may nevery be right (or even rational).

  413. Tom Scharf (Comment #163468): “Have you ever tried to compare coverage between two health insurance companies with their 72 randomized coverage levels and limits? It’s impossible.”

    I have never had the “pleasure”. There is a lot to be said for standardization of terminology so that people can understand what they are buying. But Obamacare goes way beyond that and basically writes the entire policy. I don’t want coverage for maternity care, or drug rehab, or a gym membership. I do want major medical. But I am not allowed to get what I want without paying for a lot of stuff I have no use for.

    Obamacare policies are very expensive since they are so loaded with stuff people don’t want to pay for. That is one reason people don’t buy the policies.
    .
    Tom Scharf: “Imagine if car inusrance had separate limits and levels for every possible thing that could happen to a car …”

    And imagine if car insurance had to pay for everything that might happen to a car, including things like oil changes. We’d have a lot more uninsured motorists on the road.
    .

    Tom Scharf: “… and every repair shop sent you a separate bill after the fix for the painter, the bumper, the engine guy, and you couldn’t even get an estimate beforehand. That’s our health insurance industry.

    No question the medical payment system is a mess. Obamacare does nothing to fix it.
    .
    Tom Scharf: “A silver level surgery means they are compensated at silver levels, …

    So that is just a term you made up? It is confusing, since “silver level” is a term used in Obamacare.
    .
    Tom Scharf: “I think standardized coverage allows the byzantine cost structures to be simplified.”

    I don’t see how. Obamacare certainly does not do that.

  414. Tom Scharf: “… and every repair shop sent you a separate bill after the fix for the painter, the bumper, the engine guy, and you couldn’t even get an estimate beforehand. That’s our health insurance industry.

    No question the medical payment system is a mess. Obamacare does nothing to fix it.

    I’ve had services itemized on my car repair bills. Not for body work. But if I have it serviced, the bill lists what they did– so for example, rotate tires, change oils, change wiperblades, replace muffler….whatever. They even break out parts and labor. Of course I can ask about each entry and find out what they cost in advance. (We change our own wiper blades.)

    My dentists bill is similar.
    The main problem with hospitals is they can’t seem to get their bill together all at one time. On the other hand, the servicing is more complicated.

    Hospital billing has been disorganized a long time. Obamacare neither caused it nor cured it. I don’t think the government can cure it without causing other difficulties. A flat rate for knee surgery would likely end up either too generous raising costs to patients or too stingy making surgeons unwilling or reluctant to do the surgery.

  415. Insurance is useful for high cost / low probability events that can be shared by a group. It’s not useful for things like oil changes or checkups that everyone uses, although there is some benefit to bulk buying these things and getting discounts but that is a separate matter.
    .
    Insurance a la carte has a couple problems, one is that consumers are not sophisticated enough to know what they are buying in this case because of complexity, and it imposes a lot of costs on the medical / insurance industries to support the billing for it.
    .
    There are no easy answers here. Rearranging the system without addressing the cost curve is missing the point.

  416. You can shop around for car work. If you ask them how much to replace a body panel they know the answer. You can’t do that with the health industry. If I go to a Geico approved shop, it just gets fixed and I pay the deductible. A single payer operation.
    .
    If I have to pay 15% for a gall bladder surgery I don’t have the faintest idea what the bill will be to an order of magnitude, and the chances that two local hospitals will have significant cost differences is very high and there is no way to determine which one is cheaper up front. The consumer is powerless and this kills using markets to improve efficiency.
    .
    Medicare has flat rates for many things is my understanding. If the medical industry can’t figure this out on their own, they will end up with Medicare for all, by popular demand. Single payer may be anathema, but the toxic dump of the existing system is even worse given the unsustainable trend in costs.

  417. Here is a pdf of my healthcare plan I proposed to Senator Toomey’s office staff in January during a 40-minute meeting. They loved it but the chief of staff never seemed to get persuaded to read it and I could not gain a response after that except from the field reps I met with and their apologies.
    .
    I also posted a petition for it on Change.org. You need to register (free) if you want to sign it.
    .
    Tom, my plan would be to have “silver level” surgeries. The ACA has standardized tiers but only for out-of-pocket exposure. All care, including Medicare and Medicaid, are mostly the same if the provider chooses to accept what the insurer will pay. My plan would be for providers to post their price for every billing code and all insurers pay the same as someone who pays out-of-pocket. Today if you pay out of pocket after the fact you pay up to 10X the going rate. If you negotiate beforehand you can pay less than the going rate insurers pay for many procedures (unless they discover you have insurance).

  418. Lucia: “If anything remotely like your idea existed, the “forgiveness” should also include their capital wealth.”
    .
    There would be very few people that would have high capital wealth with near poverty level income. They would have to place all of their money into collectible art and gold for many years, paying their high lifestyle out of periodic sales. Even in this case they would have capital gains.
    .
    I would not like to start the IRS looking at personal assets unless the person fails to make payment.

  419. Here is a post I prepared on my One Price plan back in Feb.
    .
    Lucia: “A flat rate for knee surgery would likely end up either too generous raising costs to patients or too stingy making surgeons unwilling or reluctant to do the surgery.”
    .
    Very few products or services give the same profit margin or have the same relative costs to any business. The key is providing a clear price that can be agreed upon in easy fashion.

  420. Science of Doom has a short review on confirmation bias, a feature not a bug which centers on Johnathan Haidt’s book The Righteous Mind: Why Good People are Divided by Politics and Religion.

    An an intuitionist, I’d say that the worship of reason is itself an illustration of one of the most long-lived delusions in Western history: the rationalist delusion..

    …most of the bizarre and depressing research findings make perfect sense once you see reasoning as having evolved not to help us find truth but to help us engage in arguments, persuasion and manipulation in the context of discussions with other people.

  422. Ron Graf

    There would be very few people that would have high capital wealth with near poverty level income.

    Perhaps. But that’s hardly a reason to not consider wealth when evaluating whether someone can pay.

    I would not like to start the IRS looking at personal assets unless the person fails to make payment.

    Of course. People who do pay wouldn’t have the IRS or anyone looking into whether or not they can pay. The only event in which people would have the IRS (or someone) looking into their assets are if they don’t pay and want to shift the burden of the cost of their care onto the public. That’s no different in a scheme considering income or one considering income and wealth.

    Similarly, people who don’t file for bankruptcy protection don’t have to reveal their wealth to a court because they aren’t asking for anything.

    The key is providing a clear price that can be agreed upon in easy fashion.

    I guess it’s not clear to me who decides the price in your system.

  425. hunter,

    The quotes are from Jonathan Haidt’s book.

    If Edit didn’t go away so fast, this would have been one post.

  427. Lucia: “That’s no different in a scheme considering income or one considering income and wealth.”
    .
    Income is reported and can be part of an automated system check. Wealth is not reported and would require an audit and possible litigation. An analogous situation today is qualifying for Medicaid where income is the most visible and the first item considered. Wealth can be shielded and distributing to heirs. I agree with your principle. The senator’s staff were most concerned about the IRS collections than any other issue so I attempted to make it as simple as possible. Conservatives don’t like the idea of pretext for having to register assets. (Neither would JF’s socialist friends, though they would not admit it.)
    .
    “I guess it’s not clear to me who decides the price in your system.”
    .
    The providers of any health product or service would have to declare a single price for each ACA billing code. The Mayo Clinic heart surgeon could post $35K for a double bypass while the local municipal hospital lowest price for the same procedure might be posted at $15K. The $35K price is considered a platinum level and thus only those with platinum policies would be fully covered. The $15K would be the bronze level. However, one could pay the difference out of pocket if they wished. Whether the Mayo Clinic was worth the extra would be determined by the market demand. My plan would facilitate the transparency of outcomes by having a national reporting center. Every bill would be accompanied by a code that would act as a chit for the consumer to give a feedback review at an appropriate interval anonymously. The code would automatically have the year of the service, the billing code, and supply pre-targeted relevant questions for pertaining to that code. Anyone else could access these reviews, which would be cross referenced by procedure as well as provider. The database would also be an ideal tool for medical researchers, providers and insurers.

  428. Ron,

    A hospital isn’t McDonalds or Burger King. It’s more like a car dealership where lots of things are negotiable. Except a car dealer knows his costs fairly precisely. With hospitals, they only have estimates at best. It’s not even clear that they can know any better than they do now. I’m pretty sure they don’t try very hard.

    Then there’s Medicare. The government sets what it will pay on a take it or leave it basis. There is no bargaining. Unfortunately, Medicare reimbursements are way less than the average cost for any hospital. So they have to make it up somewhere else along with indigent emergency care costs.

    Expanding Medicare is a non-starter precisely for this reason. A major expansion of Medicare would require a substantial increase in Medicare reimbursement. Otherwise hospitals would close or simply refuse to take any Medicare patients. Single payer doesn’t solve this problem unless you drastically restrict access to elective procedures, as in the UK, among others.

  429. Ron

    Lucia: “That’s no different in a scheme considering income or one considering income and wealth.”

    .
    Income is reported and can be part of an automated system check. Wealth is not reported and would require an audit and possible litigation.

    You’re just explaining why you think it would be more difficult to test wealth. But it’s hardly impossible. I’m not even sure it’s that difficult.

    Not having wealth would be the criteria for not having to repay the government.

    Assets are determined in bankruptcy proceedings. It’s not difficult to show you don’t have any when you don’t. People who have no assets seem to find it easy enough to prove they have no assets when they go bankrupt. Seems to me it wouldn’t be any more difficult for them to prove it when they are asking the government to pay their bills.

    It’s also pretty easy to see someone owns realestate when they own it. And income often leaves traces of wealth– for example, if you get income from sale of stocks, it’s pretty easy to tell you own or owned stocks prior to the sale.

    I’m not seeing the problem here.

    The senator’s staff were most concerned about the IRS collections than any other issue so I attempted to make it as simple as possible. Conservatives don’t like the idea of pretext for having to register assets. (Neither would JF’s socialist friends, though they would not admit it.)

    Well… I’m not the senators staff; I’m not required to share their concerns. Whatever they may have liked or disliked, I object to the notion that someone gets free health care when they have lots of assets.

    I’m not seeing where my suggestion creates any possibility of requesting people register assets. I haven’t suggested anyone register assets. Merely that those who ask the government to pay for stuff demonstrate they don’t have substantial assets. Obviously this would not involve registering assets; if one has no assets, there are no assets to register.

    As I noted: we expect those requesting bankruptcy protection to show they pretty much have no assets. I don’t see why we can’t ask the same of people who want the public to pick up their medical costs.

  430. By the way: I hate the entire idea of “bronze”, “silver”, “gold” tiers. I find the notion incomprehensible. If I am to shop for insurance, I would much rather read the features– the same way one does for car insurance, house insurance with riders and so on. It’s much easier to understand than having policies with tiers named for metals.

  431. Lucia: ” I haven’t suggested anyone register assets. Merely that those who ask the government to pay for stuff demonstrate they don’t have substantial assets.”
    .
    My examples were precious metal and collectible art. I’m sure people do evade declaring all in bankruptcy but when they do they risk forfeiting the court protections they just paid legal fees to obtain. It’s kind of like lying about your mileage to your car insurance company. You are risking giving them an out for honoring a claim.
    .
    I said I agreed with your principle. But we have a long ways to go before we have to worry about perfection, Lucia and DeWitt. Right now a large and growing number are attracted to the Bernie Sanders idea of using “someone else” to pay the medial bills. That means your service will not even look like McDonalds or an auto shop. It’ll look like the DMV or post office.

  432. Ron,
    Previously, you previously said this

    There would be very few people that would have high capital wealth with near poverty level income.

    Yet now you want to suggest its difficult to determine whether people might be hiding wealth by having it in precious metals or collectible art and so cheat the system. (Mind you: I don’t think collectible art would escape detection when someone leaves their estate to heirs. So I actually think this would get detected. The metals might work if only one heir knew they existed.)

    So, I agree I suspect that there are people who can hide wealth. But most people don’t and would find it difficult to do so. People also cheat on their taxes. Neither of cheating on income– which would already affect your system of detecting income flawed– nor cheating on wealth– make it reasonable to have the government foot the bill for medical care when people have wealth and income.

    If someone cheats: well… that happens. It will happen under your “income” test too.

    I’m sure people do evade declaring all in bankruptcy but when they do they risk forfeiting the court protections they just paid legal fees to obtain.

    And people who evade declaring all when getting the government to pay their medical bills will also risk forfeiting the money (and possibly additional fines) if they are later caught. Seems fine to me.

    For what it’s worth: Shifting will also happen under your method. People will find ways to have money and no income. For example: If you have money in a ROTH IRA, and draw it down: No taxable income. So: no income to report to the IRA. In contrast, if you have a regular IRA and withdraw, you have income. People can also have non-taxable bonds which under your method would make them qualify for the government paying their medical bills.

    If your system existed, I’m sure accountants and planners would find all sorts of ways to “not have income” for tax purposes while still having a steady stream of monthly checks to spend.

    Some already do have non-taxable income, but at least the goal is not to get the government to pay for their health care by looking “low income” even though the retain wealth and spending power.

    But before we can have a system that is perfect we need one that is good.

    Agreed. Which is why I would not support paying for health care costs of those who have wealth. A system that designed to accept that as its baseline fundamentally rotten to its core. It’s not fixable by vigilance.

    In contrast, the possibility that people could cheat and hide wealth is an imperfection to an system that’s at least good in principle. As we both recognize: We need good before perfect.

  433. Lucia,
    I challenge you to determine value from competing health insurance policies from different vendors. My wife’s company changes providers on an almost annual basis and then an assortment of X options are provided with Y deductibles and A,B,C,D,E,F,G,H,I,J,K,L variables. If you can predict the future then you might be able to optimize but you general want to go harikari in the first ten minutes. Is this better than last year? Is option B better than option C better for me? Car inusrance only has a few variables (coverage level, comprehensive, collision, etc.) and you can do an apples vs apples comparison. You cannot compare health insurance policies without an abacus with 17 levels of freedom.

  434. Tom Scharf: “I challenge you to determine value from competing health insurance policies from different vendors.”

    Obamacare policies are easy to compare. That is a bug, not a feature. I’d love to have it be more complicated, provided that the differences are real rather than cosmetic so that they provide a real choice. And provided that the differences are not gotchas hidden in the fine print.

    Car buying would be much easier if there were only one model of car available in each class, all equipped with the same options. But that would not make it better.

  435. Tom

    I challenge you to determine value from competing health insurance policies from different vendors.

    I’m saying I can’t determine the value based on ‘gold’, ‘silver’ etc.

  436. MIke M

    Obamacare policies are easy to compare.

    Comparing is not the same as “determining value”. It doesn’t even mean you can figure out which has “more” value. To some extent this is precisely for the reason you say: There is no real choice. So you are paying for many things you will never use. You don’t know which you will. It’s likely the “value” would be better if somethings didn’t buy at all, others you got at “bronze” level, others at “gold” and so on. Figuring out value isn’t simplified.

  437. Tom,
    I would also add: The challenge to a company trying to figure out “value” for customers is different from me trying to figure out what I want to buy. The company has many different employees. The choices the company makes can create winners and losers with some employees getting more and others less. So yes, judging value is very difficult for your wife.

    That doesn’t mean the precious metal rating system that’s decided what it “values” and constraining helps a individual figure out “value” to them.

  438. Hospitals can’t seem to get their billing together because they aren’t doing the billing for some of the services. Seen by a pulmonologist and a cardiologist? They are possibly both self employed or members of private groups responsible for billing for their services. I guess it’s a good way for hospitals to reduce overheads.

  439. Lucia: “I would not support paying for health care costs of those who have wealth.”
    .
    You position presumes you have numerous choices of what to support. What health system plan do you support over mine?
    .
    Let’s revisit the point in practice because how it will work in the real world makes all the difference.
    1) People with modest wealth will want to have insurance and it will be affordable since there would be little cost shifting and lots of competition.
    .
    2) People with extravagant wealth who self-insure against any casualty would certainly have higher than the maximum report-able income to start to gain subsidy.
    .
    3) In my plan care levels are tiered, with the uninsured level being the lowest. People who accept subsidy would be limited to basic care and would forfeit their option to buy up a level.
    .
    4) In my plan no care cost is 100% subsidized. Even for the those receiving government assistance would have a small portion offset. Every person should budget for going to the doctor.
    .
    5) Having any law that requires a declaration of assets (short of voluntary bankruptcy) can be seen as a dangerous precedent in a society where politicians can (and do) promise to confiscate private wealth in exchange for votes.
    .
    I just don’t see it as necessary. But you do make a good point that it could be a voluntary reporting requirement that could be enforced with a penalty on the patient as well as their heirs should they pass on concealed assets. So I could add that. Would that satisfy you?

  440. Tom S: “I challenge you to determine value from competing health insurance policies from different vendors.”
    .
    Tom, I have tried that challenge every year for the last 15 or so on behalf of my company. You are correct that the plan features are scrambled at random to confound comparison and to provide a false sense of choice while concealing the 10-90% annual cost increase. This is why I would allow the government to standardize what is basic care as well as what qualifies for premium tiers.
    .
    Once tiers are standardized this also solves the pre-existing condition problem for those with insurers that go insolvent. State insurance boards will need to be able to allow those policies to be sold and seamlessly merge another’s insurer’s client portfolio not to kick any people out of coverage.

  441. Ron

    Lucia: “I would not support paying for health care costs of those who have wealth.”
    .
    You position presumes you have numerous choices of what to support. What health system plan do you support over mine?

    No, it doesn’t presuppose that. I am telling you what I would and I would not support. I would not support that plan even if it is the only one.I would not support it for the reason I stated. Other people might, but I would not. To get my support, you would need to change that feature.

    Would that satisfy you?

    No. I think your plan is unacceptable.

    As for your points: in
    (1) you make a claim about costs. I don’t have confidence your method lowers costs.
    (2) You seem to be thinking my concern is only that those with “extravagant” wealth might get subsidized. I don’t consider $400,000 in assets “extravagant”. Your system will tempt people with medium wealth to shift to taxable income to non-taxable for the purpose of shifting costs to the government. I don’t want a system that does this, and I won’t support it.
    (3) I dislike tiers intensely. Others may like them, but for me: no. I get that it might make the task easier for business owners who are picking for multiple people all at once, but for me, privately: Non! There has to be a way for people to avoid the straight jacket of tiers. You later say “Once tiers are standardized” … Well, once they are standardized, individuals no longer have much in the way of choice to match their preferences.
    (4) is good,
    (5) my option doesn’t require “declaration of assets” , except in the case where someone is has none and is trying to shift the cost of their care to the government. So the notion that such a declaration would lead to politicians confiscating anything is absurd. In anycase, your notion that somehow having it in the health care areas would set a “precedent” is wrong. People already submit “declarations of assets” for things like college financial, bankruptcy and so on. They sometimes do this when applying for loans. These declarations exist and could be obtained by the government (some already are.) So I have no idea why you are going on about things like it being a “precedent” if used for applying for health care.

  442. If you like choices my plan more than any other is driven by consumer choice. The reason for tiers is to provide apples to apples comparisons for those choices. Having choice without knowledge does little good. Also, when a lifelong medical condition does arise if you have a unique health contract you are locked into that contract for the remainder of your life. Under my plan you are only locked into a tier. If every insurer provides that tier competition and transparency are maintained.
    .
    My plan has four levels of out of pocket expense exposure just like Obamacare. But unlike the ACA it also has four tiers of quality of care.
    .
    Lucia, you make good points about asset declaration on the college FAFSA and loan applications. I should have thought of those examples when making my proposal to Sen Toomey’s staff. I still think it wouldn’t be a point of abuse once more choices of quality of care become available and thus forfeiture of those choices become more unpalatable. Compared to Medicaid fraud it would be pennies on the dollar.

  443. Ron Graf: “My plan has four levels of out of pocket expense exposure just like Obamacare. But unlike the ACA it also has four tiers of quality of care.”

    I don’t know what that means, but it sounds like a truly terrible idea. I don’t see how there can be more than two tiers: adequate and inadequate. Unless this just refers to comfort and convenience aspects, such as a private hospital room vs. a semiprivate room.

    More fundamental is the fact that any system that relies on third party payment will result in some combination of inflated cost and poor patient care.

    The starting point of any system should be that most people pay directly out of pocket for most expenses, with insurance as a back up and government safety nets for the very poor and very unlucky (and, to a limited degree, for the irresponsible).

  444. Ron Graf,
    My wife’s company obviously looks to save money every year by changing companies. I assume health insurance companies are doing the standard trick of low balling in year 1 and then upping rates immediately after that.
    .
    The standard tiers are good because a non-expert consumer can get screwed by not reading the fine print, for example an abnormally low lifetime maximum. I think there may be confusion in this disagreement in that I’m not saying these are the only levels that should be allowed, but it should be a requirement that they sell these policy levels. If they also want to offer a Silver+ policy then that is OK by me.
    .
    With only 3 or 4 policy levels it is much easier to determine which one better fits your needs and comparison shop. Coverage for pregnancy is very import to people for short periods of time. Only once in the past 10 years has a company provided a wizard that asked questions (which prescriptions you have, anticipated or historical medical costs, etc.) that then pointed to the best option for you. Realistically if the inusrance companies are pricing fairly (a huge if…) then policy choice is just a gamble on your anticipated health.
    .
    Home insurance, at least in FL is also two tiered. I cannot even buy catastrophic only insurance. It’s basically an all or none government mandated insurance level. I see this limited choice as bad in this case, too limited. I’m sure this is to protect the insurance/finance industry more than the consumer, especially for mortgages. But if I own my home there should be more options.

  445. Ron Graf

    If you like choices my plan more than any other is driven by consumer choice. The reason for tiers is to provide apples to apples comparisons for those choices.

    Explain the mechanism for choice. Because I see very little in the plan you describe.I clicked the link to your description and it was just a bullet list of points.

    But for example: Suppose I want insurance but only to be covered for catastrophic events and able to get the best emergency room care and so on, but pay my own annual check ups, prescriptions for things like cold medicine and so on.

    Or knowing emergencies can result in later need for regular medical care, maybe what I want is a $5000 deductible for my husband and my collective costs, and then after I pay 20% of the cost. But I get to pick whether I do “bronze”, “silver” or “gold” according to whether I think oncology treatment needs to be gold, while, perhaps, various treatments for back pain… willing to do bronze. So basically, I pay 20% and I chose if the treatments are going to be “gold” or “silver”. So, if I pick “gold” I pay more. If I pick “bronze” I pay less. If I forgo, I pay nothing.

    Can I get that package?

    It seems to me that based on what your saying the answer is no. I pick “gold”, “silver”, “bronze” or “dross”. If the answer is no, my view of your plan is it provides no meaningful choice which is so close to “no choice” that I consider it “no choice”.

    Under my plan you are only locked into a tier. If every insurer provides that tier competition and transparency are maintained.
    Yes. Under your plan, I am locked into something that as far as I can tell I would never choose. That thing is called “a tier”.
    I get that companies buying for groups may find this attractive compared to making individual choices. But that’s because it can make some sense for collections of individual each of whom has different priorities, who are getting the benefit as a package from work and who otherwise aren’t allowed to make their own choices. So: their choices are severely restricted to practically nothing.

    I still think it wouldn’t be a point of abuse once more choices of quality of care become available and thus forfeiture of those choices become more unpalatable.

    I absolutely think it would be a point of abuse. I think it would be a worse one that the converse where people give their money to heirs to pauperize themselves to get money from the government. I don’t approve of that strategy but at least those people did give away their money and they can’t know what their heirs will do with it.

    With your system, clever accountants will quickly figure out ways where people with wealth enter into contracts where they pay someone a big chunk to buy a 20 year contract for something like “room and board” in a lavish house or hotels for 20 years. Then they will live in some lavish place while having no “income”. The thing would be structured like an annuity– but you get housing and food instead of money. By magic: No income. Annuities could be structured that way. Reverse mortgages basically do that. People would find ways an they would.

  446. The fired employee count is now up to 5 at CNN for Trump related coverage.
    http://money.cnn.com/2017/06/26/media/cnn-announcement-retracted-article/index.html
    .
    Story retracted apparently after editorial process not followed (and undoubtedly the target threatened them with legal action). Humorously a Russian site debunked the article.
    .
    They were also embarrassed by releasing a story a while back that Comey wasn’t going to say Trump was not under investigation.
    .
    I think we have hit peak Russia, at least for a while.

  447. Mike M: “More fundamental is the fact that any system that relies on third party payment will result in some combination of inflated cost and poor patient care.”
    .
    This is exactly my thought and which is why my plan puts the patient as the payer. Just like with your auto insurance. If you have an accident you have choices of how to handle payment but there is limits to what coverage your insurance will provide depending on the quality of your policy.
    .
    The quality tier under my plan would specify a level of coverage for each ACA billing code. All the providers of each billing code would have their price published. If it was in excess of the coverage tier of your policy you would shop for a provider that was at your coverage tier or you would have to make up the difference out of pocket. If you had no insurance and no income (or assets) to show you could pay for anything more than the guaranteed care tier you would be limited to those providers. This system rewards good service and innovation.
    .
    How does one know who the good providers are? My plan would use the Healthcare.gov marketplace and turn it into a real one that everyone would visit whether looking for a doctor, shopping a procedure or looking where to go in an emergency. Every type of care would have providers with their teir level and consumer ratings that could also be drilled down to each ACA code for the exact price and access to actual patient reviews.
    .
    Choices are empowered by access to information to make the choices. Today’s system does the opposite of this. I apologize for the confusion. I spent a lot of my paper explaining how we got where we are and why we don’t need to be here, especially in the information age.
    .
    Tom, you are correct that insurers need to be shopped every year in the current situation. This creates a huge expense for companies as well as insurers. My plan take the whole system away from employer based and makes it all individual based. This eventually makes health policies more like life insurance policies, something that you don’t usually let lapse. This brings administration costs down hugely. Our current system has to not only pay for doctors and nurses but for two or three that number of clerks and administrators.

  449. Ron Graf (Comment #163509): “This is exactly my thought and which is why my plan puts the patient as the payer.”

    That is not at all obvious. But you have not provided a description of what you propose. A good place to start would be to address lucia’s thoughtful comment (#163507).
    .
    Ron Graf: “The quality tier under my plan would specify a level of coverage for each ACA billing code. All the providers of each billing code would have their price published.”

    I think that provides no information to anyone who dos not have years of experience in medical accounting. Doesn’t a single hospital stay usually generate dozens of billing codes?
    .
    Ron Graf: “If it was in excess of the coverage tier of your policy you would shop for a provider that was at your coverage tier or you would have to make up the difference out of pocket.”

    OK, that makes sense if you are assuming some sort of radically simplified billing system, like that of the Oklahoma Surgery Center. And as long as it only kicks in above some deductible. So right there it looks like the tiers have to be at least two dimensional.
    .
    Ron Graf: “How does one know who the good providers are? …”

    Sounds way too complicated. And consumer ratings are pretty much useless to assess quality of care. But that is a problem that is independent of any specific plan.
    .
    Ron Graf: “My plan take the whole system away from employer based and makes it all individual based.”

    That would be good, but it would have to be phased in.
    .
    Ron Graf: “This brings administration costs down hugely. Our current system has to not only pay for doctors and nurses but for two or three that number of clerks and administrators.

    The big administrative costs are providers fighting with insurers over reimbursement. Another reason to restrict third party payment to exceptional cases.

  450. Lucia, I get that you do not like the idea of tiers, you would not like them in a house, you would not like them with a mouse, not here, not there, not anywhere. I just don’t understand how you are going to be smarter than providers and insurers, honed by transparent and nationwide competition in a free market on a mission to determine exactly what you need. The amount you want to pay out of pocket for meds and doctors appointments is one of four levels. This is not to mention that you can accumulate money in HSA-type accounts to pay out of pocket. In fact, my idea would be to require individuals to accumulate a certain balance in a personal medical savings account before qualifying to be able to enroll in a high deductible tier.
    .
    The main thing that everyone need to keep their minds on is what happens when you become a high insurance risk. At this point the insurers will not take you at the same rate you had before you were a high risk. They will also not allow you to reduce your deductible or increase the quality of coverage. BUT if you have insurance when you become a high risk you would be entitled to keep that insurance tier in quality and deductible level for the remainder of your life without paying any more premium than a healthy person at your age. Children would gain their lock by being born into their parent’s policies. Their freedom to move to a better tier would last as long as their health was good enough for an insurer to take them as a new enrollee.
    .
    Lucia, most of your concern about wealth test applies to people who would be on Medicare. My plan would eventually have a path to eliminate Medicare by detaching insurance to employment. But that will take some time. The trick is to overcome everyone’s objections enough to start in the right direction.
    .
    Mike M, an individual based system would phase in naturally as employers and individuals were put in same position to pay with pre-tax dollars. Employers do not want to be in charge of healthcare if they offer no advantage. HSAs should be expanded to be allowed to pay for premiums and then only the annual excess unspent contributions be capped. This eliminates them being used as “super IRA” tax avoidance vehicles and encourages the money to be spent on healthcare.
    .
    Not having standardization tiers is part of what created the swamp the ACA promised to take us out of. Remember the Grisham “The Client” with Great Benefit Insurance Co. that denied every claim the first time it was applied for? There was some bad that needed fixing. Having a high tier is also an excellent way to allow the 1 and 2-percent pay for the newest innovations and medicines just like we allow them to pay for the first model Teslas, so we can all get to have access to the technology in the mass market model a little later.

  451. Mike M: “Doesn’t a single hospital stay usually generate dozens of billing codes?”
    .
    Yes. There are thousands of codes just as there are thousands of car part codes. You still want the price to be determined based on a published number rather than your ability to pay. The later system is known as predatory pricing and it’s basically what we have now. Prices are secret information that nobody is allowed to know until a provider code is paired with a diagnostic code, a treatment code and an insurer’s code. Then a price is spit out and how much is on you. There are companies that do nothing but audits of bills to finds errors and patterns in billing. There is really no direct way for you to know if you were billed correctly. Out of three claims employees of my company filed in 2015 all three were wrong and overbilled. I did my own audit.
    .
    If the patient is the payer, even if it is out of medical savings account, they will have to be provided a verifiable bill or they will be easy pickings for a savvy provider that does good billing. This all requires a consumer feedback driven market. The secret to Ebay and Amazon is not that they provide great products, it’s that they provide a super transparent and trusted marketplace.

  452. Ron

    just don’t understand how you are going to be smarter than providers and insurers, honed by transparent and nationwide competition in a free market on a mission to determine exactly what you need.

    I haven’t claimed to be “smarter”. So I’m not understanding why you think “smarter” is the claim. But besides that, I don’t seen how you can claim “honed by transparent and nationwide competition in a free market on a mission to determine exactly what you need”. The tiers eliminates the competition to determine “exactly what (consumers) need. They pick 4 tiers. Those are the tiers. If people want something different people can pound sand. That is not “free market”. All choice has been constrained out of that market making it “not free”.

    Returning to “smarter”: I don’t need to be “smarter” then people who have never met me to know my own preferences better than they do.

    Let me put this in terms of cars. If a company had to purchase the same car for all employees, they might find the decision of what features to pick difficult. They might find it difficult to determine the “value” of a BMW X3I vs a VW Passat, vs a Ferrari vs a Yugo or what have you. All these choices, features and prices could be very “confusing” and it would be hard to judge just which single car is the best choice for everyone.

    But I had no trouble picking out the car I want for me and judging which features had value for me. Needless to day, the car I bought last spring is red. That’s the best color. (See above.)

    If a huge number of “geniuses” at car companies standardizing products in a the “gold”, “silver”, “bronze” and “dross” tiers of cars , it is highly unlikely they would come up with a choice that provides me more value than one I would pick from a truly free market that creates cars and lets individuals chose. I suspect if “geniuses” did such standardization into 4 car “tupes”, I would have a blue, black or grey car. Bleh!

    Worse: every car in the parking lot would look the same which would make it hard to find my car. But I’m pretty sure I’ve taken the analogy to far now….

    The thing is: this has nothing to do with who is “smarter”. It has to do with the fact that I value some things the “geniuses” might think I should not value. (Like Red. ) Meanwhile, I might not value something they think is more important. (Separate HVAC in front and read seating compartments.)

    The fact is: I really don’t see much difference with insurance. Cars have tons of features. As far as I can see, you are trying to solve the problem a company picking for many people have, dreaming up a “solution” for those companies and using that to dramatically reduce everyone’s choice– including companies. Sure: companies might be grateful to no longer have the task of choosing for many people — each of whom wins or loses depending on the company choice. They might be thrilled to no longer be burdeded with explaining to any employees who would rather have the “red car” they could only choose between 4 things and “red car” wasn’t in the pool. That’s less work for the companies.

    But that doesn’t make reducing everyone’s choice by narrowing down to 4 “tiers” the same as “having a choice”. In fact: 4 tiers would take away choice from companies and individuals. The problem is worse for individuals.

    The amount you want to pay out of pocket for meds and doctors appointments is one of four levels

    Is it? I have no idea if high deductables is “gold” or “bronze”. But say I want the high deductable that goes with “bronze” and the doctors that go with gold? Or what if I want a low deductible and gold doctors? Can I have which ever I prefer? Or is does one of them have tier-mis-match? (I’m going to keep asking this until I get a full answer.)

    Say I never travel. Can I save money by only using doctors in my home area? Or do I have to pay for the luxury of being able to drop into the emergency room in Spokane WA? (I haven’t seen your details. I’m only hearing “tiers”.)

    This is not to mention that you can accumulate money in HSA-type accounts to pay out of pocket.

    I like that feature, but we can do that without tiers. I might be able to support a plan that kept the good features and scrapped the bad ones. But I’m not going to support a plan that has many bad features just because it has a few that are good.

    The main thing that everyone need to keep their minds on is what happens when you become a high insurance risk.

    Who says this is the main thing? I don’t think this is the ‘main’ thing. I think it’s just as important to think about my current situation, what I have to deal with now and so on.

    Lucia, most of your concern about wealth test applies to people who would be on Medicare.

    I haven’t said any such thing. I would be even more concerned about people living their entire lives keeping their wealth while having the government pay for their health care.

    Not having standardization tiers is part of what created the swamp the ACA promised to take us out of.

    One of the major flaws of ACA was they insist choice is a swamp. I don’t accept the premise that because the ACA deemed choice a “swamp” that that makes choice a swamp. The ACA needed the tiers because it wanted to control stuff and insist that everyone had to have all sorts of services they wanted people to get. (Birth control among these. I’m an advocate of birth control. But I think policies that don’t provide it should be available to those who don’t want it.)

    The rhetoric justifiying tiers may have made claims about certain things it was trying to do. But that doesn’t mean the choice that existed before was actually a “swamp”.

  453. You’re not going to get to a true individual marketplace for health insurance until you deal with the elephant in the room: preferential tax treatment for employer provided health insurance. That’s a major factor in why the US system is such a mess. Either everybody should be able to buy health insurance with pre-tax dollars or nobody should.

    lucia,

    I had a red car once. Never again. Red paint fades faster and attracts police attention. I refer to red as a car color as ‘arrest me red’.

  454. Lucia, I should not have used “smarter.” Consumers are all smarter about their own money and what they want. But they are not smarter when it comes to crunching actuarial tables and efficacies of medicines and procedures. Some decisions are best left to doctors and some are best left to insurers and some are better for regulators. The key is having everyone harmoniously doing their part and having the right incentives in place for that to happen.
    .
    Let’s use the metals the ACA uses to specify the degree of out-of-pocket exposure and we can use gemstones (diamond high, garnet low) to label quality tiers that I propose. In the diamond tier cosmetic surgeries might be covered 50% while other tiers would pay nothing. Your choice as patient should be:
    1) How much insurance in general do you need, quality and out-of-pocket exposure.
    2) Choose and good insurance company (i.e. not Great Benefit.)
    3) Decide when you need to seek medical care.
    4) Along with your doctors make medical decisions.
    .
    The providers should be deciding how to best deliver safety, effectiveness and patient convenience.
    .
    Insurers should be concerned simply with retaining customers by determining fair premiums, processing claims efficiently, preventing waste and fraud.
    .
    Regulators should be looking at determining the most efficacious industry standardization (tiers) based on the statistics of degree of benefit to price. They also keep the insurers and providers following sound practices and protocols but much less in a free and transparent market where consumer feedback rules. The ACA and legislators since 1945 forgot about that last part.

  455. Lucia,
    Are you an expert at analyzing health care options and determining which ones you want? If you are, then when you go to Walmart and look around do you think those people are going to be able to decipher a wide open anything goes marketplace? When I go into my grocery store I see exactly zero magazines extolling the best health insurance plans on the market. I see exactly zero comparison shopping articles about which companies provide the best plans for the minivan healthcare tier. People are enthusiastic about cars, they intuitively know what they like about cars, they ride in other people’s cars, they test drive cars, they can shop at different car stores with sales people who go out of their way to highlight the features, they sell the same cars in every state, Consumer Reports ranks reliability and best choices over decades. If I want to know what the differences are between a Ford F150 and F250 it’s easy to find and why these differences may matter to someone. You have the infrastructure and knowledge base to make educated decisions.
    .
    If you want to determine if surgeon A or surgeon B is better in your local market, you are basically helpless. Blue Cross Blue Shield is regional, and states are different. What we have in the US is the furthest thing from a properly functioning free market that you can have. Car manufacturers do tier their products. Mercedes has C,E,S classes for sedans. BMW has 3,5,7 series. You can option them out from there but realistically you can only choose tiered option packages.
    .
    When you are at Walmart, ask those people what is the right maximum lifetime benefit level one should have, or whether PPO’s are better than HMO’s. If you ask them what kind of things they would like in their next pickup truck, they will likely have an informed opinion.
    .
    So we can either educate the populace to be as smart as many people on this board to make an informed selection, or we can make it easier for them by simplifying selections. Hyundai vs Chevy vs Cadillac.
    .
    This isn’t to say you shouldn’t be able to go a la carte if you want and special order something from the factory. The question is whether we can make the market work at all for healthcare. What we have appears to be intentional obfuscation of products (Chevy measures power in carrots/century and Ford uses turnips/minute) and price hiding everywhere. Healthcare costs are spiraling the wrong way and most people don’t even know what they are paying for.

  456. DeWitt: “You’re not going to get to a true individual marketplace for health insurance until you deal with the elephant in the room: preferential tax treatment for employer provided health insurance. ”
    .
    You are exactly right and it’s part of my plan but we will need new bipartisan legislation to do it, not just repeal of the ACA.
    .
    The government’s biggest mistake was attaching healthcare to employment. The next biggest mistake was covering the retired with the payroll tax Ponzi scheme. This all compromised the patient’s cost/benefit decision making and shopping. Lasek surgery is a great example of the track of price to benefit that occurs when a medical product is consumer driven.

  457. Tom Scharf,
    “I think we have hit peak Russia, at least for a while.”
    .
    Maybe, but I think CNN is entering the ‘just because we can’t proove it doesn’t mean it’s not true’ mindset. They are never going to actually accept they were wrong about anything damaging to Trump. They suffer comically transparent bias which blinds them to reality, but still think they are completely unbiased. The organization and its staff are ridiculous.

  458. DeWitt Payne (Comment #163515): “You’re not going to get to a true individual marketplace for health insurance until you deal with the elephant in the room: preferential tax treatment for employer provided health insurance. That’s a major factor in why the US system is such a mess. Either everybody should be able to buy health insurance with pre-tax dollars or nobody should.”

    Exactly so. To be fair to low income people and to reduce the need for direct government involvement at the low end, I would advocate making employer health benefits taxable and provide people with fully refundable tax credits sufficient to cover the taxes for employees in the median tax bracket with a median value plan.

  459. Tom Scharf

    Lucia,
    Are you an expert at analyzing health care options and determining which ones you want? I

    Define “expert”. Then maybe I can answer. What I think is that I know what I want and I’m pretty sure I know what I want better than some panel of other people know what I want.

    then when you go to Walmart and look around do you think those people are going to be able to decipher a wide open anything goes marketplace?

    I shop at Walmart. Good prices for breakfast cereal, white board markers, copy paper. I do think most of those people know what they want better than I know what they want and better than a panel knows what they want.

    I see exactly zero magazines extolling the best health insurance plans on the market.

    Healthcare costs are spiraling the wrong way and most people don’t even know what they are paying for.

    That doesn’t make “tiers” a solution that helps people know what they are paying for.

    If you want to determine if surgeon A or surgeon B is better in your local market, you are basically helpless.

    Sure. But as far as I can tell, Ron’s “tiers” option doesn’t address that. One surgeon might be crap, the other might be good. All the tiers say they are “gold” if they charge a lot, “dross” if they don’t. And I can get all the “golds” if I buy a “gold” plan. But I still can’t tell if surgeon A is good or bad based on whether he’s gold or dross because that’s just his price.

    Ron’s plan not limiting government subsidies for wealthy people help.
    So? I didn’t look Car and Driver or Consumer Reports to pick my car. Car and Driver’s advice is screwy. Consumer Reports isn’t screwy but doesn’t line up with my preferences either.

    Consumer Reports ranks reliability and best choices over decades.

    Which I pay little attention too. I also find their ratings on applainces nearly useless. The ratings of brands change dramatically.

    Car manufacturers do tier their products.

    Yes. The “tier”. But a consumer has lots of choice and they don’t have to be locked into perpetual “gold” just because they bought “gold” last year. Nor do they have to worry about not being able to buy “gold” in future because this year, they preferred “silver”. And, they can pick “silver” with all the options, or “gold” with few. Other sharing the word “tier” what car companies provide shares practically no similarity with what Ron is describing.

    ask those people what is the right maximum lifetime benefit level one should have, or whether PPO’s are better than HMO’s.

    Honestly, I think people at wallmart can figure out if they like one list of choices better than another if you don’t insist on requiring them to know the acronym you prefer. Many of these people have been making that choice for years — because many employers offer that choice anyway. So even with the acronym, many will know what they want.

    So we can either educate the populace to be as smart as many people on this board to make an informed selection,

    Nonsense. I’m not sure why some here are fixated on the “as smart as… this board”. The issue isn’t smart. It’s knowing their own preferences. Which people actually do know.

    Gosh, if they didn’t, we could just delegate their right to vote to a “board” of “smart” people. I know some people would like that, but I’m not for it.

  460. lucia,

    Your comments here have been excellent. One thing I feel I must add. You wrote: “It’s knowing their own preferences. Which people actually do know.” Another thing the average Walmart customer knows far more than any expert is how much they can afford to spend.

  461. Lucia, the more choices of policies the more expensive they all will be. And, bad policies will be camouflaged as good ones for unwise consumers. It will take only a few bad actors to discredit the system. Besides, we need to give the liberal control freaks something to regulate.
    .
    Standardization is beneficial as much as choice is. Like most things, one needs to strike the optimal balance.
    .
    Regarding the subsidy, people with assets will not want to go uninsured just to game a partial subsidy on basic care. Anyway, if that becomes a problem then the cost of searching and evaluating assets will be the solution. But I like to keep it simple at the start.

  462. Ron Graf: “the more choices of policies the more expensive they all will be.”

    Why? I think it will be just the opposite. If healthy people don’t like their choices, they won’t buy insurance; that makes insurance more expensive. “Bad” policies that only cover large expenses and leave people in their own for small stuff will have much lower administrative costs.
    .
    Ron Graf: “And, bad policies will be camouflaged as good ones for unwise consumers. It will take only a few bad actors to discredit the system.”

    There will have to be some regulation, so that people can know what they are buying, We can’t have people discovering that the fine print in their major medical policy says it doesn’t cover chemotherapy drugs. But that only requires standardization of terminology and of the information presented, not standardization of the policies.

  463. Ron

    Besides, we need to give the liberal control freaks something to regulate.

    No we don’t.

    Standardization is beneficial as much as choice is.

    When it’s beneficial, you can actually make a case for it, not just a bald claim. It’s beneficial for screws and bolts– but we also have quite a bit more than 4 “tiers” of screws and bolts. There is a huge range of variation in size and type. Having more than 4 options doesn’t cause those who shop at Walmart any difficulties.

    Regarding the subsidy, people with assets will not want to go uninsured just to game a partial subsidy on basic care.

    I didn’t say they would. I said they would shift asset allocations to get a subsidy on basic care. Getting someone else to pay for your insurance is not going uninsured.

    Anyway, if that becomes a problem then the cost of searching and evaluating assets will be the solution. But I like to keep it simple at the start.

    I’d like to start out not horribly flawed. There is nothing “not simple” about having people who apply for subsidies declare their assets when they have none. I have no idea why you think this is hard.

  464. Mike M: “If healthy people don’t like their choices, they won’t buy insurance; that makes insurance more expensive.”
    .
    There are two strong reasons for standardization.
    1) Entitlement to a lifelong care level is predicated on continuation of coverage one had when they were last healthy. Since this is a specific entitlement it must be clearly defined and easily interchangeable among carriers.
    .
    2) The more complex the menu must be the fewer restaurants there will be and the higher the price because of both diminished competition from having a higher gate of entry as well as higher cost to administer. There is a reason restaurants do not have unlimited menus or car dealers with unlimited options. Fine dining is a small part of the average budget so it’s nice to be able to splurge and treat ones self to a fine dining experience on occasion. If we had only one mode of delivering food for all it would not be modeled after fine dining. The most important goal of healthcare reform is to reduce costs because it is such an expensive service. Almost all problems diminish when the costs go down, including the fear that people will organize their whole life (to avoid income) out of fear of paying for care or insurance.
    .
    Lucia: “No we don’t.”
    .
    There is no way to stop people from electing meddling politicians. They will do to healthcare system what they did to the tax system. The complexity of our tax system is a huge expense on it’s own. It does not have to be reduced to a post card, because if it was that would be not be seen as sufficient for directing policy goals. There is a happy medium. Unfortunately many feel they do not need to support any system or propose one either. So the government can declare it needs to step. It’s clear to me now that there is little hope of any sizable consensus forming on any reform so we are destined for a national health service by default.

  465. lucia,
    I think you are arguing more against Ron than me here. Most people don’t know the limits of their insurance policy until they have a major health event. They are buying cars in a complex system that they never get to drive. The best counter argument here is saying we are forcing car companies to make the exact same car which is a bit crazy. Subprime variable rate mortgages are an example of people not understanding what they are buying en masse.
    .
    To repeat, I’m not saying insurance companies need to be limited to tiers, I’m saying they are required to offer them. My goal is to get to a functioning transparently priced marketplace to help drive down prices in the normal manner and this is just a small piece of that, not a magic elixir.
    .
    This is only part of the solution because even in a proper marketplace it’s still going to be expensive. The cost of health care has about quintupled per capita since 1970. Over at SSC he discusses cost disease (education, healthcare, etc):
    http://slatestarcodex.com/2017/02/09/considerations-on-cost-disease/
    .
    He asks this question:
    “Or instead of slogging through the statistics, we can just ask the same question as before. Do you think the average poor or middle-class person would rather:

    a) Get modern health care
    b) Get the same amount of health care as their parents’ generation, but with modern technology like ACE inhibitors, and also earn $8000 extra a year”
    .
    It’s obvious why the US has such a problem making changes to the system, it’s herding a million cats (and half of them automatically vote no due to tribal loyalty). Ultimately if we can get some “free” marginal gains in efficiency then we have to make sacrifices somewhere. Less R&D, less services, lower quality hospitals (Japan’s hospitals looked like low rent when I was there), longer waiting times, limited access to expensive treatments, death panels, less compensation for health professionals, etc.
    .
    Is the current system OK with you? What is your favorite plan? Any ideas?
    .
    I can tolerate the current system if I must, but if my family only made $30K / year and had to spend $10K for health insurance then it’s way past the point of pain.

  466. Ron

    There is no way to stop people from electing meddling politicians.

    No. But that doesn’t mean we need to aid their meddling. There will be plenty or places where meddling is useful without this. We don’t need to encourage meddling where it is extremely harmful as this would be.

    It’s clear to me now that there is little hope of any sizable consensus forming on any reform so we are destined for a national health service by default.

    I don’t see that as our destiny. More importantly, I don’t think creating tiers and standardization is on the path to avoiding it. Standardization is one of the major bad things that would come with national health service and is one of the reasons we want to avoid national health service. Having a program that retains the worst features of national health service — that is no real choice for the consumer– is little better than having a national health service.

  467. Tom

    To repeat, I’m not saying insurance companies need to be limited to tiers, I’m saying they are required to offer them.

    I’m not sure I agree they should be require to offer them. But this is certainly a better position that saying only those four will exist.

    I might find the notion that “tiers” are defined and insurance companies may describe their plan matching a tier if they do so. I suspect many would then voluntarily offer tiers– while also offering other options individual customers would prefer. People could also then compare their plan to a “tier” and see if the items left in or left out match and so on.

    Is the current system OK with you?

    Are you asking if the current system– the ACA– with tiers which I have been saying over and over I object to is OK with me? Obviously not. It has other flaws too.

  468. I’m asking how you think we can reduce the cost curve. Perhaps the curve magically flattens out, perhaps not. I’m with Ron that once TrumpCare gets rejected and the ACA fails due to a death spiral we are heading to national healthcare.
    .
    People care about this enough (much more than Russia) that something needs done and politicians’ careers are going to be threatened for doing nothing. Many people just want the government out and this is fine by me if the cost curve is addressed. The only thing worse for Republicans than passing TrumpCare is doing nothing. They should have let the ACA fail first.
    .
    You cannot make people pay $10K and counting every year for health insurance for long before they storm the castle. Reduce the costs, do a wealth transfer, or get kicked out of office.

  469. Tom Scharf

    Perhaps the curve magically flattens out, perhaps not.

    Mostly fairly high deductibles so most people pay attention to their own costs. Substantial co-payments. Recognizing the not poor should individually shoulder most of their predictable for health care even if they are old. By not poor I mean people with income or assets. Wealth must count.

    As long we have the notion that individual consumers of health care– including older ones– should be insulated from the costs of their health care the costs will rise rapidly.

    That said: to the extent costs increase because people are willing to pay for things, there isn’t much to fix. Maybe one needs to face the fact that somethings are expensive.

  470. Tom, Lucia, I’m not sure you’re understanding my cure against the problem of becoming un-insurable. The single largest cause of increase in premiums is that people now cannot be refused the standard insurance policy, priced by only their age. Thus healthy want to avoid buying insurance because it is a bad deal when they have the option to wait to see if they get an expensive to treat condition. At any point they can buy a plan. Heck, why not go for the platinum and have little out of pocket expense? I would.
    .
    The point is that the ACA killed the heart of the insurance concept of healthcare insurance. It would be like saying insurers would not be able to turn down somebody for building insurance that has had 5 fires in the last five years. If nobody could be turned down in all the types of insurance there probably would be no more insurance industry. Many think this is exactly what was intended to drive the system to single payer and then a national health service. The reason the health insurers went along with the idea was the promise that everyone would be mandated to be a customer and that there would be standardized minimums. The tiers, gold silver, etc.. are really cosmetic and only determine the out-of-pocket exposure per year. Catastrophic insurance was eliminated to prevent people from escaping. (Almost everyone should have a bronze plan if they are in the small business or individual plans unless you know for certain that you would pay your deductible).
    .
    The other side of the coin, what we had before, is a system where if you get sick and lose your job you could risk losing your insurance and become un-insurable. We cannot go back to that.
    .
    My solution is to guarantee one will remain insurable, under any circumstances, to the extent that they were insured when they became un-insurable. And if they had no insurance or let it lapse they will get basic care, the same as those on public assistance. In order to establish and classify for legal purposes what level of care someone had when they became un-insurable there must be standardization, apples to apples. Otherwise, the system fails by litigating every case.
    .
    If you like choice, (who doesn’t?), then save your appetite for the vast number of new procedures, devices and medicines that would be born if we had a transparent market that also allowed people to pay to get premium quality care over the basic standard care. Don’t waste your choice on whether you want $100 out of pocket on Xrays rather than $125.

  471. I’d be convinced people are willing to pay more if they had a low cost option they were not taking. The only low cost option now is no insurance so it’s high risk.
    .
    Subsidized for the poor universal catastrophic coverage would be a good start. I agree the “skin in the game” factor needs to be addressed to get people to find low cost options and just as important entrepreneurs to create them. Allowing something like registered nurses to open their own limited medical care / limited liability doc in a box places would be useful. The medical industry is going to need to be told to go f*** themselves when they howl.
    .
    We know we are making progress when the pharmaceutical, medical, and insurance industries start going apocalyptic. There’s nary a peep out of them now so that puts little hope costs are going to be controlled.

  472. Ron

    Tom, Lucia, I’m not sure you’re understanding my cure against the problem of becoming un-insurable.

    Why do you think we don’t understand your proposed cure?

    If you like choice, (who doesn’t?), then save your appetite […] Don’t waste your choice on whether you want $100 out of pocket on Xrays rather than $125.

    I like choice. In fact, I even prefer to chose my own choices rather than have you tell me that you should chose my choices for me.

    I don’t consider me making my own choice a “waste of my choice”. I don’t consider you, your senator or some panel making my choice to be having a choice at all. I really think you need to stop thinking that your panel dictating my choice is somehow “my choice”. It’s not.

    In order to establish and classify for legal purposes what level of care someone had when they became un-insurable there must be standardization, apples to apples

    No this goal does not require standardization of insurance policies into a small number of “tiers”. One can establish “basic care” without limiting choice for those who pay to “four tiers”. It’s not even difficult to establish it and creating tiers doesn’t help.

  473. Ron,
    The only cure for gaming the system on pre-existing conditions is mandatory enrollment as far as I can tell. Whether this is paid directly by the consumer through penalties like the ACA or indirectly by taxes is basically the same thing.
    .
    TrumpCare apparently imposes a 6 month penalty before you can sign up which is probably enough to bankrupt most people in an event like a car accident so I don’t think this fixes much.
    .
    Even if non-insured people get “rice and beans” healthcare by default it still needs to be paid. It’s a binary decision on if you want to allow people to turn down insurance and potentially bankrupt themselves which is, let’s face it, the American way.
    .
    These bills need to stay away from things like free screenings, checkups, and free birth control. It’s OK to try to push people to cost effective behavior but that’s for another day after a workable cost system is in place.

  474. Ron
    other comments

    The tiers, gold silver, etc.. are really cosmetic and only determine the out-of-pocket exposure per year.

    That’s the way I see it: they drastically limited choice and only focused on price. That’s a huge flaw. But for some reason you want to keep it.

    Catastrophic insurance was eliminated to prevent people from escaping.

    Eliminating catostropic insurance was one of the very bad things about the ACA. It’s not clear to me if your tiers includes a catastrophic only plan.

    (Almost everyone should have a bronze plan if they are in the small business or individual plans unless you know for certain that you would pay your deductible).

    Perhaps. Unless you already know you are ill, and getting a higher prices plan is a net positive. I realize you are trying to eliminate the flaw associated with this. But I don’t think having healthy people pay for “platinum” while they are young and healthy to “lock in” the opportunity to get platinum service when they are older is a good solution. It is better for the young to do more productive things with their money than to spend it on the extra cost of too much insurance– which ends up “paying for insurance to be eligible for insurance.”

    I realize you latched onto this notion of “tiers” and have some sort of idea they and “standardization” are necessary, but I’m just not seeing it.

  475. Ron,

    The pre-existing condition thing was primarily the result of employer provided health care not being portable. If you developed,say, rheumatoid arthritis and then lost your job, you were SOL under the old system. There was no mechanism to transfer this risk between different insurance providers.

    The reason the ACA is in a death spiral is exactly the opposite, otherwise known as adverse selection. Healthy people don’t have to buy insurance until they’re sick and they are guaranteed to be able to buy when they get sick.

    Because we can’t be forced to buy health insurance, we will probably be forced to pay for a likely far more onerous single payer system.

  476. Tom

    These bills need to stay away from things like free screenings, checkups, and free birth control. It’s OK to try to push people to cost effective behavior but that’s for another day after a workable cost system is in place.

    That’s right. If the goal is to protect people from bankrupting themselves due to sudden uncontrolled costs, the insurance needs to be for “catastrophes”, not “health care”. One can argue about where the line should be drawn– but high-ish deductables generally do that.

    TrumpCare apparently imposes a 6 month penalty before you can sign up which is probably enough to bankrupt most people in an event like a car accident so I don’t think this fixes much.

    Insurance for catastrophes is precisely what would cover this sort of thing. However, it’s unaffordable if all insurance also covers routine medical like annual physicals, birth control and so on.

    The pre-existing condition thing was primarily the result of employer provided health care not being portable.

    It seems to me that to some extent this problem would continue to exist if the insurance is selected by the employer. Suppose you had “platinum” while working as the janitor for “Super Start Up Company Du Jour”. It goes bankrupt. You were only the janitor. You now get a job with “Mom and Pop hardware” who offer their employees “dross”. You’re a janitor. Ron’s system may give a right to be locked into “platinum”, but you can’t afford the premiums. So, it’s now dross for you!

    What if an employer wants to provide “platinum”, but they hire someone with a pre-existing condition who was only “locked in” to dross and who has a pre-exsiting condition? What’s the rule? And what if that employee works for the company only 6 months (with the goal of “locking in” platinum,) but then quits. Are they now “locked into” platinum?

    If yes, why can’t someone just create a “company”, take out “platinum” for the employees or — say “partners” who pay in some amount like lawyers and accounts do– and use that as a mechanism for hiring short term people who only stay for the job to escalate their “lock in”?

    Connecting insurance and health care was a mistake. We made it long ago. Of course it seemed like a good thing at the time when people didn’t expect insurance for their needs and it just seemed like a perk. But it has big problems as “the way” to get health care.

  477. lucia,

    It seems to me that to some extent this problem would continue to exist if the insurance is selected by the employer.

    Exactly. That’s another reason why employer provided health care ends up being a disaster one way or the other. But the tax preference for employers, which Trumpcare allows to continue, means that will also continue.

  479. DeWitt,
    I know. I need to go in and figure out what happened with the clocks on the update. The time zone changed. Sometimes it’s best to wait a few weeks for WordPress to push out a fix to whatever they broke.

  480. Lucia: “They [tiers] drastically limited choice and only focused on price. That’s a huge flaw. But for some reason you want to keep it.”
    .
    Lucia, under my One Price plan you have 4 tiers of out of pocket exposure and also 4 tiers of quality of coverage for each of those out of pocket choices. Four times four is 16 policies, plus going completely self-insured makes 17 choices. I will add another catastrophic level to the first group and eliminate the top tier from the second group since non-medically necessary procedures and experimental drugs should not be part of a pre-tax dollar subsidized system. People can purchase the high end package as a premium add-on plan to the third quality tier. Thus my plan would be revised per your input to have the following:
    .
    The out of annual out-of-pocket exposure:
    Platinum– $250
    Gold– $1000
    Silver– $2500
    Bronze– $5000
    Iron– $12,500
    .
    Quality levels:
    Diamond — Add on for non-medically necessary and experimental
    Ruby — Covers most all facilities and doctors, including the top
    Emerald — Covers most facilities and doctors fee levels
    Garnet — Covers basic care
    .
    Lucia: “Why can’t someone just create a “company”, take out “platinum” for the employees or — say “partners” who pay in some amount like lawyers and accounts do– and use that as a mechanism for hiring short term people who only stay for the job to escalate their “lock in”?”
    .
    My plan get’s away from employer purchased plans and gives tax savings directly to the individual. And, anyone can change their coverage at any time as long as they can find a licensed insurer to sign them to the standard policies (tiers). It’s when insurers would refuse to take someone that the policy that they have becomes critically important. It’s like musical chairs. The music stops when you get a long-term expensive condition for your age. Having diabetes at 60 likely would not make you un-insurable but at 20 it likely would. Prostate cancer would likely not disqualify a 70-year-old.
    .
    DeWitt: “The pre-existing condition thing was primarily the result of employer provided health care not being portable.”
    .
    Yes, insurance should be tailored to the individual, not the company. People need to be able to maintain the same policy for life if need be. This a reason they need to be standardized.

  481. Ron

    Lucia, under my One Price plan you have 4 tiers of out of pocket exposure and also 4 tiers of quality of coverage for each of those out of pocket choices. Four times four is 16 policies, plus going completely self-insured makes 17 choices.

    Could you provide the link that describes things to this level of detail? I clicked one and all I got was a bullet list. The sort of thing that gets discussed as “high level” PR– more like advertising telling people “the benefits” without describing any details. I may have missed another link.

  482. Universities, by getting the feds to allow 18-24 year old young adults to take on massive non-dischargeable debt for expensive yet too frequently dubious education have destabilized the education process tremendously. This is very similar to the health care system where even the well to do are frequently disconnected from actual costs and responsible decision making

  483. In my Comment #163475 I have a link to a 9-page document detailing my plan as well as a link to Change.org petition with a streamlined version. Here is an earlier 4-page composition from 12-7-16 that might be easier to digest.

  484. Ron Graf: “Four times four is 16 policies, plus going completely self-insured makes 17 choices.”

    I would be happy with one choice, if it is what I want. I don’t care how many choices there are if none of them is what I want, except for the inconvenience of having to sort through a lot of irrelevant “choices”. Let the market come up with creative solutions. I still might not get what I want, but my odds are better.

  485. Ron,
    Yes.I’ve seen the “streamlined” version. Do you have anything that is not streamlined? The 4 page also seems fairly “streamlined”. Such that a person can know the details of what you actually propose?

    Less “easy to digest” might be more useful here.

  486. Ron: FWIW, I suspect given your comments here, anything less than 30 pages does not actually describe your proposal.

  487. Mike M, tell us what you would like in an insurance innovation. Also, I’m curious to know the last innovation that you thought health insurance companies came up with. Was it captive networks? HMOs? What am I missing? The innovations I want to foster are medical ones not insurance ones. Although just like banks the insurance companies will likely be competing on web apps and conveniences as well as rates. That is all doable under my plan.
    .
    Lucia, there is nothing more that I have composed but there is also nothing in this string that I described that I cannot point to in one of my papers. I very much appreciate you and Mike M, Tom, JF and DeWitt participating in critiquing my plan. If I can make the time I will recompose using your arguments to highlight that which addresses them. A doctor friend who read it was concerned that the anonymous online published reviews would chill the doctor-patient relationship. What are your guys thoughts on the transparency mechanism of my plan, which I think is the real key to driving innovation and high quality, IMO.

  488. Online reviews will be hard, just like Amazon a lot of work would be needed to ensure the integrity of the system. Doctors will only do this if they are dragged kicking and screaming. The hospital can kick in with official stats on outcomes and frequencies of procedures, etc. Some surgeons do higher risk surgeries which would result in more “unfortunate outcomes” even if they are great. So plenty of people will be able to poke holes in whatever system is proposed, but the current system provides almost no way for consumers to make a knowledgeable choice so imperfect is likely better than what we have now. As it sits, asking around at the office is as good as it gets.

  489. Ron

    Lucia, there is nothing more that I have composed but there is also nothing in this string that I described that I cannot point to in one of my papers.

    Can you point to the 17 tiers?

  490. Here’s why I’m asking about the 17 tiers. I read this:

    Tiers of deductibles and coinsurance cominbations
    1) Platinum $500 deductible 0
    2) Gold $1000 deductible 5% coinsurance to $10,000

    4) Silver $2000 deductible 10% coinsurance to $10,000

    5) Bronze $4000 deductible 20% coinsurance to $10,000

    6) Tin $10,000 deductible 20% coinsurance to $20,000

    That’s from this:
    https://drive.google.com/file/d/0B84Ov8Kg0YQUVGljWndJbUxIbmc/view

    That doesn’t look like 17. If you want people to support your plan, they need to know what it is first. Now that you tell me it’s got 17 combinations, I really don’t have any idea what you propose.

    The document has a lot of answers to FAQs, but it’s hard to determine what the proposal is.

  491. Ron,
    Given your 17 choices, can I get $5000 deductable, 10% coinsurance to $1,000,000 and pick gold doctors? Yes/No. (Don’t explain the importance of standardize again. Tell me if this is something I can get in you plan.)

  492. Tom Scharf,
    ‘Kicking and screaming?’ Absolutely. But I don’t think making evaluations of doctors available is all that difficult. MD’s are licenced to practice by the public. It would be simple enough to make licensing contingent on complete disclosure of every malpractice case, including all out of court settlements. Of course some fields are more subject to malpractice suits, but the agency collecting the data could say: “as compared to a frequency of xxx for other doctors in this field”. Also quite easy to set up a formal complaint registry and make those complaints public. Would these things generate a huge political push-back? Of course…. and that is a good indication of one of the big problems with US health care. Doctors make more money in the States than in any other country in the world, and disproportionately more than professionals in other fields (not the case elsewhere)…. and that is because they face no competition, face no honest evaluation, and their patients have zero motivation to shop for better value.

  493. Ron Graf (Comment #163550): “tell us what you would like in an insurance innovation”.

    What brought that up? I don’t think it is anything I said.

    But since you ask, I would like the option of buying some sort of major medical insurance that does not require significant interaction with or interference from the insurance company.
    .
    Ron Graf: “Also, I’m curious to know the last innovation that you thought health insurance companies came up with. Was it captive networks? HMOs? What am I missing?”

    Huh? Is that somehow relevant?
    .
    Ron Graf: “The innovations I want to foster are medical ones not insurance ones.”

    Of course we want to foster medical innovation. But that hardly seems relevant here, other than to note that government control kills innovation.

    We need an actual market for medical care. The sort of thing that exists for things that insurance does not cover (like Lasik eye surgery). That requires clear, understandable pricing; what the Oklahoma Surgery Center is doing looks like a good start. It also requires some sort of transparency on quality, but I don’t know how to achieve that. I think it would likely develop naturally as a market develops.

    Patient reviews of doctors are of limited value. Most people have no meaningful way of evaluating the actual care.

  494. We have “three years to safeguard our climate”, according to this article by Figueres, Schellnhuber, Whiteman, Rockström, Hobley & Rahmstorf.

    But it will be all good. “A report this year by the International Renewable Energy Agency and the IEA shows that efforts to stop climate change could boost the global economy by $19 trillion. The IEA has also said that implementing the Paris agreement will unlock $13.5 trillion or more before 2050.”

  495. HaroldW,

    Can you say Broken Window Fallacy? Claiming that efforts to stop (hah!) climate change will boost the economy looks like a poster child for that. These calculations always seem to ignore opportunity costs.

  496. Tom S: “Online reviews will be hard, just like Amazon a lot of work would be needed to ensure the integrity of the system.”
    .
    What makes Ebay work is the ethic to respond, knowing that you are helping the enterprise as well as fellow consumers. Anonymous medical feedback would be powered by the same ethic. Each patient’s bill would be accompanied by a code or link to feedback with relevant questions pertaining to the billing codes. It’s something that would evolve with innovation. My plan would have the government start it then license the site out and allow a certain amount of advertising to fund it.
    .
    Lucia: “Given your 17 choices, can I get $5000 deductible, 10% coinsurance to $1,000,000 and pick gold doctors?”
    .
    No. The reason is that $1,000,000 per year is for practical purposes open ended out of pocket. One might as well self-insure as can be demonstrated by the fact that many plans before the ACA had $1,000,000 lifetime caps. My plan encourages people to insure by giving them something to gain by doing so: the privileged of enhanced care through a standard mechanism without need to pre-qualify with some sort of deposit or financial disclosure.
    .
    Part of the problem I see in our current system is that there is only one standard of care. When care is free to some that distorts the system. For those with skin in the game they will be more conservative before deciding to have the knee replacement while they are forced to pay (through taxes) for that same procedure for those who are getting it free. We need tiers.
    .
    Mike M, you said: ” I don’t care how many choices there are if none of them is what I want, except for the inconvenience of having to sort through a lot of irrelevant “choices”. Let the market come up with creative solutions. I still might not get what I want, but my odds are better.” I thought you were talking about insurance because your comment mirrored Lucia’s and that is what she was talking about. My plan expands choice for healthcare. Right now you probably have a “preferred provider network.” Even the Oklahoma idea, which is better than the current model, limits you to subscribe to their network. My plan makes everyone publish their prices and opens every provider to be available to every insurer. In HMOs the insurer is protected by pre-signed contract with the provider. In my plan they are protected by pre-published rate and the insurance obligation to be limited by government set standardized tiers.

  497. Gallup 2017 confidence in institutions survey out today:
    .
    Republican confidence in newspapers = 12%
    Republican confidence in television news = 14%
    Republican confidence in internet news = 14%
    Republican confidence in congress = 14% (up 8% ha ha)
    .
    Republican confidence in presidency = 60% (up 46%)
    Democrat confidence in presidency = 10% (down 49%)
    .
    Military / Small business / Police lead the way in confidence. Maybe the left could connect a couple dots in that attacking institution Americans actually like is a bad plan for winning elections.
    .
    http://www.gallup.com/poll/212840/americans-confidence-institutions-edges.aspx

  498. Ron Graf (Comment #163560): “My plan would have the government start it then license the site out …”

    Doomed to failure from the start.
    .
    Ron Graf: “$1,000,000 per year is for practical purposes open ended out of pocket.”

    That looks like nonsense to me. Can you justify that claim?

    Ron Graf: “One might as well self-insure as can be demonstrated by the fact that many plans before the ACA had $1,000,000 lifetime caps.”

    Looks like a non-sequitur to me.

    I’d love the chance to buy a cheap policy with a $20,000 deductible, 20% coinsurance above that, and the right to use any provider I want. A $1,000,000 limit would make it less attractive, but I might choose that over more expensive options.
    .
    Ron Graf: “My plan encourages people to insure by giving them something to gain by doing so: the privileged of enhanced care through a standard mechanism without need to pre-qualify with some sort of deposit or financial disclosure.

    That makes no sense to me. There is one, and only one, good reason for insurance: to protect one’s financial resources. Access to higher quality care might encourage people to buy pre-paid health plans, but why would you want to encourage that? The main effect would be to hurt poor people by making it hard for them to find a doctor.
    .
    Ron Graf: “Part of the problem I see in our current system is that there is only one standard of care.”

    No, there is also Medicaid. Any plan that deliberately creates wide gaps in the standard of care is politically impossible. Especially if middle income people think that they will be among those getting substandard care.
    .
    Ron Graf: “For those with skin in the game they will be more conservative before deciding to have the knee replacement ..”

    Right. Which is why everyone should have skin in the game.
    .
    Ron Graf: “My plan expands choice for healthcare.”

    I don’t see how.
    .
    Ron Graf: “Right now you probably have a preferred provider network.”

    I wish. I am in the individual market, where PPO’s are basically extinct. My impression is that the are also disappearing from the group market. You are making me think that you don’t know much about this.
    .
    Ron Graf: “Even the Oklahoma idea, which is better than the current model, limits you to subscribe to their network.”

    Totally wrong. No network to subscribe to. They don’t take insurance.
    .
    Ron Graf: “My plan makes everyone publish their prices and opens every provider to be available to every insurer.”

    I want providers to be available to patients.

    It would be a good thing to separate providers from insurers. The only way to really do that is to have the patient pay the provider. Any system based around third party payment will be very expensive or poorly serve the patient, or both.

  499. Ron

    Lucia: “Given your 17 choices, can I get $5000 deductible, 10% coinsurance to $1,000,000 and pick gold doctors?”
    .
    No. The reason is that $1,000,000 per year is for practical purposes open ended out of pocket.

    Huh? My expenses are capped at $5000+$100,000. That’s not “open ended”. It’s perfect for making sure I don’t risk losing my house. So, what I’m seeing here is you want your choice, not mine.

    One might as well self-insure as can be demonstrated by the fact that many plans before the ACA had $1,000,000 lifetime caps.

    Are you suggesting eliminating that option was a good thing about the ACA? (Real question.)

    My plan encourages people to insure by giving them something to gain by doing so: the privileged of enhanced care through a standard mechanism without need to pre-qualify with some sort of deposit or financial disclosure.

    Your plan appears to give me the choice between (a) unattractive policies where I pay for stuff I don’t need or want and (b) risking bankrupting myself if a catastrophe occurs.

  500. Earlier, statements were made about whether the average Walmart customer is able to understand health insurance. Here is a truck driver’s take: http://thefederalist.com/2017/06/29/blue-collar-middle-class-truck-drivers-rant-americas-health-care-mess/

    My favorite bit: “It reminds me of the old Mafioso days where the neighborhood boss would come around to your business demanding “protection money.” When it comes down to it, there’s not actually any real protection service on offer. The only real benefit you receive is the peace of mind that the boss may not send his henchmen to put a bullet in your head for non-payment.”

    He has a point.

  501. Mike M.
    Yep. It’s clear the truck driver understand: The price of this means sacrificing my daughters education.

    Often, people seem to think the high price of policies under ACA can be afforded if people just sacrifice “frills”, like a luxury car or vacations to Aruba or something. But for many parents the choice is comes down to their children’s future. Given the choice between

    (a) You can’t pay for cancer treatment 20 years from now because you didn’t ‘lock in’ the ‘top tier of insurance’ and are then excluded for existing conditions when you get cancer and
    (b) Your elementary – high school kids can’t get decent schooling because you are paying to ensure your access to cancer treatment (should you need it) 20 years from now,
    lots of people would pick (a). They would rather die from cancer than have their kids grow up uneducated with no access to later career opportunities when they make it to adulthood.

    The reason they pick (a) is it’s the best most moral choice. Programs predicated on the assumption that (a) was the wrong choice, which you should not have made if you’d been smarter or wiser are foolish. Because (a)– not having cancer treatment and instead educating your kids– is the right choice.

  502. Prepaid third party payer health care plans are as bad an idea as the ripoff extended warranties for appliances and cars. They’re by and large third party payer plans too. If they’re inexpensive, nobody actually takes them. If they’re expensive, you’re paying too much for what you get.

    I understand the original logic of the auto companies in WWII with wage and price controls in effect. ‘Free’ health car was a way to keep the unions happy. But it puts your health care in the hands of an unaccountable clerk at the insurance company rather than in your and your doctor’s hands. Single payer changes that to a government clerk.

    I saw a chart a long time ago showing the cost of health care over time. There was a break point that coincided with the introduction of Medicare. Before then, doctors didn’t get rich and made house calls.

  503. lucia,
    When the person who makes the right choice by sacrificing for their children gets cancer now what should happen? If the answer is he should get treatment anyway then he didn’t actually make any sacrifice at all. The people who made the sacrifice for his kids are those who are paying for his cancer treatment now.

  504. Tom,

    If the answer is he should get treatment anyway

    I’m pretty sure that’s not the point Lucia, Mike M and the Trucker are driving at.
    .
    I’d like to be able to choose what to spend my money on; what’s worth more and less and most and least in my life. If I end up dying of cancer earlier than I might have otherwise – OK. It’s not for the government to override me on that, in my view.
    .
    Certainly, I don’t expect anybody to ‘rescue’ me from the consequences of how I prioritize spending my money; I.E., I get cancer and I didn’t pay for coverage, nobody shells out the money for my treatment.
    .
    But I demand the flip side of this in return. It’s my damn money. Don’t take it from me (government) because you know better and force me to get coverage, to subsidize whatever the heck you decide needs to be subsidized. Let me spend it as I see fit, on things that matter to me, like my children’s education.

  505. Tom Scharf: ” If the answer is he should get treatment anyway”

    Of course he should get treatment anyway. That is the prevailing ethic of the medical community: Treat first, bill later. That is not so coldly libertarian as mark bofill’s reply sounds (perhaps unintentionally).

    In most cases, the patient will have to pay and, quite possibly, suffer financial hardship as a result. With a less dysfunctional system, that hardship would be much less than with the protection racket we have built. With any luck, the kids will be grateful for the sacrifices the parents made and help out.

    The issue in such cases is what happens when the patient can not pay. I’d like to see a system in which hospitals are guaranteed at least Medicare rates for all reasonable charges. I’d have no problem with some of my tax dollars going to that, provided the system makes sure the patient pays as much as possible.

  506. mark,

    It’s my damn money. Don’t take it from me (government) because you know better and force me to get coverage, to subsidize whatever the heck you decide needs to be subsidized. Let me spend it as I see fit, on things that matter to me, like my children’s education.

    IMO, exactly the same logic applies to employer provided coverage. But there’s the problem that, like in a restaurant, a la carte will probably cost more than prix fixe.

  507. I might have this thing by the wrong end.

    In most cases, the patient will have to pay and, quite possibly, suffer financial hardship as a result.

    All I can say is, if something horrifically expensive brings me down, I hope I retain sufficient freedom of action and wits to be able to put my own lights out before somebody makes a financial choice for me that will affect my kids.
    .
    I don’t mean to oversimplify and say all cases are like this. But for at least some of them – say, when I’m already old. Say I’m ninety frickin five years old (90-fickin-5) and I get cancer. For goodness sakes! Do I have to be ruined? What for!

  509. Mike M.,
    But let me recognize points of agreement:

    With a less dysfunctional system, that hardship would be much less than with the protection racket we have built.

    Yup. As Lucia said earlier – maybe some things are just expensive. But I’ve yet to notice the class of thing that gets cheaper when a big government bureaucracy gets control of it.

  510. mark bofill,
    I’m totally on board with determining one’s own risk and rewards. The system already gives treatment to anyone without insurance and that is likely not going to change. There is the inability to pay and the choice not to pay. It’s not clear to me what happens when someone chooses not to pay (education for their kids, want’s an iPhone, etc.). I’m not sure I see the moral hazard here.
    .
    Looks like the 401K is untouchable, but your house and assets are fair game for the medical debt collectors or bankruptcy. Apparently in Florida your house cannot be seized (ask OJ Simpson).
    .
    If most of your assets are in your home and 401K (probably pretty common) the smart move may be to forgo insurance completely and stick it in your 401K considering what a $10,000 yearly investment turns into over the long term.
    .
    I just think it needs to be clear what that risk / reward is when choosing not to pay.

  511. mark bofill,

    Of course, a person should have the right to choose to not take on a debt. Even if that means turning down treatment for a life threatening condition.

    But I don’t want a society where a person is denied treatment, either for themselves or for a child, because someone in authority thinks they won’t be able to pay off the resulting debt.

    Addition: Of course, insurance is no guarantee that a person will be able to get the treatment needed.

  512. Tom,

    Moral hazard. I’m not sure I follow. I presume you are referring back to Lucia Comment #163565

    The reason they pick (a) is it’s the best most moral choice. Programs predicated on the assumption that (a) was the wrong choice, which you should not have made if you’d been smarter or wiser are foolish. Because (a)– not having cancer treatment and instead educating your kids– is the right choice.

    So I’m not actually saying there’s a moral hazard anywhere, I think. I think it’s closer to morally correct to let me choose how to dispose of my own stuff, all other things being equal. ~shrug~ It’s immoral to force me to spend my money a certain way, perhaps. I don’t know. I don’t think this is likely what you meant by moral hazard, but I don’t really know what you meant. I sorry.

  513. FYI: The most common cause of bankruptcy is medical bills. ~70% of people who declare bankruptcy due to medical bills had medical insurance.

  514. Lucia, Mike M, I must assume by now you understand why I have standardized tiers. My plan calls for the a readjusting of the metrics of each tier as to account for a changing, medical industry, insurance industry, national demographic and inflation. If you have a bzillion plans it becomes expensive and unpractical to be sure they all get equitably adjusted. If they do not get adjusted properly there is potential harm to those who get locked into their plan by becoming otherwise un-insurable. To avoid wasting options of affordability and quality tier combo the adjustment are made driven by the market. If a tier combo gets too little participation the interval for that combo is expanded to attract its targeted market share. This is all in my plan but maybe it was not clear.
    .
    Mike M: “Any plan that deliberately creates wide gaps in the standard of care is politically impossible. Especially if middle income people think that they will be among those getting substandard care.”
    .
    Yes, this is the most difficult nut to overcome, the fact that human nature would rather everyone have poor care than anyone having better care. This is the heart of the socialist dogma and the opposite of the American ideal, which I think was only perpetuated by great elementary public education touting American Exceptionalism. I think that has been gone from the curriculum for many decades now. But I digress…
    .
    Mike M:

    “Even the Oklahoma idea, which is better than the current model, limits you to subscribe to their network.”
    Totally wrong. No network to subscribe to. They don’t take insurance.

    .
    I’m felt sure you are talking about this program that Steve Forbes has been promoting. If not let me know.
    .
    Mike M: “I want providers to be available to patients.”
    .
    This is the heart of my plan. Insurance will reimburse based on published prices and coverage determined by quality tier. I wish you would read my plan. You might like it.
    .
    Mike M, your plan, whether individual or group, is likely a PPO, EPO, HNO (not HMO) or HSA. Most all have preferred provider networks. HMOs have restricted networks. My plan would make networks obsolete the celebration of patients, doctors and probably insurers, except maybe the baby Blues.

  515. mark bofill: “maybe some things are just expensive. But I’ve yet to notice the class of thing that gets cheaper when a big government bureaucracy gets control of it.”

    Yes, we do agree on that. Medical care is inherently not cheap. But I suspect our dysfunctional system doubles or triples costs over what they need to be.

    Hmm. What things are causing great angst due to increasing costs? I come up with medical care, housing, education. Am I missing something? (real question) All three are arguably due to government meddling.

  516. mark bofill,
    Moral hazard as in there is no effective punishment if you choose to not pay, or if a logical analysis of risk leads one to conclude it is better or small risk to not have insurance. The risk needs to be much greater than the reward to convince reasonable people to buy insurance. Is it? Maybe.

  517. Mike M,

    But I don’t want a society where a person is denied treatment, either for themselves or for a child, because someone in authority thinks they won’t be able to pay off the resulting debt.

    When you say someone in authority, do you mean somebody in government, or the somebody in private practice fronting the money or service? real question.

  518. I’ll be back later, sorry folks. My carriage has just turned back into a pumpkin for the next several hours.

  519. Mike M, I was thinking the Surgical Center of Oklahoma was part of the FFMA (Free Market Medical Association) since they are both in Oklahoma City. It appears SCO is straight fee for service. They would take insurance from companies that self-insure. Conventional insurance should reimburse the expense as an “out of network” care.

  520. mark bofill (Comment #163581): “When you say someone in authority, do you mean somebody in government, or the somebody in private practice fronting the money or service?”

    Either.

  521. Lucia, you asked if I think the ACA’s elimination of payment caps was a good thing. I believe the ACA was fundamentally flawed by not addressing most of the major problems with our healthcare and failing even to accomplish the one thing it set out to achieve: universal coverage. The caps did not particularly disturb me but looking back, considering my family and estate, I would have been happier not to have had the exposure if I had a decent selection or plans to choose from. My small business limited me to three companies in my locale that were competitive. This year we are down to two and next year we may only have one.
    .
    Also, you changed your example from $1,000,000 to $100,000 per year but I still feel there is not enough other people that would select that exposure when the worst case scenario is basic care, not zero care. Trump and the GOP will be obviously vilified, and perhaps rightfully, if they do not fill the gap. It is not right to leave it to individual doctors and hospitals to decide that it’s OK not to get paid if someone doesn’t want to. But muni hospitals will give urgent care to anyone who walks or is ambulanced in.

  522. Ron Graf (Comment #163578): “Lucia, Mike M, I must assume by now you understand why I have standardized tiers.”

    Can’t speak for lucia, but I haven’t a clue.
    .
    Ron Graf: “My plan calls for the a readjusting of the metrics … a bzillion plans it becomes expensive and unpractical to be sure they all get equitably adjusted.”

    Central control of payment leads to crony capitalism, disempowering of the individual, and a major drag on innovation.
    .
    Ron Graf “human nature would rather everyone have poor care than anyone having better care.”

    Perhaps. But what I, and most people, want is for everyone to have very good care.
    .
    Ron Graf: “This is the heart of my plan. Insurance …”

    Insurance will always get between provider and patient.
    .
    Ron Graf: “your plan, whether individual or group, is likely a PPO, EPO, HNO (not HMO) or HSA.”

    It sounds like you are not familiar with the individual market. There are four choices where I live. That is, I think, a lot. The choices are: HMO, HMO, HMO, and HMO. I think that is normal.
    .
    Ron Graf: “I wish you would read my plan.”

    That’s an option?

  523. Lucia, under my plan the $20,000 per year max out of pocket tier will be as inexpensive as the $60,000 tier (if it existed) today. Eliminating cost shifting and 50% of the overhead, honed by transparency and competition will cut prices at least three-fold.

  525. Ron Graf,

    The links do not work for me (it looks like they want to execute a slew of scripts). And judging by lucia’s comments, there is nothing much there.

  526. Mike M, I think Kaiser is the one successful HMO model out of the 1970s. It has been blessed with superb management. But I am shocked that your only choice is a narrow captive network. So you have zero coverage out of network? You should be supporting my plan, which would open the nation to you for both providers and insurers. The one thing Trump and GOP pound the drum about to bring prices down is the open up state barriers. You can’t do that when the local networks are captive to the local insurance giants.

  527. The links are to my Google docs. I thought they were universal but you may have to be logged into a gmail or google account.

  528. Tom Scharf

    If the answer is he should get treatment anyway then he didn’t actually make any sacrifice at all. The people who made the sacrifice for his kids are those who are paying for his cancer treatment now.

    Of course.

  529. Ron

    Lucia, Mike M, I must assume by now you understand why I have standardized tiers.

    Yes. I understand your reason and recognize it’s a bad one.

  530. Ron

    Also, you changed your example from $1,000,000 to $100,000 per year but I still feel there is not enough other people that would select that exposure when the worst case scenario is basic care, not zero care. T

    No. I didn’t change anything. I pay 10% of the amount until the amount reaches 1,000,000. 0.10*$1,000,000= $100,000. That’s the way these things are described on web pages that describe what 10% deductible up to $1,000,000 describe how policy terms are worded.

    I’m not sure why you are focusing on ‘other people’. My complaint is lack of choice. I want my choice. It’s one thing if the free market doesn’t provide it. It’s unacceptable if the free market would provide it but can’t because the government won’t permit me or the insurance agency that choice.

  531. Ron

    Lucia, you asked if I think the ACA’s elimination of payment caps was a good thing.

    I re-read your answer twice. No I have to ask again: do you think elimiantion of the caps was a good thing? Yes? No?

  532. Ron,

    Lucia, under my plan the $20,000 per year max out of pocket tier will be as inexpensive as the $60,000 tier (if it existed) today.

    (a) How do you know this? and
    (b) Why shouldn’t I get my choice of the $60,000 tier which, presumably would still be cheaper?
    Real questions. I’m especially interested in (a).

  533. Mike M,

    But I don’t want a society where a person is denied treatment, either for themselves or for a child, because someone in authority thinks they won’t be able to pay off the resulting debt.

    I don’t either. A couple of options occur:
    1) We can use the power of government to prohibit people in authority from denying treatment. Somebody pays though. If nothing else, the doctor who provides the treatment against his better business judgement pays when the client doesn’t.
    2) We can take it upon ourselves, as free people, to do the right thing, to the extent we can afford to and the extent we choose to. We can donate, give to charities, churches, so on. We can volunteer. This option has a virtue (in my view) which makes it superior to option (1) – we put our money where our mouth is.
    I get where you’re coming from maybe. I suspect you’re a good natured compassionate person. That’s no bad thing. I like to think I am too. Maybe most people are. Leave us free to choose to do the right thing. The rest of this in my view – if we aren’t going to choose to do the right thing when nobody is making us, government is never going to fix that anyway.
    Thanks for talking with me on this Mike. 🙂

  534. Ron Graf: “I am shocked that your only choice is a narrow captive network. So you have zero coverage out of network?”

    It is official: You haven’t a clue what you are talking about. I have no out of network coverage, other than emergencies. Just like almost everyone else in the individual market. You used to be able to get PPO’s in large cities. Now New York City and Houston have, combined, zero. http://www.slate.com/articles/business/moneybox/2015/12/ppos_are_disappearing_from_obamacare_why.html
    Actually, there no PPO’s on the Texas exchange in any city, just like many other states. There is still one in Illinois. I am lucky in that I get a choice of four HMO’s.

    I see no reason to believe your claim that your plan will change that. Your claimed cost reduction defies belief. And I doubt you know what you are talking about re state barriers.

  537. Mike M, thanks for the slate article. I knew the ACA ship was sinking but I did not know those particular deck chairs (PPOs) were sliding off the marketplace so fast. It only makes reform more urgent I would assume. And, right now you sound like you are a worse victim of the ACA than most people. I am genuinely curious in what direction you would like to go to bring down costs, improve care and be humane to those without means to pay?
    .
    Lucia, I understand you want to see a catastrophic $100,000/yr out-of-pocket exposure plan option. If more than 3-5% of the population think that is the sweet spot for the deductible in my proposed plan’s Iron tier then that is what would exist. I am not sure where you see unlimited choice in the current system or anyone proposed. So I will ask you the same question as Mike M. What direction you would like to go to bring down costs, improve care and be humane to those without means to pay?
    .
    Regarding ACA caps prohibition and other ACA “reforms,” there are some I like and some I don’t. In general I am a libertarian capitalist but I see there is a place for regulation to establish fair market rules and consumer protections.
    .
    Eliminating caps was a mildly good reform. If it added to the costs of plans it did so at the protection of those needed and expecting that protection.
    .
    Standardized tiers was a good attempt implemented poorly. The plans are still too jumbled to compare apples to apples. The classification did not help even the most inept consumer but it was needed to classify silver plans for the purpose of that is the limit (second most expensive silver plan) of what qualifies for subsidy.
    .
    Lucia, you say my reasoning for tiers is bad. Can you elaborate?

  538. Ron Graf: “right now you sound like you are a worse victim of the ACA than most people.”
    .
    You still don’t get it. I am not happy with my situation, I am probably lucky compared to most people who aren’t getting government subsidies.
    .
    Ron Graf: “I am genuinely curious in what direction you would like to go to bring down costs, improve care and be humane to those without means to pay?”
    .
    He who pays the piper calls the tune. So the patient paying the provider has to be the basis for reform. Because of the variability of medical expenses, HSA’s would probably have to play a key role. Most people should only have insurance to help with catastrophic expenses. There would have to be safety nets for the very poor, very unlucky, and very irresponsible. Any plan designed to change the whole system as of some effective date is pretty much guaranteed to fail; it will take at least a generation to clean up the mess and change entrenched ways of thinking. The best we can hope for is to create an environment in which people have the option of trying something new.
    .
    There needs to be transparency as to costs. That is a big problem. A properly functioning market solves the problem. Current billing practices effectively preclude a properly functioning market. The only hope would seem to be to make sure that innovators such as the Oklahoma Surgery Center can get a toehold. I am tempted to say that there is a role for the government in opening up the market, but in practice that would probably do more harm than good.
    .
    For example, if I understand your system at all (which I may not), each provider would publish a price list and each insurer would publish a corresponding payment list. Then if you choose a provider who charges more than your insurer pays, you pay the difference. Sounds OK at first, but it would require a standardized list of billing codes. Wave bye-bye to the Oklahoma Surgery Center, since their whole model starts with “screw the billing codes”.
    .
    If market based solutions are to take hold, there needs to be a critical mass of consumers. That means people without pre-paid health plans and with enough disposable income to build up substantial HSA’s. I doubt there are enough such people at present. We need to make that an attractive option, without forcing people out of what they have.
    .
    I think that something like the following might work to give market based solutions a toehold. Make employer paid insurance fully taxable. Provide a fully refundable tax credit sufficient for someone in the median tax bracket to pay the tax on a median value plan. Any credit not used to pay tax on an employer plan would be paid into a HSA, provided that the taxpayer makes a qualifying contribution equal to the lesser of the credit or a certain percentage of the taxpayer’s income. Permit people to opt out of their employer plan, with an equivalent sum paid by the employer into their HSA. Let people decide for themselves how to spend their HSA money, subject only to the restriction that it be health related (medical bills, buying insurance, buying a prepaid plan, etc).

  539. Addendum to my last comment.

    We need a medical care market if we are to improve medical care and control costs. No one can design a market. Markets have to design themselves.

  540. Mike M: “So the patient paying the provider has to be the basis for reform.”
    — check.
    .
    “Most people should only have insurance to help with catastrophic expenses.”
    — Yes. insurance per se is to protect against un-budget-able casualties. Making a critical service free was a huge mistake. But insurance companies sold what customers (employers, unions) wanted. Markets sometimes drive themselves into bad places.
    .
    “…Wave bye-bye to the Oklahoma Surgery Center…”
    .
    They would have to publish prices for all the codes they bill for. Anything else cannot protect against predatory pricing. Right now OK Surgery Center is a white knight, but there can be bad players too that will give price favoritism based on who knows what. I like to shop by browsing rather than having to schedule a visit to get a quote. Plus, unique procedures confound comparison feedback and followup statistical ratings.
    .
    “Make employer paid insurance fully taxable.”
    .
    That would create chaos if not phased in. However, I think all reform plans, including mine see the need to level the playing field with the introduction of a tax credit or by making premiums payable out of HSAs.
    .
    “Any credit not used to pay tax on an employer plan would be paid into a HSA, provided that the taxpayer makes a qualifying contribution equal to the lesser of the credit or a certain percentage of the taxpayer’s income.”
    .
    Now your talking. We could expand HSA in huge fashion to allow self-insurance under my plan because HSA contributions are reported to the IRS and thus one would not be able to get government assistance until after both HSA was emptied and application of income testing.
    .
    Mike M, it may be difficult to create or control markets but creating a marketplace like Ebay or Amazon is do-able. I agree that it is doomed to fail if it is run by the government. I would have one with government auspices but licensed by auction to private enterprise.

  541. Ron Graf,

    Your proposal is based on centralized government control. Large insurers and hospital systems will be able to influence the government to get much of what they want. Individual patients and doctors will get screwed. Innovation will only be allowed if it fits within the government’s rules. Since the large existing players will influence the writing of the rules, they will be biased against disrupters. In the eyes of the established interests all would be disrupters are “bad players”.

    If we want real change, we must let go of the idea that the government protects individuals. The government protects best those with the most power to influence government.

  542. HaroldW,
    Thanks for that. I have always liked Keith Kloor’s work. At the start of his article I was already thinking RPJ is the poster child of science policing gone wrong, and he went on to tell that story. The response is so vociferous to him because the evidence for extreme weather is so incredibly weak.
    .
    RPJ was my first step to becoming a climate skeptic and my first step away from the worship of science. After the 2005 /2006 hurricane years in Florida caused a huge spike in insurance premiums the insurance companies stated climate models predicted a 30% increase in future damages. I decided to take a look at the actual data and a search brought me to RPJ’s site. Well it was a WTF moment to find out there was basically zero evidence that hurricane characteristics had changed over the previous 100 years.
    .
    The last 11 years have been some of the quietest in Florida history. Even with the wicked 2005/2006 seasons the decade of 2000 to 2010 still ended up exactly at historical averages.
    .
    2017. RPJ’s out of job. Insurance premiums haven’t declined. Everyone in the media still thinks extreme weather is getting worse. Tom’s become disillusioned about the scientific process in environmental science and how the media covers it.
    .
    Scientific monocultures are the ebola of academia.

  543. Ron Graf

    Lucia, I understand you want to see a catastrophic $100,000/yr out-of-pocket exposure plan option. If more than 3-5% of the population think that is the sweet spot for the deductible in my proposed plan’s Iron tier then that is what would exist.

    But no matter what, your plan seems to have (we know understand) only 17 plans. That is: it limits choice.

    You don’t seem to understand: I want choice. That means I want to be able to exercise my preference, not whatever your “smarter” panel decides is one of the “correct” choices to include under what is available. I also want to be able to change my choice. I don’t want to have to buy something I don’t need now in order to avoid being “locked out” of something I don’t need later.
    Your plan is flawed in both regards.

    I get it: you think this flaw is a positive thing. I think it’s a negative. So, I don’t support your plan. (Of course, if it turns out that the world loves it, I might be stuck with it just like people who don’t like the ACA are stuck with that for the time being. But the fact that it might turn out others like your proposal doesn’t mean I need to support the idea it be implemented nor would I be required to like it after it is implemented.)

    For what it’s worth, I think the GOP plan where people are locked out of insurance for 6 months if they forgo insurance is much better than your tiers. Yes: people risk that if they get hit by a bus, they will be out of pocket. Or, they risk not being able to get prompt treatment for some things unless they assume the cost. That means: yes, the people who don’t get insurance risk having to pay for things themselves. That makes insurance insurance.

    I am not sure where you see unlimited choice in the current system or anyone proposed.

    I haven’t claimed to see unlimited choice in the ACA, nor as far as I am aware, does anyone. One of the main criticisms of the ACA is lack of choice. For some reason, you want to retain that. You should hardly be surprised that people who criticize the ACA for lack of choice also criticize your alternative for lack of choice.

    So I will ask you the same question as Mike M. What direction you would like to go to bring down costs, improve care and be humane to those without means to pay?

    I’m not sure why you are asking this in context of tiers, since that’s already for people who can afford care. So I’ll respond to your question with mine: Why are you changing the subject from “tiers” to “providing care for the poor”?

    If you want to change the subject from tiers, I guess that is ok. I do, however, want to go on record as pointing out that this new subject has nothing to do with tiers.

  544. “I am tempted to say that there is a role for the government in opening up the market, but in practice that would probably do more harm than good.”
    .
    Even from a libertarian point of view, the government fills a very important role of ensuring a fair marketplace by allowing contracts to be enforced, etc.
    .
    I think the government’s role here is to force hospitals / insurance / pharmaceutical companies to stop price hiding and allow the products to be purchased on the open market at market rates.
    .
    This is a perfect example of a market not working, it seems to be some sort of convoluted distributed monopoly from a consumer’s point of view. The government needs to step in and make the market work and if they can’t then they need to nuke it. I’m not sure how to do this without even more regulations such such as requiring that people with catastrophic only insurance be allowed to get surgeries at the same rates offered to insurance companies.

  545. Ron

    Lucia, you say my reasoning for tiers is bad. Can you elaborate?

    Here are at least two bad things. Your reasoning appears to be that

    (a) limiting choices lowers price in the aggregate – that is averaged over the country, and that that reduction is meaningful. You haven’t shown there would be any reduction at all and there are good reasons to imagine the tiers would escalate costs.
    (b) you deem limiting myability to lower my own costs to a controllable level to get what I want rather unimportant or at least unimportant relative to other things you think are more important.
    (c) you seem to be ignoring other methods to achieve the goal you consider primary– that is being locked out of higher levels of coverage based on pre-existing conditions. But the GOP plan making people wait seems better than your “tiers” where 20 year olds need to “lock in” just in case they need more care when they are 70. This is very costly to the young, while the 60 day plan lets people who may only need “dross” plans giving “standard care” when they are 20 and don’t have much money move up as they age in a controlled manner.

    I suspect I could find more explanations about what is bad about tiers. But this is a start.

  546. Ron,
    I should add

    Standardized tiers was a good attempt implemented poorly.

    No. Standarized tiers was a bad attempt by people who think “no choice” is a good thing (because consumers are too stoooooopid to know what they want) and who harbor the delusion it results in lowered costs (which we see it does not).

    It may have also been implemented in a way that made it even worse. But I have yet to hear a good reason for tiers.

  547. Ron

    But insurance companies sold what customers (employers, unions) wanted. Markets sometimes drive themselves into bad places.

    It isn’t as if the “market” just drove insurance companies there.

    Insurance companies offered what the tax codes favored. Had employer contributions for insurance been treated as taxable income to employees, many employees (including unions ones) would have wanted higher wages. They might have also liked the opportunity to voluntarily participate in group plans organized by the employer or union paying through payroll deduction or taking the money and spending it as they saw fit. One of their choices might have been to find a different plan that better suited their needs. (Note: not ‘tiered’.)

  548. This just in. Japan plans to build 41 new coal plants over the next decade after it closed its nuclear reactors. Amazingly they won’t meet their PA emissions target for 2030.
    https://www.reuters.com/article/us-japan-environment-analysis-idUSKBN19K15Z
    .
    The irony of the entire world tut-tutting the emissions cutting US for pulling out of the PA while being willfully blind to a nuclear to coal transition in Japan and Germany is hard to overstate. If only we could bottle up proselytizing intentions and use it as an energy source.

  549. Tom Scharf: “Even from a libertarian point of view, the government fills a very important role of ensuring a fair marketplace by allowing contracts to be enforced, etc.”

    I did not mean to imply that there is no role for the government. I was objecting to the idea that more government meddling is the way to clean up a mess created by government meddling .
    .
    Tom Scharf: “I think the government’s role here is to force hospitals / insurance / pharmaceutical companies to stop price hiding and allow the products to be purchased on the open market at market rates.”

    Insurance companies and pharmaceutical companies don’t hide prices and certainly do allow products to be purchased on the open market. Hospitals do hide prices. I am in favor of making hospitals publish their prices and prohibiting them from charging more than the published price. But I don’t like the idea of having the government regulate those prices, as Ron Graf wants to do by specifying which prices must be published and by prohibiting discounts.
    .
    Tom Scharf: “This is a perfect example of a market not working”

    No, it an example of there not being a market for the individual paying directly for treatment.
    .
    Tom Scharf: “The government needs to step in and make the market work …”

    When has that ever happened? I think the answer is “never”.

    Tom Scharf: “… and if they can’t then they need to nuke it.”

    Nuke what?
    .
    Tom Scharf: “I’m not sure how to do this without even more regulations”

    I am not sure how to do it either. But I am pretty sure that the solution to over regulation is not more regulation.

    The only hope I see is for there to be a critical mass of consumers demanding the sort of product that the Oklahoma Surgery Center offers. Then some providers will start to offer that. That will increase the number of consumers looking to go that route, which will encourage more providers to go that route, which will encourage more consumers to go that route, and so on.

    The best I can come up with to get the ball rolling is the last paragraph of my Comment #163608.

  550. [third attempts a charm, right?]
    [Hosed link the first time]
    Mike,

    Tom Scharf: “The government needs to step in and make the market work …”
    When has that ever happened? I think the answer is “never”.

    Thank you. I would almost rather hear that my mother in law is going to step in and supervise procreation activities between myself and my wife than the phrase ‘the government needs to step in to make a market work’.

    Tom Scharf: “… and if they can’t then they need to nuke it.”
    Nuke what?

    The entire site. From orbit no less.
    It’s the only way to be sure.
    …

  551. For fans of single payer, here is something to chew on. The British National Health Service (NHS) has decreed that an infant named Charlie Gard must die. There is an experimental treatment available in the U.S. that might help him. I suppose it is understandable that the NHS won’t pay for it. The shocking thing is that the parents have raised the money to pay for the treatment, but the NHS won’t let them take their child to the U.S. for treatment. That is the endgame of the government knows best.
    http://www.bbc.com/news/uk-england-40423371

  552. Guys,
    Pandora’s box has been opened. The chances of it going back to Pre-ACA is lower than it just flat-out getting taken over by the government, the nuclear option. What I see is zero help from the industry to try to fix the cost problem, and why would they when they are getting paid way more than other developed countries?
    .
    To be clear, I am laser targeted on costs. The cost of healthcare must go down. LOOK AT THE GRAPHS AND TABLES:
    http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/
    .
    The private sector and capitalism are losing this argument on the merits. The US market is failing here. FAILING. FAILING. You can be the biggest gung-ho capitalist on earth but you need to also be able to recognize a dysfunctional market when you see it.
    .
    Reasonable people can look at this and say let the government run it like those other countries because somehow it is cheaper. Feel free to shoot the messenger, but understand the facts.
    .
    If less government is a fix for this problem, please elaborate. At least Ron is trying to square that circle. I want the market to fix this problem because if a government takeover occurs, and costs come down, which is a real possibility, then Republicans will spend the next 100 years trying to explain away how socialized medicine won the cost battle.
    .
    It’s indefensible to keep the system as costly as it is and bankrupt people left and right without even allowing them a tolerably low cost option. People want this fixed “somehow” and are going to summarily execute any party that tries and fails. Guess who is up to bat?
    .
    Fix the cost problem, or watch the government implement socialized medicine by voter demand.

  553. Mike M,
    Examples of the government stepping in and making the market work are the split up of AT&T and Standard Oil. Power/water utilities. Imagine your power company doubles its bills today, you are screwed with very little recourse. They have to be regulated.
    .
    Monopolies are the free market going wrong. The banking industry would likely consolidate into one massive “way too big to fail” company if it was allowed to. The market is not without its faults, it is just a better system than all the others. It needs to be watched, the government has a role to play. Admittedly it overplays that role way too often.

  554. Tom,

    You point to the current situation as if it is proof that the private sector and capitalism are failing. I think it is absolutely absurd of you to suggest this. We have had government intimately involved in healthcare for a long time now, and the extent to which our current system sucks is substantially attributable to this from my perspective.
    .
    You are quite correct that Republicans are going to screw this up and that they are going to pay a price for doing so, in my view.

  555. Tom Sharf

    The private sector and capitalism are losing this argument on the merits. The US market is failing here. FAILING. FAILING.

    Yes. This is proof positive evidence that heavy control by the government, followed by heavier control followed by even heavier doesn’t work.

  556. I’m on your side here.
    Look at the data. We have the most privatized medical industry on earth. Lucia, that argument simply does not stand up to the facts when you compare other countries.
    Other countries have:
    1. Equivalent or better outcomes.
    2. Half the cost.
    3. A much heavier hand by government than the US, if not total.
    How are you measuring it? I think these facts are going to win the debate every single time using a single slide, mic drop.
    .
    A much better defense than “markets R great, at least theoretically” is needed here.

  557. Our federal government spends something north of a trillion dollars a year these days (here is a crappy and dated link) on Medicare, Medicaid, CHIP, and Obamacare. Is this part of what you are using to compute costs? Is this the ‘failure’ of the free market you are referring to? Real questions.

  558. My God, think about that for a second. There are what, 330 million Americans ballpark, and our Federal government is shelling out around a trillion a year. Over 3K per American citizen on average.
    .
    Please, let’s not pretend that this is anything remotely resembling private enterprise or the free market. That’s insanely misleading.

  559. The US still pays more for Medicare and Medicaid which are government controlled, so that’s a counter argument. But it pays less for these than the private sector. One could also look at the VA.
    .
    Is the private sector / dysfunctional market causation for US spiraling costs? Is there something unique about the US that makes it expensive for any system? Expensive shiny new MRI’s? Hospitals that look like the Ritz? Consumer demand? Overpaid personnel? All that and more I suppose.
    .
    Government steps in, moves hospitals to warehouses, take it or leave it national salaries to healthcare professionals, upgrades new equipment at a lot slower pace, throttles expensive treatments, doesn’t buy expensive drugs. It can make that happen, would it? Doubtfully.
    .
    I think its going to take 25 slides to explain how government is the problem, not the solution, and everyone’s eyes are going to glaze over. This is the opposite to the “capitalism is a better economy than socialism, look at Cuba!” argument. This is “Government run medicine is better than the US, look at everyone else”.

  560. To be fair, it’s not all on the Feds. State governments have done their bit to screw the pooch as well. here. Regulation happens at every level. All of it costs us I think.

  561. Tom,

    I think its going to take 25 slides to explain how government is the problem, not the solution, and everyone’s eyes are going to glaze over.

    This is a point where we are on different pages. I don’t much care that I’m not going to be able to persuade a majority of voters about this. I don’t expect to persuade a majority of voters. This (what I can persuade people of) has no relationship on what I think is true or false.
    I shrug at you before I call it an afternoon.
    look: shrug There.
    but it’s been fun talking. 🙂 Thanks.

  562. mark bofill,
    Keep in mind that Medicare is for oldsters, who have higher costs, so it’s hard to do a direct comparison here. The VA / Medicaid comparison would be better.
    .
    The CBO says:
    “Although the structure of VHA and published studies suggest that VHA care has been cheaper than care provided by the private sector, limited evidence and substantial uncertainty make it difficult to reach firm conclusions about those relative costs or about whether it would be cheaper to expand veterans’ access to health care in the future through VHA facilities or the private sector.”
    .
    “What Has Previous Research Concluded?
    Distinctive features of the VHA system—such as its mission, mix of enrollees, and financing mechanism—complicate cost comparisons with other sources of health care. One useful analytic approach, which was most carefully and comprehensively employed by researchers in 2004, estimates what costs would be if private-sector doctors, hospitals, and other health care providers supplied the same number and types of services as those actually delivered by VHA. Similar to earlier studies, those researchers concluded that the health care provided by VHA generally cost less than would equivalent care provided in the private sector, even though the comparison used Medicare’s relatively low payment rates for private-sector doctors and hospitals.”
    https://www.cbo.gov/publication/49763

  563. Tom Scharf

    The US still pays more for Medicare and Medicaid which are government controlled, so that’s a counter argument. But it pays less for these than the private sector. One could also look at the VA.

    The counter argument to what?
    Anyway the government pays less for services than the private sector because they limit what they pay. Many doctors won’t accept Medicare or Medicaid patients because they aren’t willing to accept the losses. In other cases, the losses get passed on to private clients. This is an example of what can go wrong when the government controls something.

  564. Tom Scharf

    Is there something unique about the US that makes it expensive for any system?

    Yes. We have a system that attempts to let consumers buy candy without regard to cost; they buy it. Those selling candy also tend to promote more and more and more candy (as in more tests procedures than someone might get if they were footing the bill.)

    This system exists because the government regulations encouraged when “health care” as an employee benefit was given favored tax status long ago. Naturally, policies that took the most benefit of this favored tax status stepped forward. The policies has low deductibles, covered lots of things and so on.

    All the various ‘fixes’ have tended to focus on the wrong thing. The correct fix is to have consumers get some benefit from buying less “candy” and sometimes forgo candy altogether. Or pick Mars instead of Godiva when that makes sense. Right now, they don’t do either. And it’s not just a question of finding procedure “XYZ” for less. Sometimes it’s a matter of knowing that procedure “X” is just as effective as fancy procedure “XYZ”.

    But with respect to consumer right now, if use less health care, well… you used less health care. Your out of pocket costs is often close to the same. (Not everyone– but lots of people.)

    This is not a “free market” thing except in the sense that the market did respond to government regulations. So it’s hardly evidence of “free market failure”.

  565. Tom Scharf (Comment #163631): “Examples of the government stepping in and making the market work are the split up of AT&T and Standard Oil.”

    OK, splitting up monopolies so that a market can work can be a good thing. But that is very different from the government trying to “fix” the market by controlling it. Which is what we have in the medical industry.
    .
    Tom Scharf: “Power/water utilities. Imagine your power company doubles its bills today, you are screwed with very little recourse. They have to be regulated.”

    Because there is little choice other than monopoly in those cases. Regulation is better than nothing, but we get poor service and little innovation. I don’t want medicine run that way.
    .
    Tom Scharf: “Monopolies are the free market going wrong.”

    Monopolies are the absence of a market. The government has been steadily turning health care into a virtually monopoly. That needs to be reduced.

  566. Tom Scharf (Comment #163628): “Pandora’s box has been opened. The chances of it going back to Pre-ACA is lower than it just flat-out getting taken over by the government, the nuclear option.”

    The status quo is unacceptable. Pre-ACA is unacceptable. Complete government control is unacceptable. We need something better.
    .
    Tom Scharf: “What I see is zero help from the industry to try to fix the cost problem”

    Industry and government arm-in-arm. Nothing good ever comes of that.
    .
    Tom Scharf: “The cost of healthcare must go down.”

    That needs a market. A real market, not a phony one.
    .
    Tom Scharf: “The private sector and capitalism are losing this argument on the merits. The US market is failing here.”

    There is no market.
    .
    Tom Scharf: “Reasonable people can look at this and say let the government run it like those other countries because somehow it is cheaper.”

    That is a real danger.
    .
    Tom Scharf: “If less government is a fix for this problem, please elaborate … I want the market to fix this problem”

    Me too. So guess I need to repeat myself as to how to give market based solutions a toehold so that they can start to grow and gradually change things.

    Make employer paid insurance fully taxable. Provide a fully refundable tax credit sufficient for someone in the median tax bracket to pay the tax on a median value plan. Any credit not used to pay tax on an employer plan would be paid into a HSA, provided that the taxpayer makes a qualifying contribution equal to the lesser of the credit or a certain percentage of the taxpayer’s income. Permit people to opt out of their employer plan, with an equivalent sum paid by the employer into their HSA. Let people decide for themselves how to spend their HSA money, subject only to the restriction that it be health related (medical bills, buying insurance, buying a prepaid plan, etc).

    Implicit in this is relaxing Obamacare requirements and eliminating the individual mandate (made superfluous by the tax credits) so that people are free to buy what they want.

  567. No, this is an example where the government can fix the problem, as actually demonstrated by other countries. You need to understand how other countries work. Other countries strongly regulate what hospitals can charge for services, US costs are 85% higher. Hospital stay:
    .
    US: $18K
    Canada: $5K
    .
    How does less regulation solve this problem? Service providers are way overpaid relatively and have to be squeezed hard to get costs down. Insurance companies I’m sure try to get costs lower but aren’t very successful at it for whatever reason.
    .
    So the US simply compensates everything medical twice as much. There is nothing particularly wrong with this in theory but medical care is not optional to citizens. I can’t choose to have less (required) gall bladder operations. I can’t choose a less expensive surgery. Everything’s a Chevy that costs the same as a Cadillac.
    .
    “Many doctors won’t accept Medicare or Medicaid patients because they aren’t willing to accept the losses…”
    …and under “Medicare for all” they can only choose to not be doctors. These aren’t “losses”, they are simply lower compensation.

  568. Tom

    No, this is an example where the government can fix the problem,

    I don’t see why it has to be the government. But if you mean they could “fix” the problem by changing the current tax system (which they created) so people had more skin in the game, sure. The government could do that.

    FWIW: Canada also has long wait times. http://www.ctvnews.ca/health/healthcare-wait-times-hit-20-weeks-in-2016-report-1.3171718

    Sure people don’t die when waiting for things like knee surgery. The wait may take zero time off their lives. I’m not sure that’s where we want to go.

  569. Tom

    Make employer paid insurance fully taxable. Provide a fully refundable tax credit sufficient for someone in the median tax bracket to pay the tax on a median value plan. Any credit not used to pay tax on an employer plan would be paid into a HSA, provided that the taxpayer makes a qualifying contribution equal to the lesser of the credit or a certain percentage of the taxpayer’s income. Permit people to opt out of their employer plan, with an equivalent sum paid by the employer into their HSA. Let people decide for themselves how to spend their HSA money, subject only to the restriction that it be health related (medical bills, buying insurance, buying a prepaid plan, etc).

    I’m for these by the way. But I’m not sure why you are grousing about the current system being some sort of failure of the (presumably free) market. These are all mechanisms to free the market. So they would be cures for a market that is not free because the consumer side was distorted. Then the governments response to the consumer side being fiddled by tax regulations was to control the supply side.

    To my way of thinking both the consumer and the provider side of the market need to be “free” for a market to be called “free”.

  570. Tom Scharf (Comment #163634): “We have the most privatized medical industry on earth.”

    Not true. I don’t know about less developed countries, but among developed countries, Singapore has a highly privatized system and by far the lowest costs. And very good outcomes.
    .
    Tom Scharf “Other countries have:
    1. Equivalent or better outcomes.”

    Questionable.

    Tom Scharf: “2. Half the cost.”

    No. Less cost, but not half. Except Singapore.

    Tom Scharf: “3. A much heavier hand by government than the US, if not total.”

    Not “much” heavier. That is hardly possible considering how much the government dominates the U.S. system.

    And you leave out:
    4. A tiny fraction of the innovation.
    .
    I think this, which I cited above, wins the argument every time. Except among those who are OK with this.
    http://www.bbc.com/news/uk-england-40423371

  571. Mike M,
    I will agree that the problem is closer to there not being a functioning market than the market is failing, semantics but good point.
    .
    How does your plan get providers to accept less compensation? It seems to cleanup some of the dysfunction in how insurance is bought. We have to somehow open up the hospitals to transparent competitive pricing, such as Ron has suggested.

  572. Mike M,
    Outcomes are worse by many measures. A big one is life expectancy. It may be tied to unhealthy American habits but outcomes across the board are not improved by the costs. There are many sources for this information.
    .
    Costs are actually over twice the OECD average. $8.2K vs $3.3K per capita. Canada is $4.4K.
    .
    More innovation, I can buy that but why should the US be paying for all that work?
    .
    Restricted medical care is part of cost control. Obviously you shouldn’t be disallowed from using your own funds for treatment, a bridge too far.
    .
    I’m all for implementing any system that brings costs down, Singapore or any other example.

  573. lucia (Comment #163646): “Sure people don’t die when waiting for things like knee surgery. The wait may take zero time off their lives.”

    Actually, people can have their health ruined by forced inactivity while waiting excessively long for things like knee and hip replacements. Canadians who can afford to often go to other countries to get such elective procedures rather than endure the wait.

    And Canadians do die directly from more severe conditions thanks to the difficulty the system has matching resources to needs.
    .
    lucia (Comment #163647): “I’m for these by the way.”

    I’m glad that somebody liked my suggestion. 🙂
    .
    lucia: “To my way of thinking both the consumer and the provider side of the market need to be “free” for a market to be called “free”.”

    Well said.

  574. Obviously we would need to accept lower medical care quality for lower prices. I want this to be an option.

  575. Tom Scharf (Comment #163649): “How does your plan get providers to accept less compensation?”

    I don’t know that less compensation is needed. I don’t think that the doctors at the Oklahoma Surgery Center are impoverishing themselves. A huge part of the cost of medical care is bureaucracy, especially in billing. Another big part is unnecessary tests and treatments. If enough people are paying directly, some providers will change their ways to take advantage of that market and the ball will start rolling downhill.
    .
    Tom Scharf: “It seems to cleanup some of the dysfunction in how insurance is bought.”

    You mean by weaning it away from employment? Also, by bypassing insurance.
    .
    Tom Scharf “We have to somehow open up the hospitals to transparent competitive pricing, such as Ron has suggested.”

    Ron would put pricing in a straight jacket, which would suppress innovation. Forcing price lists to be published would be good. But beyond that, I think the only thing that will really work is to have a decent population of price conscious customers.
    .
    Tom Scharf (Comment #163650): “More innovation, I can buy that but why should the US be paying for all that work?”

    Because other countries have centralized systems that refuse to pay for it.
    .
    Tom Scharf (Comment #163652): “Obviously we would need to accept lower medical care quality for lower prices. I want this to be an option.”

    Only if it is the individual making the decision. Price is not the same thing as cost. Price differences between the U.S. and other countries are smaller than cost differences. In other words, stuff is paid for here that would not be paid for elsewhere. That does not mean that the extra expenditures here are well spent. People should decide for themselves, with their own money.

  576. Obviously we would need to accept lower medical care quality for lower prices. This should be an option.

  577. Lucia: “I think the GOP plan where people are locked out of insurance for 6 months if they forgo insurance is much better than your tiers.”
    .
    So, if one get’s diagnosed with cancer or heart failure or COPD they delay their care 6 months and then the taxpayer and healthy insured pay for hundreds of thousands bill. This increases the cost of treatments while reducing medical outcomes, the opposite of the concept of preventive medicine. But on a tight budget will take the 6 mo gamble as they are doing currently to chance needing to wait for open enrollment.
    .
    Lucia, your argument that young healthy people don’t need insurance is colored by the current cost-shifting. In my plan young people will get very affordable rates because there will be no cost shifting. Insurers will compete to get the low cost young and healthy as much as the high premium paying elderly. EVERYONE who has the potential for a casualty they cannot budget for needs insurance. Saving and investing should work in healthcare as it does in all other life endeavors. If one waits and neglects preparation for a likely need their cost should be higher. If they are not because they can shift the cost to someone else in the time of need then regulation is needed.
    .
    I am a libertarian, Lucia. But I am not so extreme that I do not see a place for regulations. I want to utilize free market forces under sound regulation. My beef with most progressives is that they do not appreciate investment and consumer driven markets. They only see resources and those who need them and direct distribution.
    .
    I understand the socialist’s empathy and even agree that our wealthy society has some moral obligations to help those who will not or cannot contribute, and thus have no means for necessities of life, including today’s medical care. If we cannot find a compromise that address ALL societies demands we will be left with a national health service as a new entitlement added to the tax base of those who earn enough to pay taxes. It will be crushing.
    .
    My plan tries to please everyone and, of course, it does not please the extremes on either side. I stopped my lobbying efforts when it became clear that the GOP was not going to do a bipartisan approach on reforms.

  578. Ron Graf,
    “…have no means for necessities of life, including today’s medical care.”
    .
    When did expensive health care become a necessity of life? (Not rhetorical.) So long as unlimited health care expenditures are considered a ‘necessity of life’, along with the notion the public must provide ‘necessities’ to everyone, health care cost will grow without limit. If we have an obligation to provide unlimited health care to everyone in the States, then it seems logical to expand that to include everyone on Earth, but I doubt you would propose that. We could still all join hands and sing Kumbaya.
    .
    Health care expenditures are grossly inflated by health insurance (which means the patient has no skin in the game), including Medicare and Medicaid, aggravated by making employer paid health insurance tax free. Make health insurance paid by employers fully taxable, require employers to offer that money as regular income at an employee’s discretion, and make all medicare/medicaid have significant deductables and co-pays, and the market will lower costs.

  580. Ron Graf,

    the opposite of the concept of preventive medicine.

    One can say many good things about preventative medicine. But the idea that it lowers cost is either (a) not at all true to (b) just barely true.
    http://www.nejm.org/doi/full/10.1056/NEJMp0708558
    http://www.reuters.com/article/us-preventive-economics-idUSBRE90S05M20130129

    Lucia, your argument that young healthy people don’t need insurance is colored by the current cost-shifting.

    I didn’t make that argument.

    My beef with most progressives is that they do not appreciate investment and consumer driven markets.

    Yet, your proposal here is to create a new market that is not consumer driven. Also: it doesn’t seem to have anything that fosters investment. You shouldn’t be surprised others who lean libertarian don’t like it.

    I understand the socialist’s empathy and even agree that our wealthy society has some moral obligations to help those who will not or cannot contribute, and thus have no means for necessities of life, including today’s medical care.

    But your tiers have nothing to do with helping those who cannot contribute. And there are better ways to deal with those who will not.

    My plan tries to please everyone and, of course, it does not please the extremes on either side.

    I don’t think I’m extreme. I also find it difficult to believe your plan will please a lot of people. If it turns out it does, ok. I’ll be surprised. But it’s not as if your plan has currently been embraced by huge numbers of people and stands as a compromise about to be passed. As far as I can see, it’s a plan you came up with. So, of course, it’s going to tend to have features you like.

    You seem to have imitated many of the worst features of Obamacare. I don’t know why you like those– but evidently you do.
    Sure, it may be that we’ll end up with single payer. I won’t like that. But I’m not seeing how the situation is either (a) your plan vs (b) single payer. If anything the situation is (a) the GOP plan somewhere along the lines of what the Senate and the house proposed or (b) … something.

  581. Mosher,
    The youtube video includes a link to this

    http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all

    Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.

    So basically: The patients don’t bargain because insurance covers it. Insurers don’t bargain much because they raise premiums.

  582. Steve Mosher,
    Sure it is complicated. No, that guy’s take does not address all the important issues. We are spending about $10,000 per year per person on health care… but most of that very late in life, where little is added to life expectancy, nor even “health outcomes”. The video asserts (without support) that people will spend any amount of money on health care to ‘stay alive’, so will never try to negotiate a lower price. This is absolute rubbish. They will spend any amount of other people’s money to stay alive, and will never try to negotiate a lower price. What is lacking is skin in the game.

  585. SteveF,
    Interestingly, that video linked to an article about colonoscopies, for which American’s pay a lot. People aren’t getting colonoscopies because they need them at the particular time the get them. In principle, anyone should have time to shop around if they had the inclination and it was possible to do so . They don’t because insurance companies pay. The insurance companies are willing to pay for anesthesia that’s beyond the necessary level, and for having the procedure done in the most expensive way possible.

    Worse, there isn’t even evidence these annoying, time consuming procedures are any better than cheaper procedures. But the fact is: no one shops around.

    There are lots of other procedures one might shop around for. Some are recommended routinely for everyone in a class. Mammogram?

    If people had to pay for these out of their deductibles, they would be willing to do a little research to find better prices. They would ask about price and they’d ask about alternative procedures.

  586. The failed Obamacare system, defended reactionary democrats has laid the groundwork for a true American compromise. The final outcome born if pain and hard negotiation promises to not onlyv fix what Obama and the dems wrecked but to build something that can work vwell into the future. This is how the process is supposed to work…hard fought, well defended, highly contested. It is actually refreshing.

  587. Next time you get a colonoscopy ask the Doc how many cancers he’s seen – not polyps, cancers.
    .
    I asked. “None, but lots of polyps.”
    .
    we figured the guy had done over 17,000 viewings. We suspected that a reason he’d never seen any was that his patient population didn’t include the folks most likely to develop this problem.
    .
    My brother Dr. Dr. F. asked his guy and got similar answer.
    .
    we also decided that this dearth of cancer viewings did not diminish the value of the exam, but suggested that maybe the problem isn’t as frequent as thought at least among old white men.
    .
    And of course we each were asked, “What do you care, you aren’t paying for it.”
    .
    Grrrrrrrr.

  588. j ferguson,
    The thing is, these are used as screening. But other cheaper screening procedures exist.

    They did not directly compare screening colonoscopies with far less invasive and cheaper screening methods, including annual tests for blood in the stool or a sigmoidoscopy, which looks at the lower colon where most cancers occur, every five years.

    This points to exactly the problem:

    And of course we each were asked, “What do you care, you aren’t paying for it.”

    Well you aren’t paying for your specific procedure. Just your contribution to everyone’s– through insurance rates.

    A very expensive procedure is being used to do something that could be done fairly inexpensively. But with our system individuals have no incentive to do the less expensive procedure nor to shop around for a cheaper colonoscopy. This isn’t money spent to stay alive. It’s just spent because a doctor recommends it and our system buffers the patient who follows the advice from paying the outrageous cost.

  589. From the NT Times article cited by lucia (Comment #163661): “Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.”

    That defies belief. Insurers can’t just raise premiums; they have to get their premiums approved by state regulators. And even if they get their rates approved, they have to compete with other insurers. It’s like saying that auto companies can pay their employees anything the employees want, since the company can just raise the price of cars.

    The article cites prices of $6,385; $7,563.56; $9,142.84 and $19,438. Then it says “While their insurers negotiated down the price, the final tab for each test was more than $3,500.” Sounds like they negotiated pretty deep discounts.

    Insurers are desperate to keep prices down. That is why we have narrow networks. The bargaining power of providers comes from being able to say “we don’t want to be part of your network”. Insurers can only push the prices they pay down so far before they lose customers because the networks are too narrow.

  590. j ferguson,
    Colonoscopies are a good candidate for poster child for stupid health care waste. In the UK, it’s once near age 60, then no more, unless there are symptoms. The procedure is costly, inconvenient, carries real risk, and almostly certainly is done far too frequently. My dad (at 78) nearly died after a botched colonoscopy (perforated large intestine). My question for the quack who did the procedure: “Do you really think very elderly people need a colonoscopy every 24 months, or do you just like all the money?”

  591. Lucia, I thought the whole thing was a racket. And yes, I usually explode when someone suggests that I shouldn’t object because I’m not paying for it. Latest exposure to the “it’s paid for” was hospice care. “It’s covered so why would you not want it?” It is potentially a less expensive morphine delivery system – details if anyone is interested.
    .
    We didn’t want it and my 102 year old mother in law wouldn’t hear of it. She’s gone now. I don’t think she missed much. And we certainly didn’t miss the hand-holding by a social worker which was part of the package.
    .
    I limit my objection to us. This might be perfectly reasonable for other people – particularly people who are easing on down the road at home, not in assisted living.

  592. MikeM

    That defies belief. Insurers can’t just raise premiums; they have to get their premiums approved by state regulators.

    Sure they need approval. But they can just say they negotiated and brought the price down. That doesn’t mean they all negotiated that hard.

    Sounds like they negotiated pretty deep discounts.

    The discounts are only large if you assume the prices listed were ever reasonable. In fact, prices in other developed countries much are lower than the “deep discount” in the US. That may suggest pre-negotiation prices like $19,438 were never reasonable initial prices and may only exist to make the discount look large.

    In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.

    Colonoscopy is a quick procedure for the doctor. Rather longer for the patient who has to drink all those beverages before hand.

  593. a couple in an apartment with a single toilet should NEVER schedule simultaneous colonoscopies thinking that there might be comradery in the preparation. that may be but there is also a logistical problem which will present itself in a very unpleasant way.
    .
    I doubt that I need to explain how I know this.

  594. lucia,

    I am not saying that the final price is reasonable. I am saying that it is not due to a lack of negotiating by the insurers. That claim is nonsense.

  595. SteveF:
    Colbert King in tomorrow’s WAPO: “Putin had his reasons for loathing Clinton. ”
    .
    I think King loathes her as do a couple of other people I know. It does seem the right word.

  596. This thread is utterly bizarre.

    I have a lump in a lymph gland in my neck. About 3 years ago I went to see the ENT specialist at my local public hospital. She said it’s OK. but sent me for a CAT scan. She picked up on a tumour peeking in to the scan and located on my thyroid. She sent me to the prefecture’s (that’s State for Americans) top specialist at a private hospital. He diagnosed a tumour.

    Then I had another CAT scan plus an NMR scan, and was passed on to the surgeon. The surgeon passed a needle (under ultrasound) through my neck into the tumour and took a sample for biopsy. On my second visit, he took a second sample. Both biopsies came up with benign tumour. The surgeon decided to operate anyway.

    The operation (partial thyroidectomy) took two surgeons 10 hours. They had to cut my throat, tunnel down through my neck and remove part of my thyroid. I was walking the next day, drips and drains came out on day two, stitches on day four and I was free to go home.

    The entire thing cost me about Y200,000 (less than $2,000), and most of that cost was for a private room. Part of this is we have a National Health system. Part of this is practioners work to benefit society rather than to get rich. Part is to do the absence of lawyers and compensation claims

  597. Seth Roentgen: “This thread is utterly bizarre.”

    What makes it bizarre? The fact that some parts of the world are different from where you live?

    Seth Roentgen: “Y200,000”

    Y? Yuan? No, that is $30,000 U.S. Yen maybe?

    Seth Roentgen: “Part of this is we have a National Health system.”

    We? Who might that be? I am guessing Japan.

    In other words, your treatment is paid for by taxes. Using technology invented in other countries.

  599. j ferguson (Comment #163678): “200,000 x .0089 = < $2,000"

    And j ferguson takes home the award for "Most Cryptic Comment".

    I suppose that .0089 is a currency conversion. Yen to U.S. dollars?

  600. @ Mike M

    Sorry, you’ll only be able to give that award to j ferguson when you pry it out of Mosher’s cold dead fingers.

  602. Neither ObamaCare nor TrumpCare addresses the costs of healthcare, they just put who gets insurance coverage and who pays for it in a blender. That’s why I don’t like either of them.
    .
    The first party who says they are bringing a sledge hammer down on hospitals, doctors, et. al. to bring US costs in line with the rest of the earth and use those “savings” to shore up social security gets my vote, I don’t care what color that tribe is.
    .
    I will absolutely take government healthcare with mandated prices
    over the current system. The more I look at this the more disgusted I get. If they don’t like it doctors can effing quit, hospital administrators can go sell doughnuts.
    .
    That solution is going to sell to the electorate I’m afraid. If I was the left I would pound this message 24/7, demonizing the “greedy healthcare sector” is a winning platform in my opinion. The healthcare sector is overcompensated and we are all paying for it. I would call it unintentional collusion between all the major players.
    .
    I have zero confidence the healthcare sector is going to fix itself, there are no incentives for them to do so. The cost trajectory of the last 40 years is inexcusable and indefensible. The rest of the world has solved this problem better than the US, time to swallow that bitter pill. Those systems have a lot of flaws but one of them isn’t paying twice as much for healthcare.

  604. The simple answer: Government price controls on ALL medical procedures and prescriptions. Starting at the OECD average.
    .
    The byzantine insurance and payment system can stay in place, as well as private sector doctors, etc. They just can’t decide how much to charge anymore, and quite frankly they don’t deserve to.
    .
    Justified by healthcare is a public utility. The medical industry will innovate to keep their costs down for more profits, and then the heavy hand of govt will lower the allowed procedure costs.
    .
    Can this go wrong somehow? Uh, yeah. It’s worth trying. Maybe in 25 years if the healthcare industry starts behaving then they will be allowed to start setting their own prices again.

  605. Tom Scharf: “The simple answer: Government price controls on ALL medical procedures and prescriptions.”

    H. L. Mencken: “There is always a well-known solution to every human problem — neat, plausible, and wrong.”

  607. Lucia: “The discounts are only large if you assume the prices listed were ever reasonable. In fact, prices in other developed countries much are lower than the “deep discount” in the US.”
    .
    I am glad you at least agree with the premise of my call for one price healthcare, that hidden discounts and negotiations between insurers and providers has proved ineffective against preventing costs from accelerating. Mike M, you commented that you wanted the ability for providers to give discounts. Well this is exactly what we have. It provides no protection for those who are uninsured from predatory pricing on emergency care.
    .
    Tom S: “Neither ObamaCare nor TrumpCare addresses the costs of healthcare, they just put who gets insurance coverage and who pays for it in a blender. That’s why I don’t like either of them.”
    .
    Tom, thanks for being the voice of reason. Trumpcare is not any more than an attempt at a first step at repair of the ACA while doing the best to fulfill the political promise by declaring a repeal of Obamacare. HSA expansion will help a little. Tax credits to individual plan holders will help. A transparent marketplace would be the true cure. And I agree with your up-thread comments stating that there is no real choice but of having insurance or medical industries that are regulated. The decision is only whether we have the brains and will to legislate a regulated market that is functional or to have a national health service that will lower costs but also service and innovation. By the way, the world’s medicine will suffer by the US going this direction, as Mike M, pointed out responding to Seth.
    .
    If one disagrees, as SteveF does, that the poor and the freeloading do not deserve the same level of care as the responsible and successful, and they certainly do not deserve free care at the expense of the responsible insured and taxpaying citizens who are prudently managing their own health cost, then I don’t see how you are not for tiered care. Medicaid is not tiered care. It simply is a limited provider care but then most care now is limited provider, especially individual market HMO plans.
    .
    If you believe that some people do not deserve any care if they don’t have any money then you are in a political minority that will never be able to get elected to implement that plan.
    .
    My answer is a consumer driven transparent market with incentives to be insured and incentives to compete on price and quality to gain customers.
    .
    Lucia, you day you don’t like tiers. Which option that I have provided above do you prefer? If there is another please let me know.

  608. Lucia: “you deem limiting myability to lower my own costs to a controllable level to get what I want rather unimportant or at least unimportant relative to other things you think are more important.”
    .
    I am going to challenge your premise that limiting your choices will raise your costs. Choices are limited all the time to lower costs. usually one has to pay more to have choices. At least this is my experience.
    .
    My plan, unlike the ACA does not force you to buy insurance, and if one has any faith in the free market and power of consumer frugality then insurance will go down in cost across the board. Because under my plan a consumer will be armed with the real prices of products and services before or after they have received them. And, under my plan, even the platinum coverage has the first few hundred dollars out of pocket. There would be zero free health care. Even the basic (lowest tier) of care that everyone would be entitled to would have a minimum out of pocket, even if it meant giving up a carton of cigarettes or a gallon of ice cream.

  609. Ron Graf,
    You have a poor understanding of my comments. WRT what ‘your plan’ is missing: skin in the game for the insured is the most glaring. Costs can be controlled in two ways: establish a real market with real competition and real incentives for patients to pursue lower costs, or establish a single payer system which cuts the earnings of health care providers by setting prices and which effectively rations care to further reduce costs. The other alternatives will not reduce costs.

  610. Ron

    I am glad you at least agree with the premise of my call for one price healthcare, that hidden discounts and negotiations between insurers and providers has proved ineffective against preventing costs from accelerating.

    I agree costs should be more transparent. I don’t think that necessarily means I agree with the “premise of [the] call for one price health care..” and so on

    I am going to challenge your premise that limiting your choices will raise your costs.

    Cahllenge away. I’m saying it seems to me more likely. But you are claiming the limiting choices will lower costs and keep repeating that as the reason for lowering costs. But you haven’t shown any evidence to support that claim.

    Choices are limited all the time to lower costs. usually one has to pay more to have choices. At least this is my experience.

    Nonesense. Limiting choices often raises effective costs because one has to buy and pay for crap they don’t want to get the bit they want.

    The Soviet Union limited choice. Prices were not low.

    My plan, unlike the ACA does not force you to buy insurance, and if one has any faith in the free market and power of consumer frugality then insurance will go down in cost across the board.

    Your plan requires people to buy something they don’t want now (e.g. “silver plan” ) to retain the right to buy it later. This is not “free market”. FWIW: I do believe in markets being more free rather than less. But your “tiers” thing takes away a huge amount of choice. That’s not “free market”. I don’t like it.

    I’m pretty sure we are kicking a dead horse though. You like your plan. That’s not surprising, you came up with it.

  611. Ron

    Which option that I have provided above do you prefer?

    The options you’ve provided are tiers. I don’t prefer those. If think you’ve provided another option, you’re going to need to repeat what that option is.

  612. Mike M: “Your proposal is based on centralized government control. Large insurers and hospital systems will be able to influence the government to get much of what they want. Individual patients and doctors will get screwed.”
    .
    I have no problem with a state, federal and multi-industry partnership to decentralize the decision making. There can also be protocols set into law that places economic and quality of life tests in determining the coverage protocols and tier reapportionment.
    .
    Where there are no protocols doctors and administrators need to individually consider each cases ethical standing and efficacy, as well as legal liability. This is extremely costly and leads to things like defensive medicine. Oklahoma Surgery Center does not have to deal with these questions since they are not doing emergency care or dealing with payment questions. They specifically state they offer “no extended payment plans.”

  613. Fact free rants are of little value. So I decide to do some fact checking.

    It is often claimed that people who don’t pay are driving up costs for the rest of us. In 2013, such uncompensated care was claimed to be $84.9 billion. Hospitals were $35 billion of that, dropping to $27 billion in 2014 (presumably due to Obamacare). So something like $60-$70 billion uncompensated care out of total spending of $3.35 trillion. 2%. I think that is not the cause of high prices.
    http://www.kff.org/uninsured/report/uncompensated-care-for-the-uninsured-in-2013-a-detailed-examination/
    http://www.cnbc.com/2015/03/23/obamacare-windfall-big-drop-in-uncompensated-care.html

  614. SteveF, if you feel I am not understanding your position you need to let me know in what way. I agree with:

    Costs can be controlled in two ways: establish a real market with real competition and real incentives for patients to pursue lower costs, or establish a single payer system which cuts the earnings of health care providers by setting prices and which effectively rations care to further reduce costs. The other alternatives will not reduce costs.

    .
    My plan is to make markets super transparent in publishing costs for every code by every provider and their patient satisfaction statistics pertaining to each of those codes. Did you read my plan?
    .
    Lucia, I think you are down to just word games or snipes. I don’t see anymore intelligent arguments left in your comments. I appreciate that you have forced me to better compose my points though. I will give it one more go.
    .
    The goals for success are universally agreed to be a system that brings down costs for the system as a whole while providing as close to universal coverage as possible. The problem lies in that healthcare is a very expensive product that many cannot afford today. To bring down costs we need a transparent consumer driven market since we almost all agree that the insurance companies are not holding the line on costs.
    .
    Men getting pregnancy coverage does not bring up the costs for men anymore than women’s or young mens’s coverage for prostate brings up their costs. This is a common canard put out be rightwing media. I wish they wouldn’t push this. If your policy has a coverage that you don’t need chances are that other people don’t use it much either and it is not expensive. If you think only women considering getting pregnant should buy coverage that includes pregnancy that is about the only exception that even comes close to being reasonable. But when should you allow the women to buy the pregnancy coverage, just before she gets pregnant? That is not exactly fair. You will then end up paying for the pregnancies in your policy anyway as the same insurance pool is being used to pay it out. Do you see that this allowance for choice did not lower your costs? It was just an illusion that you thought it would. On top of not lowering your policy costs it actually raises it since the insurers must to the extra work of policing and litigating abuses. The issue also becomes part of the “War on Women” political football and undermines millions of dollars of political resources.
    .
    Just keep it simple.
    .
    Tell me again with an example of how having to buy on of 15-20 packages each having 3-5% market share is so painful. I will give you a good reason why allowing insurers to offer plans to 0.1% marketshare is bad. It takes the same amount of government resources to compose protocols for and to police as to the larger marketshare ones. Also, it allows insurers to prey on the small percentage of consumers that think they are getting a special bargain when really they are getting less than a fair deal. A consumer is in a very poor position to evaluate their risks in competition with the insurance industry designed surviving by accurately calculating them.

  615. It is “obvious” that those greedy doctors are the problem. Let’s see.

    There are 850, 0000 active doctors in the U.S.
    https://www.statista.com/topics/1244/physicians/

    Average compensation is a bit under $300K/yr.
    https://www.statista.com/statistics/250214/average-physician-compensation-by-us-region/

    That comes to $255 billion per year, less than 8% of total health care spending.

    In 2014, $600 million was spent on physician and clinical services. That includes everyone who works for the doc, all his other business costs, and probably some tests.
    https://www.statista.com/statistics/184775/us-physician-and-clinical-services-expenditures-since-1960/

  616. Mike M.: “I think that [uncompensated care] is not the cause of high prices.”
    .
    I agree. My claim is that the primary costs increases recently were due to the ACA administrative burdens. Cost-shifting happens in many forms from Medicare and Medicaid to group to indivdual market. Yes, the group markets subsidize the individual markets under the ACA, although that has been diminishing in recent years for a variety of reasons including the ACA’s phase-in design.
    .
    The main driver of ACA costs outside of admin burden is the unexpected high volume of use by the newly Medicaid enabled free care receiver as well as under-participation in the individual markets by healthy people (shocker).

  617. Ron Graf: ” The problem lies in that healthcare is a very expensive product that many cannot afford today.”

    I do not believe that is the problem. The problem is the term “healthcare”. It leads to the fallacy that healthcare is important to health. And that leads to thinking that spending on medical care is vitally important, which leads to third party payment schemes. When people don’t have to spend their own money, they are willing to spend a lot on something that they think is important and never question whether it really is important.

    From what I understand, the frequency with which many specific treatments are performed varies enormously from country to country and from state to state in the U.S. There appears to be no sound reason for the variation. And the variation seems to have no measurable impact on health. The implication is that a large portion of medical care does not really matter. I suspect it is just giving people peace of mind.

    You can not stop that with any top-down system, at least not without killing people. I see no way to change it without making people pay enough of the cost that they think seriously about whether it is worth it. If people want to spend their own money on peace of mind, fine.

  618. Mike M,
    “The problem is the term “healthcare”. It leads to the fallacy that healthcare is important to health. And that leads to thinking that spending on medical care is vitally important, which leads to third party payment schemes. When people don’t have to spend their own money, they are willing to spend a lot on something that they think is important and never question whether it really is important.”
    .
    Yup, that is a big part of the problem. A hard nosed cost/benefit analysis is never going to be done when costs are disconnected from benefits. Single payer systems substitute system-wide rules on benefits, presumably based on a cost/benefit analysis done by some bureaucrats. Spending what we do on health care is madness… we don’t have longer or healthier lives than in other developed countries, we just pay much more. I think it is also important to keep in mind that most lifetime health care costs are incured in the last few years of life… which means that the money spent is not ever going to have much impact on average lifespan.
    .
    BTW, I think you meant $600 billion for physicians services.

  619. Ron Graf,
    Where does your plan provide incentives for individuals to do a cost/benefit analysis WRT health care expenditures?

  620. Ron

    To bring down costs we need a transparent consumer driven market since we almost all agree that the insurance companies are not holding the line on costs.

    I’ve already said I like transparency. I like it whether or not insurance companies are holding down costs.

    Lucia, I think you are down to just word games or snipes. I don’t see anymore intelligent arguments left in your comments. I appreciate that you have forced me to better compose my points though. I will give it one more go.

    Snipes?

    If your policy has a coverage that you don’t need chances are that other people don’t use it much either and it is not expensive.

    Untrue.

    Do you see that this allowance for choice did not lower your costs?

    No.

    On top of not lowering your policy costs it actually raises it since the insurers must to the extra work of policing and litigating abuses.

    Wrong. Nothing about choice results in “extra work of policing and litigating abuses”. Besides which, you didn’t focus on the major factors I want choice on:
    (a) size of deductible, (b) size of co-pay, (c) stop-loss level. Those are the features I mentioned in my examples for a difference in what I wanted. But for some reason, you decided to focus on prostate– an issue which, evidently– you consider a “right wing canard”. When you find people who are focusing on that, engage them on that specific. And don’t bring up non-cost issues like ‘war on women’ in your costs analysis. Just do a cost analysis.

    Meanwhile, I suggest you go back and crunch actual numbers about choice on size of deductible co-pay and stop-loss level. Then show that your method makes things cheaper with numbers. Not just verbal claims.

    Repeating that your entirely untested method will be cheaper over and over, while ignoring the major cost and choice factors when mentally estimating costs is not a convincing argument.

    Tell me again with an example of how having to buy on of 15-20 packages each having 3-5% market share is so painful.

    Painful? I said more costly. I can better adjust my own needs and costs if they offer a combination of size of deductible, co-pay and stop-loss that matches my budget.

    A consumer is in a very poor position to evaluate their risks in competition with the insurance industry designed surviving by accurately calculating them.

    No one is asking them to evaluate their risk. But even someone was, you are omitting that consumers are much better positioned to evaluate (a) their priorities (b) their budgets (c) what goals they are willing to tradeoff.

    Look, if you really want to convince people your policy is good, you need to engage the arguments they make and the points they advance. Structuring your explanation around some argument you think “right wing media” might advance somewhere else isn’t going to get you anywhere. And you really need to do a cost analysis to justify the lack of choice in major important factors and to show the lack of cost saves money. Repeating the claim is not going to suddenly convince people.

    I’m pretty sure I’m going to leave this alone now. You’ve got a plan I don’t like, it’s not a plan that’s being considered widely.

    For now, I think it makes more sense for me to spend time watching the plans actually being considered in the Senate and Congress.

  621. I continue my project of collecting actual facts (Comment #163693 and Comment #163695).

    One sees claims that reducing administrative costs in U.S. healthcare is the key to controlling costs. I have seen estimates from 10% to 30% of the fraction of total spending on administration.
    .
    Here is an excellent primer on administrative costs in medical care:
    http://voices.washingtonpost.com/ezra-klein/2009/07/administrative_costs_in_health.html

    Some key points:
    – It is tricky to define just what is an administrative cost and how to calculate such costs.
    – For insurance companies, costs depend on the size of the customer. They are lowest for very large groups, much higher for small groups, and highest in the individual market.
    – Complexity of the payment system increases administrative costs.
    – Some administrative costs are not only necessary, they are actually desirable.
    – The article quotes an expert named Rick Kronick: “The main question is why are health care costs going up at 2.4 percent a year faster than GDP? And most of the answers to that question have nothing to do with administrative costs. The answers are that we do more stuff and have more technology. Even if we could wring administrative savings out of the system, which I’m all in favor of and would be a good thing, we’d still be facing the question of how to slow the rate of cost growth.”
    .
    A study saying that administrative costs are 31% of all spending:
    http://www.nejm.org/doi/full/10.1056/NEJMsa022033

    All the individual parts of the system seem to have administrative costs less than 30%. Note that if insurers spend 20% on administration and hospitals spend 25% on administration, then the total is 40%.
    .
    Here are two summaries of a study comparing administrative costs in hospitals in eight countries, one by the authors and one by a reporter:
    http://www.commonwealthfund.org/publications/in-the-literature/2014/sep/hospital-administrative-costs
    http://www.beckershospitalreview.com/finance/why-u-s-hospital-administrative-costs-are-among-the-highest-in-the-world-7-things-to-know.html

    Some key points:
    – U.S. hospitals spend 25% on administration, other countries spend from 12% to 20%.
    – Lump sum payments to hospitals, rather than patient-by-patient billing, lowers administrative costs.
    – Single payer lowers costs compared to multiple payer.
    – Cutting hospital administrative costs to the lowest level (Canada) would save about 5% of U.S. health care spending.
    .
    My conclusion: Reducing administrative costs would be nice, but it is not a magic bullet.
    .
    p.s. As SteveF has pointed out, in my Comment #163695, $600 million should have been $600 billion.

  622. Imagine if hospital administrators ran airlines. You want to buy a ticket, so you go to the airline web site and find:

    – a list of boarding fees, one for each airport the airline serves

    – a list of takeoff fees, one for each airport the airline serves and having no relationship to the boarding fees

    – a list of fees for climbing to cruise altitude, depending on the type of airplane used

    – a list of fees for cruising, depending on the type of airplane used and stated per mile traveled with different rates depending on the direction of travel; with a note stating that the calculation will use the actual miles traveled, not the distance between airports

    – … well, you get the idea
    .
    Of course, it would not be that simple. There would be different rates depending on who is paying. And you would not be able to see the actual list of fees; you’d just have to give them your credit card number and wait to get the bill a few weeks after your trip.

  623. The biggest problem with deciding healthcare is the biggest problem in any representative democracy, stripping away the emotions to decide and act. One would think that economics is math an therefore has a concrete answer but economies rely on emotional forces, so both need to be taken into account. My attempt to craft a system that optimizes all these factors may, I admit, be an impossible task due to political divides, which I see as modern tribalism. Parties are not only digging in their heals on national issues they are going out of their way to be extreme and contemptuous. And, this string has barely discussed arguments from progressive viewpoints. Is there any hope for a majority consensus on anything? If the USA can pull this off it will be the greatest political triumph since the years of debate led to the founding of the US Constitution. Nobody thinks the current GOP House of Senate bills are the ultimate answer, not even them.
    .
    What are the directions? What are the extremes? What is the compromise that is acceptable to all? Hopefully people will start there and at least begin with similar assumptions.
    .
    Why should we listen to anyone’s plan? Who is an authority on healthcare is very similar to the question of who is an authority on climate science. The answer is no one and everyone. Can ideas be tested? Yes, we fifty states. Perhaps Lucia’s state could have a bzillion health plan choices and we they will prove to the rest of the country that consumers can divine the best odds on their risks and costs and pick the best plan and bring down costs. I think this is as useless as people trying to beat the casino or the stock market. There are places where we need consumer choice and empowerment but like anything there is diminishing return as infinity is approached.
    .
    Again I very interested in ideas and opinions to improve my concept and thank all who contributed to that, intentional or not. Anyone who has a plan that they think will gain bipartisan support (after the ACA is history) I am particularly interested in. I don’t think the GOP will control the government forever.

  624. Ron

    And, this string has barely discussed arguments from progressive viewpoints

    I’m telling you what I support. Obviously, that’s my view point. Others are doing the same, which is their view point. Not engaging the viewpoints actually posted by complaining they don’t reflect progressive views isn’t helpful. (Beyond that, it’s not clear your plan would be accepted by progressives either.)

    But regardless: The issue of what is or is not “more expensive” is not a “view point” nor is “tribalism” involved in figuring it out. If you want to make lowering costs a part of your goal you need to do the real work to show your plan lowers costs and then be willing to explain that.

    Hopefully people will start there and at least begin with similar assumptions.

    Yes. I hope we all share the similar assumption that choice is a good thing rather than posting arguments about why choice is a bad thing because people are too stupid to make choices.

    Perhaps Lucia’s state could have a bzillion health plan choices and we they will prove to the rest of the country that consumers can divine the best odds on their risks and costs and pick the best plan and bring down costs.

    The state doesn’t need to offer plans. In fact, barring regulations to avoid things like fraud or lack of transparency, my view is the state should not be offering them and should mostly get out of the way of deciding what the market offers. That would mean: none of your tiers.

    There are places where we need consumer choice and empowerment but like anything there is diminishing return as infinity is approached.

    Your reasons for this seem to be that people are too stupid to make choices.

  625. Mike M: “My conclusion: Reducing administrative costs would be nice, but it is not a magic bullet.”
    .
    I concur. If it were the magic bullet then a national health service would be the obvious route. The ACA did increase administrative costs significantly, both temporarily with chaotic implementation and phase-in and permanently by expansion of Medicaid and driving yearly insurance plan enrollments instead of only by change in personal needs.
    .
    Your airline reservation analogy is a good illustration where choice confounds good decision making when it is not accompanied by clear and relevant information and apples to apples comparisons born of standardization.

  626. Ron Graf,

    I concur with virtually everything lucia has said in this thread.

    Ron Graf (Comment #163704): “The biggest problem with deciding healthcare is the biggest problem in any representative democracy, stripping away the emotions to decide and act.”

    Nope. The biggest problem is that we don’t really understand what is driving the cost increase and instead focus on relatively minor issues.

    People focus on the wrong question. They ask “Why does medical care cost so much?” The answer to that question is easy: It is because medical costs have been rising faster than inflation for a very long time. The question that should be asked is “Why have medical costs been rising so rapidly?” Any solution will fail unless it is rooted in a firm understanding of the answer to that question.
    .
    Ron Graf (Comment #163706): “Your airline reservation analogy is a good illustration where choice confounds good decision making when it is not accompanied by clear and relevant information and apples to apples comparisons born of standardization.”

    Astonishingly wrong. Are airline fares standardized? Of course not. Did bundled fares come about by government decree? Of course not. If airlines did price tickets as hospital administrators do, some entrepreneur would come along and introduce bundled pricing. Then he would eat the other airlines lunches until they followed suit.

    But imagine if the airlines had to deal with a single payer that demanded detailed justification of the prices. Billing would likely be pretty much as I described in my joke example.

  628. Malcolm Gladwell was on the Chuck Show this morning. He observed that Canada had had little friction devising their single payer system having agreed (he said) that everyone must be covered, it must be affordable, that it needn’t include the latest and best (whatever’s all the rage in medicine), and that some advanced procedures would be unavailable. In a sense, he suggested that Canada did not need to support the cost of advancing medical technique and potions.
    .
    Rat that I am, I observed to the others who were watching this that Canada was quite comfortable having us (US) support these costs at OUR expense. But he didn’t say it.
    .
    While I’m here, I note that no-one has broached the notion that “Fee for Service” is at the root of our runaway cost of medical care. This idea seems popular with hospital administrators and I think presupposes that they would better like a system which populates their local establishments with a body of consumers who will now provide the facility with a monthly fee so long as they are well. I can’t see how this could work. Maybe it’s like the Mafia where you stay healthy so long as you make your payments. …or maybe not.

  629. Tom
    They no consumer choice on anything because decisions about which products were produced were made by the government. I hear toilet paper prices were sky high…. on the black market.

    Low choice doesn’t cause low prices.

  630. I apologize that this isn’t cryptic.
    .
    I have a pretty good memory for amazing tales. This one has tangential relation to provision of medical services in US.
    .
    Friend who is Board Chairman of hospital on Treasure Coast (Ancient Treasure – now more middle class) told me that his shop employed the Docs, instead of simply providing them a place to run their rackets.
    .
    Two of his Docs were a couple and came to him together in search of some way to increase their salaries. He went over the economics of the place, how they fit into it, and their situation as far a a raise might be – none soon. They were quite unhappy with this and explained that they were having a tough time meeting their obligations to their family on what they were currently earning.
    .
    My friend was quite alarmed at hearing this and asked if they could share some detail.
    .
    the detail was that they had three daughters, two at university and the third just turning 16. The instant problem was that they could not afford to buy her the C-Class Benz that it had been their practice to give to their daughters as they reached 16. Two down, one to go – so to speak.
    .
    Here was an opportunity for my friend to laugh, or ridicule his staff-members for the absurdity of their complaint but he did neither. And that is one of the real challenges of a management position, providing a sober reaction to the most outrageous demands which even terrific employees can make of you without revealing any loss of respect for them.
    .
    I might add, that in the dot.com melt-down in 2000, I read a similar story in the WSJ, but in this case the third daughter wasn’t going to get the sweet sixteen rhinoplasty job, alas. Now you have some insight into how the other half, well maybe 1%, lives. Aren’t you sympathetic to their plight? (Lucia, I apologize if that’s rhetorical.)

  631. MikeM

    But imagine if the airlines had to deal with a single payer that demanded detailed justification of the prices. Billing would likely be pretty much as I described in my joke example.

    With a real market, the airlines wouldn’t go to the expense of such billings unless many customers wanted that sort of billing. They’d just let someone else have those customers (and likely most airlines would be happy to let you drive to New Jersey rather than fly.)

    If lots of customers wanted to see itemization including things like “cruising altitude” we’d see it. It’s unlikely many do.

    That’s what happens in all markets.

    But notice: nothing about this justified creating “tiers” where bureaurocrats decide what “level” of air travel (or travel of any kid) is available through different “travel policies”. In fact: the market for air travel works mostly ok. Perhaps it could be better… or not.

  632. j ferguson,
    I have a friend who was complaining her sister was ‘irresponsible’ because she hasn’t saved in advance for the kids to go to college. The kids were about 15 or so at the time. I pointed out the friend lived in a very swank part of NY city where rents had to be in the neighborhood of $20K a month and that… well… if her sister really wanted to her sister could move to a lesser neighborhood and pay for some pretty expensive colleges out of income. (Or if she owned, she could sell and use proceeds to pay for college. Of if she owned outright, she could take out a loan and spread the cost of college over time. But in which case, the cost of living in that area remained high so she might be somewhat strapped.)

    But…. omg… move to New Jersey? Clearly, the only solution was for her to decree that college must always be paid from a “fund” that was created in advance. Since she hasn’t done that, she must be seen as unable “afford” to pay for kids college. (In the end, it seems my friends nephews went to state universities which for all I know is where they wanted to go anyway. Her sister had gone to Stanford– paid by her parents. )

    People often have a blind spot about especially when they can claim “can’t afford” when the truth really is “other priorities”.

  633. j ferguson (Comment #163709): “Malcolm Gladwell was on the Chuck Show this morning. He observed that Canada had had little friction devising their single payer system …”

    That is rewriting history. There was a lot of controversy at the time.

    “… having agreed (he said) that everyone must be covered, it must be affordable … ”

    As a former resident of Canada, I can confirm that there is general agreement on those points.

    “… that it needn’t include the latest and best …”

    Uh, no. That is at best sullenly accepted, but more often people just deny it is so.

    “… and that some advanced procedures would be unavailable.”

    Again, the reality is a mix of acceptance and denial, not approval.

    .
    j ferguson: “Rat that I am, I observed to the others who were watching this that Canada was quite comfortable having us (US) support these costs at OUR expense. But he didn’t say it.”

    Can I join your rate pack?
    .
    j ferguson: “While I’m here, I note that no-one has broached the notion that “Fee for Service” is at the root of our runaway cost of medical care.”

    In medical billing, “fee for service” means the extreme itemization of billing. I have repeatedly expressed preference for the bundled payment model, as used by the Oklahoma Surgery Center and as being pushed by Medicare. Fee for service might be contributing to cost increases and is a barrier to a proper market, but I don;t think it is a root cause.
    .
    j ferguson: “This idea seems popular with hospital administrators and I think presupposes that they would better like a system which populates their local establishments with a body of consumers who will now provide the facility with a monthly fee so long as they are well.”

    This seems to need a word or two added or changed to make sense.

    Are you referring to capitation payments? I think that idea was the basis for old style HMO’s, and is now deservedly dead. It is used in some concierge type practices, but only for primary care, I think.

  634. lucia (Comment #163712): “With a real market, the airlines wouldn’t go to the expense of such billings …”

    Well, that was my point.

  635. Mike M,
    The airline analogy is pretty funny.
    .
    Physicians are paid more in the US than anywhere else by a large margin. A few countries do pay specialists more.
    https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/
    .
    It looks like the entire world is paying more and more for healthcare, as in the health cost trend exceeds the inflation rate everywhere. The US rate is rising faster than elsewhere. Something “bad” happened around 1980.
    .
    See Exhibit 1 below.
    http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

  636. Still working on diagnosing rather than prescribing.
    .
    There is much frustration as to hospital pricing. Part of that is unavailability of price information and part of that is the fact that price information is often so disaggregated as to be useless. But part of the frustration is over the fact that prices vary widely between providers and often seem to have little relationship to what things actually cost. Anger at the latter is misguided, since it is really no different than grocery store pricing.
    .
    A grocery store buys product from distributors at one price and sells to customers at a higher price; the increase is called the markup. A typical markup might be 25%, but that does not mean that grocers are making out like bandits; profit margins are only 1-2%. Most of the markup goes to cover fixed costs such as leasing the space, electricity bills, opportunity cost, basic staffing required so that the store can open.
    .
    The markup is not uniformly applied to all products. Products that are price sensitive and can be sold in large volume will have a small markup. Sale items meant to draw people into the store might have no markup. Less price sensitive items will have larger markups. Impulse buy items will have very large markups, especially if they are displayed in the checkout line.
    .
    Markups also vary in time and from store to store. The cut of meat that was on sale last week at $7.99/lb might be $14.99/lb this week. People who really want to save money on groceries check the flyers in the paper and break up their grocery lists into different items from different stores. A lot of trouble, but there’s an app for that.
    .
    Varying markups in grocery stores don’t bother us so much because they are a secondary factor in price. That is because fixed costs are relatively small in the grocery business. In high fixed cost business the markup might be almost the entire price; then pricing can get very strange indeed. If you have ever purchased an airplane ticket, you have probably experienced this.
    .
    Hospitals have high fixed costs. They need to distribute fixed costs among products. In many cases (Medicare, for instance) they are limited in how big a markup can be applied. So they need larger markups elsewhere, such as in the ER. If the government requires insurance companies to pay 100% of something, you can count on a huge markup. Different hospitals will make different decisions as to how they distribute fixed costs, resulting in big variations in price.
    .
    I am not saying the way it is is the way it should be. I am only trying to understand the way it is.
    .
    I think I am starting to understand the reasons behind the fee-for-service model and the price secrecy, but those will have to be future comments.

  637. Tom Scharf (Comment #163716): “Physicians are paid more in the US than anywhere else by a large margin.”

    True. And the physicians in other countries probably had their education paid for mostly or entirely by taxpayers. And they are less likely to be funding pensions, disability, etc. out of their pay. And where is the graph comparing hours worked by doctors? I am guessing it is much higher in the U.S.
    .
    Tom Scharf: “It looks like the entire world is paying more and more for healthcare, as in the health cost trend exceeds the inflation rate everywhere. The US rate is rising faster than elsewhere.”

    Yes, it is a global problem. Most countries are powerless to do anything other than restrict service as much as they can get away with. The U.S. must change, but it would be a big mistake to settle for the slightly less bad systems most other countries have.
    .
    Tom Scharf: “Something “bad” happened around 1980.”

    Well, the graph starts in 1980. Otherwise, I don’t see what you mean.

    Addition: With respect to the slower growth of cost in other countries, I found the following: “On a historical basis, Medicare spending per enrollee grew at an average annual rate of 7.5% between 1969 and 2013, slower than the 9.1% average annual growth rate in private health insurance spending per enrollee”. http://www.kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/

    7.5 vs. 9.1 might not sound like much, but over 44 years, it is a factor of two.
    My guess it that government controlled spending is pushing more and more development cost into being paid for by non-government payers, otherwise known as “Americans”.

  638. Mike M, capitation payments is what I was trying to get at. I don’t think I misrepresented Gladwell’s portrayal of the Canadian ‘debate’ over what to do as quite benign ultimately leading to some sort of concordance. He also had some negative things to say about us (here in US) and the volatility of our discussion.

    I,too, liked the airline analogy. Maybe with the pilots, attendants, ground crew, leasing company, ticketing people, and with innovation from Trump, air traffic control each tendering their invoice.

    Yours is really a proposal that needs fleshing out in a pub, at a big table with a lot of people, lot of cask ale, and a lot of ideas. and at least someone, maybe you, writing them down.

  639. j ferguson: ” I don’t think I misrepresented Gladwell’s portrayal of the Canadian ‘debate’”

    I apologize if I seemed to imply that you misrepresented Gladwell. My intent was that I think that Gladwell was misrepresenting the situation in Canada. It was not, and is not, a big chorus of Kumbaya.
    .
    j ferguson: “Yours is really a proposal that needs fleshing out in a pub, at a big table with a lot of people, lot of cask ale, and a lot of ideas. and at least someone, maybe you, writing them down.”

    Thanks. But I fear that the combination of a generous supply of ale and debating health care could lead to police involvement. So this forum will have to do. But, come to think of it, I could use a pint of Guinness.

  640. Mike M,
    “And where is the graph comparing hours worked by doctors? I am guessing it is much higher in the U.S.”
    .
    What? On the rare occasion I have played (hugely) expensive private golf courses, the staff had to address most everyone as “doctor”. Doctors are the highest paid and least overworked group I have encountereed. There is no doubt they work hard in school and their early years, but on average? Pretty cushie.

  641. Mike M,
    I have two brothers who are anesthesiologists and my daughter is very likely going to go that route, so I’m not entirely unsympathetic to doctors getting paid “market” rates. Physicians have higher stature here and it legitimately attracts the best and brightest of our society as well as world leading R&D.
    .
    My rookie diagnosis is everything is more expensive so everything must come down in costs, and thus the prescription is to implement the time tested starve the beast strategy. Throw less money into the arena and let the participants fight it out for who gets what. This opinion is worth what you paid for it, and only useful to the point it might reflect a general exhaustion with healthcare that leads voters to the blunt tool of a single payer socialized medicine solution.
    .
    My brother does all the business for his group and has told me many stories of how they do contracts with the hospitals which is a nightmare with a small doctor group fighting a regional hospital administration that is much better at the negotiating game. This is repeated a 1000 times over in the US with highly variable results.
    .
    The divergence starts in 1980, it’s possible it existed prior to that with US costs being lower although it likely didn’t continue the trend below zero, ha ha.
    .
    The market should actually work now. Lower priced insurance companies should attract more customers (business or individuals). These inusrance companies should be very keen on getting better rates from hospitals. Hospitals should want to compete for inusrance company business. Insurance companies should really, really care about prescription rates. It’s a mess. It’s easy to throw up one’s hands and say blow up the entire thing and start over.

  642. Mike M.

    Are airline fares standardized? Of course not. Did bundled fares come about by government decree? Of course not. If airlines did price tickets as hospital administrators do, some entrepreneur would come along and introduce bundled pricing. Then he would eat the other airlines lunches until they followed suit.
    But imagine if the airlines had to deal with a single payer that demanded detailed justification of the prices. Billing would likely be pretty much as I described in my joke example.

    Mike you are making straw men. My plan would give providers freedom to set their pricing. The airlines, even after the Reagan era de-regulation are still heavily regulated. There are no examples of economic success extreme regulation or lack of regulation. Good regulation is when market forces are incentivized and all parities are protected from unfair play.
    Mike M:

    If the government requires insurance companies to pay 100% of something, you can count on a huge markup. Different hospitals will make different decisions as to how they distribute fixed costs, resulting in big variations in price.
    .
    I am not saying the way it is is the way it should be. I am only trying to understand the way it is.

    My plan emphasizes coininsurance and everyone having skin in the game.

  643. Airlines are hyper competitive. Imagine a world where you could price compare a medical procedure/prescription like you can a flight search on the internet.
    .
    One part of that imagination would likely end up with a Spirit airlines of colonoscopies where you have the procedure in a parking lot and have to bring your own pain killers, ha ha.

  644. Ron

    My plan would give providers freedom to set their pricing.

    But they would lack the freedom to decide what products they offer.

    There are no examples of economic success extreme regulation or lack of regulation.

    None? Define regulation. Perhaps when making your claim your view is fast food restaurants are “regulated” because inspectors make sure they aren’t preparing food right next to a cesspit or we have minimum wage laws. That regulation is a heck of a lot different from the government dictating menu choices.

  645. Tom Scharf: “It’s easy to throw up one’s hands and say blow up the entire thing and start over.”

    Yes, that is tempting. But the temptation should be resisted.

    Capitalism produces beneficial change by creative destruction, at least when it works properly. But the sequence is important: creation precedes destruction. It is only the success of the new that destroys the old.

    With respect to the individual insurance market, Obamacare was basically “destroy and cross your fingers”. Sort of like Operation Iraqi Freedom. Destruction? Check. Creation? Not so much.

    What is needed in medical care is room for creation to operate. If something good gets created in that space, displacement of the old way will follow.

    At present, there is no direct market for hospital services. Hospitals cater to the big payers: insurers and the government. That leaves 30 million people out. I think the hospitals don’t see the uninsured as 30 million potential customers, they see 30 million potential deadbeats.

    But what if we had 30 million people putting, $5-10K a year into Health Savings Accounts and, in a few years, accumulating ballpark $1 trillion in those accounts? At least some hospital administrators are going to say “I gotta get me some of that”. If the hospitals don’t, entrepreneurs will. Then we get creation, and destruction of the old will follow.

  646. >A grocery store buys product from distributors at one price and sells to customers at a higher price; the increase is called the markup.

    This generally only applies to store brands. Most of the stuff is sold at price set by the company, who rents shelf space from the grocery store.

  648. Lucia:

    Define regulation. Perhaps when making your claim your view is fast food restaurants are “regulated” because inspectors make sure they aren’t preparing food right next to a cesspit or we have minimum wage laws. That regulation is a heck of a lot different from the government dictating menu choices.

    .
    Ideal regulation is identical to making great game rules.
    1) Rules should be simple to understand.
    .
    2) They should allow a maximization of freedom to strategize, thus allowing maximum ingenuity to be applied.
    .
    3) They should keep a level playing field for allowing all types of players to contribute an important role.
    .
    4) All players should be subject to equal enforcement as well as have equal access to means of enforcing game rules.
    .
    The same items that make a game fun make business fun. It’s no accident that Monopoly is the most popular board game of the USA.
    .
    Mike M.

    Capitalism produces beneficial change by creative destruction, at least when it works properly. But the sequence is important: creation precedes destruction. It is only the success of the new that destroys the old.

    .
    Exactly, products and services should be able to quickly evolve but the game needs to evolve slowly. Changing the game by legislating need to be careful not to destroy the game by throwing all the pieces up in the air or knocking player out unfairly. Rule changes need to be announced in advance and tested where possible to see how they affect the game.
    .
    Lucia:

    But they would lack the freedom to decide what products they offer.

    .
    Then I blew it, because my intention was to create a premium market (with the upper tiers) where new products and services could get quick introduction and market traction. If we had the transparency in medicine that we do in airlines we would need much less FDA restrictions. Informed patients would be able to make their own judgement of safety and efficacy vs price. Their reporting would inform the FDA as well as the NIH and fellow patients.

  649. Ron,
    You didn’t define regulation. You explained how regulation should be designed. You claimed

    There are no examples of economic success extreme regulation or lack of regulation.

    I’m trying to understand your claim. McDonald’s was economically successful. Do you consider it “regulated”?

    On your rules for regulations, you left out the most important ones
    (a) The number of regulations should be kept to a minimum.
    (b) They should restrict the choices of those regulated as little as possible given their goal.
    (c) They should be justified based on their goal.

    I could probably think of more. Perhaps you agree with my a-c, but you left them off. Your list as written permits infinite regulation for any arbitrary reason.

    Even if you don’t like my a-c, your “tiers” violates “They should allow a maximization of freedom to strategize, thus allowing maximum ingenuity to be applied.”. By not allowing insurance companies or consumers choice of product, it reduced freedom to strategize or apply ingenuity.

    According to numerous sources, chess is the most popular board game of all times:
    https://hobbylark.com/board-games/The-Top-Ten-Board-Games-Of-All-Time Monopoly is #3.

    Monopoly isn’t even in the top 20 list of current best sellers at amazon.

    But regardless: I think it’s great for business to be fun. But whatever we do to improve health the goal of “make business fun” isn’t anywhere near the top of the list.

    Then I blew it, because my intention was to create a premium market (with the upper tiers) where new products and services could get quick introduction and market traction.

    You created a market where there is very little choice in the type of insurance policy that is offered. That’s not debatable: there are (evidently) 17. Insurance policies are products. So you have created a system where insurance companieslack freedom to decide what products to offer.

    Whether your upper tiers would encourage creation of new medical products is debatable. Presumably, the question would be “relative to what?” I can’t see that your system does much to especially encourage business creating new medical products relative to the system we already have. I certainly don’t see how tiers in general do anything to encourage innovation.

    Transparency in medicine is great: we all agree. But once again, that is separate from the issue of choice.

    Informed patients would be able to make their own judgement of safety and efficacy vs price.

    They might be able to judge these things. But those who were locked into a lower “tier” whose coverage restricted them to choosing “dross” or “aluminum” wouldn’t be able to act on that judgement.

    I’m really not getting why you don’t just rethink this whole tier business. Changing the subject to “transparency” isn’t going to make the “tiers” issue go away.

  650. Ron Graf (Comment #163729): “Ideal regulation is identical to making great game rules … The same items that make a game fun make business fun.”

    Wow. That explains a lot. And pretty much settles the question of whether Ron has anything useful to say on the subject.
    .
    The value of a market is in its ability to serve the customer, not the vendor. Proper regulation exists to protect the consumer, not the supplier. Markets and regulations designed to serve business are crony capitalism.

  651. Lucia:

    On your rules for regulations, you left out the most important ones
    (a) The number of regulations should be kept to a minimum.

    This falls in logically with maximizing regulation simplicity. The more regulators the more potential for inconsistency or conflict.
    .

    (b) They should restrict the choices of those regulated as little as possible given their goal.

    This is just another way of stating my point: ” maximization of freedom to strategize, thus allowing maximum ingenuity to be applied.”

    (c) They should be justified based on their goal.

    .
    Yes, any restriction on maximizing freedom to strategize should be justified by necessary protection and fairness of all parties. This last point responds to Mike M as well. All parties need to be protected or the consumer loses in the end. Dodd-Frank putting the small banks at a disadvantage and causing them to disappear is a perfect example.
    .
    Lucia, I would not have created tiers if they did not serve critical and necessary purposes. I’m sorry but I’m not going to explain them again. I think your valuing complete freedom at the expense of the general welfare is the balance between government and anarchy. Insurance has always been regulated. The choices before us are can we have a working regulatory system of health insurance or do we blow up the industry and give that part of the economy to the government. You are being infantile if you think there is choice 3.

  652. Mike M. I always thought the value of a market was to serve both the vendor and the customer. But I agree with your remark about crony capitalism, particularly in instances where the regulations are devised by the regulated. In that case the usual aim is to restrict competition or favor a particular method or design over others which might better favor competitor’s products.

    In the ’50s, there was a particularly egregious effort bye one of the electrical equipment manufacturers to revise the national electrical code so as to disqualify the use of high voltage fuses (inexpensive) in certain applications with the result that only breakers (expensive and their main product line) could be used.
    .
    the experiments on which this effort was based were proven to be fallacious (not innocently either) and the rules were not changed.
    .
    I suspect this sort of thing goes on all the time. And it is definitely not for the benefit of the customer.

  653. Mike M

    ““Part of this is we have a National Health system.”

    We? Who might that be? I am guessing Japan.

    In other words, your treatment is paid for by taxes. Using technology invented in other countries.”

    Yes, Japan. The NMR scanner (Nuclear Magnetic Resonance) was invented by EMI in the UK. Subsequently renamed as “MRI”.

    I’m guessing you are in the USA using technology invented in other countries Jet engine, perhaps?

    Part (majority?) of my treatment was paid by taxes. I’ve lived here (Japan) for 17 years and have been paying medical health insurance for all that time. Sometimes you have to call on insurance to pay out

    Lucia: “how much did the NHS pay?” I don’t know how the numbers break down. I was struck by JD Ohio’s comment that having gone for a test, the specialist expected loadsamoney to interpret the results.

    My local (public hospital) ENT specialist referred me to her Professor (that’s Professor in in the sense of having climbed to the top of the professional tree rather than the US sense of getting a job at university). He (Professor at the Private teaching hospital) gave me an opinion and referred me to a surgeon. The cost to me was the same as visiting my GP or the public hospital intern.

    FWIW I had an appointment but had to wait for 2-3 hours in the queue of other patients before being seen. The scan (taken at a different hospital) was there when he called it up. With a clutch of trainee doctors in attendance he took advantage of a teaching moment. The interview and diagnosis was conducted in immaculate and fluent English.

    I claim no expertise, but my impression of the health service in Japan is that it exists to serve the needs of the nation. Doctors do well but they aren’t getting rich. If they want to get rich thay can always move to the USA, assuming the Union Closed Shop lets them in.

  654. j ferguson: “I always thought the value of a market was to serve both the vendor and the customer.”

    The vendor benefits from a market, but he would be better served by a monopoly. The market is a means for the consumer to partially impose his will on the producer. Here are a few illuminating quotes from Adam Smith:

    “Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to, only so far as it may be necessary for promoting that of the consumer.”

    “People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”

    “The interest of [businessmen] is always in some respects different from, and even opposite to, that of the public … The proposal of any new law or regulation of commerce which comes from this order … ought never to be adopted, till after having been long and carefully examined … with the most suspicious attention. It comes from an order of men … who have generally an interest to deceive and even oppress the public”

  655. Amazing over-reaching by National Health Service in Britain.

    “Gard’s case has created an international uproar and sparked debate over whether the government should be able to mandate “death with dignity” over a family’s wishes to seek out experimental medication for their sick child.

    Gard was born with a rare genetic condition and cannot move or breathe on his own.

    His parents want to bring him to the U.S. to seek experimental medication or take him home so they can spend their final hours together.

    The Great Ormond Street Hospital where he is staying has argued that the child would suffer harm because there is no prospect he will recover. The British Supreme Court is backing the hospital, opening the door for doctors there to withdraw life support for the child.

    Gard’s parents will also not be allowed to take him home to die.”

    See http://thehill.com/homenews/administration/340513-trump-offers-help-for-critically-ill-british-child
    ….

    Amazing that anyone would ever consider that they had the power to separate parents from what appears to be their dying child, and even more amazing that they would do so in this situation. Not knowing Britain that well, I can only assume that its Left is the same as that in the US — it has a simple-minded sense of moral superiority which leads to a closed-minded inability to respect those who think differently. (I could never understand why Obama administration would try to force Catholic hospitals to provide birth control — apparently, the ideas are coming from the same place.)

    JD

  657. Oh heh. That was in your link as well. I read your comment but didn’t bother to follow your link.
    Sorry!

  658. Ron

    I think your valuing complete freedom at the expense of the general welfare is the balance between government and anarchy.

    I don’t value complete freedom at the expense of general welfare. You haven’t shown your tiers benefits the general welfare at all. The only thing it seems to benefit is — possible– some people running businesses who find making the choice for a collection of employees inconvenient.

    Insurance has always been regulated.

    Sure. There haven’t always been tiers. But remember: I objected to your “tiers” not any and all regulation.

    he choices before us are can we have a working regulatory system of health insurance or do we blow up the industry and give that part of the economy to the government.

    This doesn’t mean our choice is is limited to (1) your system with tiers (2) blowing up the industry and nothing else. That’s crazy talk.

    You are being infantile if you think there is choice 3.

    I don’t think not seeing the choice as “Ron’s program vs. blowing up the industry” makes me infantile. I think it makes me correct. Because we certainly have additional choices beyond “Ron’s program” and “blowing up the industry”. At a minimum we have the polices the GOP Senate and Congress have floated and, adding those to “Ron’s program” and “blowing up the industry” already makes 4 which is two more than two.

    So: No, I don’t think I am infantile for thinking there are more than 2 choices of programs to restructure insurance in our country. Some of those choices don’t have tiers.

  659. Seth,
    Sometimes our out of pocket costs are also quite low. JD buys his own insurance with a deductible. That’s why he’s hyper aware of charges. My husband and I are covered under group insurance from his job. Mostly our out of pocket costs are low, and often free. It all depends.

    We do have a weird system.

    If they want to get rich thay can always move to the USA, assuming the Union Closed Shop lets them in.

    I suspect we’d let them in. We have lots of doctors who trained elsewhere. I’m not quite sure how that works.

  660. Seth: “If they want to get rich thay can always move to the USA, assuming the Union Closed Shop lets them in.”

    ….
    You have no idea what you are talking about. I practiced workers comp law for 17 years, and my boss’s wife was a pathology professor. I negotiated medical bills, deposed doctors and routinely dealt with medical issues. Also, both of my Chinese wives (first deceased) were doctors in China — not licensed in the US, but doing medically related jobs in the US.

    ….
    A doctor’s education is very expensive, and the academic and preliminary work (brutal residencies) is very difficult. When practicing, they are under extreme pressure because people’s lives are at stake and many doctors have to be available for emergencies at odd hours. Additionally, they have to wade through ridiculously complicated and time-consuming paper work. They are highly paid because of the skill involved, the cost of their education, and the very high stress that they labor under. I have had many interactions with doctors and my experience has been that approximately 80% of them are not that financially motivated at all. They make enough money, and their main concern is their time and the pressure they are under. This is confirmed indirectly, by the fact that physicians are well-known for being horrible investors. They don’t have the time and inclination to monitor their investments, and so quite often they are very poor investors.

    JD

  661. Just to state the obvious, if we dropped our twice as expensive than anyone else’s healthcare to just 1.67x then we can insure all the uninsured for “free”.

  662. Tom, one person’s expense is another’s income. Does anyone know of a healthcare money-flow diagram or spreadsheet? It would show that, e.g. Hospitals receive $X from insurers and $Y from individuals, pay $A to medical personnel (including benefits), $B to acquire capital equipment, $C for administrative personnel, etc., leaving $P profit. Insurers receive from companies and individuals, pay out in claims, have administration costs, and profit. Doctors (medical practices more generally) receive payment for services, have administrative expenses, malpractice insurance, and net income or profit. Pharmaceuticals, etc.

    Along the lines of the famous climate energy balance diagrams which we’ve all seen in various forms.

    All that money eventually ends up as individuals’ income, capital acquisition, expenses related to services (utilities, expendables), corporate profit, etc. Perhaps the money mainly ends up going to TV ads for meds!

  663. Lucia,
    I suppose I should add regarding the cost of the examination of my entrails that I suffered a $40 co-pay. We are on medicare with an advantage plan (US Healthcare) which has no visible cost (premium) to us. It is paid for out of our standard medicare deduction – which everyone pays. So I suppose that when someone says “why do you care, you’re not paying for it” there is a little more resonance; although…
    .
    The trick is that these plans’ handling of their relationships with the Docs, means that our favorite dropped US Healthcare and we had the choice of going to Humana or finding another doctor. I miss Lupu who was an EE before coming to his senses and going to Med School. He, too, spent his off hours devising and building small computers – not as smelly, he told me.
    .
    So each fall we review the plans and choose between the two. Blue Cross is also available, but there are some tricks in their plan that Jan doesn’t like.
    .
    On our plan, some of the co-pays can add up to real money, but there is a cap of $10k annually which we feel protects us from runaway devastating expense.
    .
    needless to say, the plan is heavily subsidized by the government, and I think grossly unfair to someone, but not us.

  664. HaroldW (Comment #163761): “one person’s expense is another’s income. Does anyone know of a healthcare money-flow diagram or spreadsheet?”

    I have been wondering the same thing and posted some partial answers above: Comment #163693, Comment #163695, Comment #163702.

  665. Thanks Mike M. I had read those posts (without commenting) and appreciate that information. It’s part of the picture. I was hoping for a single source which had done comprehensive work, using a consistent method.

  666. HaroldW: “I was hoping for a single source which had done comprehensive work, using a consistent method.”

    If you find it, please let me know.

  667. HaroldW,
    Basically it would be a tax on the overcompensated healthcare sector to fund insurance for poor people. “From Whom Much is Given, Much Is Expected”, ha ha.
    .
    I expect this to be about as popular as letting a bioweapon loose in NYC. Eventually people are going to notice the bias in expenses for the US vs the World. If the media treated this subject like it treats cop shootings then a solution might come about.
    .
    I don’t think doctors are bad people just because they suck as much revenue as possible from the system and will resist changing that equation. What I think is bad is that the left/right answers to healthcare seem to be dumping EVEN MORE revenue into the healthcare system.
    .
    To be clear if you are going to take on the healthcare industry, you better bring some pretty big guns. I think it would be a mistake for this industry to play a withering defensive strategy that might ultimately result in a taxpayer revolt and government cost controls. That’s where I think this thing ends.
    .
    People want lower priced healthcare, not care for the uninsured. Check the polls.

  668. JD Ohio,
    “They are highly paid because of the skill involved, the cost of their education, and the very high stress that they labor under.”
    .
    They are a lot less highly paid in other developed countries, though certainly with a similar education, work conditions, and stress. MD’s charge what they charge because they can. If high steel construction workers could get away with charging as much, they would.

  669. Tom Scharf,

    Basically it would be a tax on the overcompensated healthcare sector to fund insurance for poor people. “From Whom Much is Given, Much Is Expected”, ha ha.

    The other thing is that if you are going to start limiting doctors income, you probably also have to start paying their medical school fees.

    Some other countries (e.g. France) pay for medical school. This doesn’t get counted under “costs of health care”. It’s often tallied under “education”. Obviously, training costs something. In our system medical students often carry the full costs which they then need to cover from what they make once they are doctors. In some sense, that ‘cost’ ends up under “health care costs” in our tally.

    I actually don’t favor the state picking up 100% of the cost of advanced education. But I also recognize that to the extent that our physicians take on debt to cover education and need to pay it back later, the cost of their education gets reflected in “health care”.

    (FWIW: I do favor the state picking up some costs of education including that for those training in areas that are critical and which may have an under supply. So– like medicine, science, engineering teaching to the extent that not enough students may be entering those fields. To the extent the supply of graduates exceeds demand: not so much. The key issue is how to do this fairly. I suspect the correct method is to have a combination of loans and scholarships with the amount of scholarship money somewhat tied to the default rate on loans with that rate being set by a score that considers both the default level at a school as a while and the default level for individual departments within a school.

    So for example a score for a degree in French at “Schmoe University” might be determined by a 50%-50% weighting of the default rating of all students at “Schmoe University” and for those with degrees from the French department. Then that rating would be used to determine the amount of scholarship aid granted to a school. Those with high ratings get more scholarships. Of course tweaks are required! )

  670. SteveF “They are a lot less highly paid in other developed countries, though certainly with a similar education, work conditions, and stress. MD’s charge what they charge because they can.”

    …..
    Please give me figures from other countries. I expect the low paid MDs come from countries that have nationalized health care. I doubt that they have the administrative responsibilities and potentially very long hours that US doctors have.

    For instance, the UK nationalized hospitals around 1946. In China, the doctors have a very low salary, but it is expected that they will receive gifts from patients. In any event, I am interested in what comparables you have.

    …
    I would add that I don’t think the US doctors are greedy. Quite often they don’t know the cost of their own procedures. On the other hand, the large organizations that they typically work for do try to maximize profits. For instance, when I fell down the stairs in January, I asked the ER doctor, why a urinanalysis was ordered and he said he didn’t know. The way I interpret this is that if a patient speaks up the doctor will give an honest answer irrespective of the financials. However, if no one speaks up the doctors will follow the procedures of their employer. I have other examples I could give.

    JD

  671. JD

    On the other hand, the large organizations that they typically work for do try to maximize profits.

    I think our system has encouraged formation of large organization that get ever larger. So…. yeah.

    Individual doctors do not necessarily profit by ordering other tests. The organization does. Other doctors or someone at the hospital may make money from doing the not necessary test, but the individual being paid to do the test doesn’t have information to know whether the test is truly required. They just receive an order to do the test.

    I’d say colonoscopy’s fall in this category. By the time I show up for a colonoscopy, the person doing it only knows it’s been ordered. They don’t have information about why it was ordered nor are they asked to judge whether it is needed. (Mind you, at this point, most individual doctors doing the procedure probably know damn well it’s just routine. Some may even know it’s not all that important for most people and that cheaper alternatives might do just as well. It’s not clear that they individually should be turning away the business. Anyway, the doctor doing the procedure may not own the facility. They are probably fairly well paid– but not raking in the bucks the facility may be raking in.)

  672. I imagine a lot of “unnecessary” tests fall into the CYA, better safe than sorry, the more information the better category. The penalties for failing to make a correct diagnosis are potentially severe and not diagnosing something “obvious” but unrelated to the problem at hand is not a defense against ending up in court.
    .
    In the case of falling down stairs, you might need to be administered pain killers, which, depending on what’s prescribed, can cause problems in the kidneys, especially if you have an existing issue. A urine analysis to ensure good kidney function could be considered a prudent course of action.

  673. DaveJR,
    With respect to colonoscopys– which are sort of the poster child for mostly unnecessary, some board or another “recommends” them for certain age groups. After that, they are all covered with low copays by most plans. All doctors advise them.

    Doctors aren’t making individual decisions– it’s just “the”advise” from higher up. The companies the doctors work for set things up to maximize profits from having patients under go this. And there you are.

  674. If foreign doctors want to practice in the US, they have to complete a US residency.
    If we got rid of this requirement, the doctor wait times and fees would drop, while Canada’s health system would collapse.

  676. Dave JR “In the case of falling down stairs, you might need to be administered pain killers, which, depending on what’s prescribed, can cause problems in the kidneys, especially if you have an existing issue.”

    ….
    I went through this in exhaustive detail before. I was very lucky in that all I had was a 4 staple cut on the back of my head. No history of any problems with kidneys at all. No bad bruises, no pain 5 minutes after the fall. I had the lights off and unknowingly walked down the basement steps instead of the hallway in my relatively new house. They were probably suspicious that I was drinking or taking drugs. So as a matter of authorized routine, they wasted an insurer’s money doing a urine analysis. The doc could see my condition and almost certainly knew what was going on and gave an honest but politically smart answer. The nurses still administered the urine analysis even though the doc hadn’t authorized it.

    I had no pain in my hands, arms or neck and they wanted to do a neck ct scan, which, as time has borne out, I correctly refused. (I did have a head ct scan, which I needed but turned up nothing) They gave me many tests which I knew were wasteful, but I was in no position to refuse and they would have been suspicious of me if had opposed the myriad of tests that they did do.

    JD

  677. After some quick research, it looks like the rental of shelf space at grocery stores is for new products only.

  678. JD Ohio,
    “I expect the low paid MDs come from countries that have nationI would add that I don’t think the US doctors are greedy. alized health care.”
    .
    Of course. Their pay is then controled mainly by national health services. Specialists make more in most developed countries than GP’s, but still usually less than in the States. A quick Google search for doctor’s pay by country will give you a blizzard of hits.
    .
    “I would add that I don’t think the US doctors are greedy.”
    .
    No more than construction workers, chemists, or lawyers. Medical doctors are just often in a position to charge a fortune for their services… and so they do. Not greedy or evil, human. The system is the problem, not the individual doctors. When I work as a technical consultant (which is rare over the last few years), I charge between $1,500 and $2,000 per day….. because I can.

  679. MikeN (Comment #163808): “If foreign doctors want to practice in the US, they have to complete a US residency.
    If we got rid of this requirement … Canada’s health system would collapse.

    Nope. That requirement does not apply to doctors who did residencies in Canada.

  680. JD,
    In the hospitals effort to get a good grasp of you and your condition’, I never would have imagined that they might suspect drugs.
    .
    When we were living on the boat, Jan fell through an upper deck hatch to the deck below and got pretty banged up. A neighbor told me NOT to take her to the hospital myself, she would; and did.
    .
    What I apparently avoided was an arrest for spouse abuse. This was a situation which apparently happened often enough (in Stuart btw) that it was suspected in every case involving a black and blue woman. Jan was able to describe exactly how it happened, and how her landing produced the abrasions and bruises she exhibited, but against an uphill presumption that I had done it.
    .
    I suspect, JD, that you got the battery of tests that the usual gang gets, and although they may not have made any sense in your case, maybe they do most of the time.
    .
    My Dad was prescribed a chemically dangerous (for him) post operation medication without consideration of what he was already taking “because we always prescribe this under these circumstances.” Had not the side effects been so obvious and so bad, we might not have caught it in time.
    .
    One last thing about the 80% of the Docs who are dedicated and hard-working. I suspect this is pretty close to the right percentage. Obviously, most of the stories would be about the other 20%.

    Forgive me for asking such a thing, but are you sure your wife didn’t throw you down the stairs? thats what they would have thought in Stuart. Sorry SteveF

  681. J Ferguson — Similar story of being wrongly accused.

    One Christmas my mother was drinking too much and passed out in front of the refrigerator. She got a black eye on the way down. (In another room, I heard her fall like a large sack of rice) She told everyone exactly what happened, but still many people didn’t believe her and were very suspicious that my father had punched her.

    Re: Wife pushing down stairs. Divorced my second wife about 18 months ago. If she had been around, she wouldn’t have messed with something as ineffective as pushing me down the stairs. She would have used a more effective weapon. 🙂

    JD

  682. SteveF — Re “greed” of doctors.

    My experience is that many are not motivated that much by extra money. For instance, my main doctor only works half days and recently went out of her way to do get a substitute doctor up to snuff when I recently had a minor hip strain. I see a lot more of the greed you are talking about in a good many chiropractors and to a lesser extent dentists.

    Also, please give me one or two links to studies showing the lesser compensation of doctors in other countries. I don’t doubt that it is true, but apparently you have looked at it more closely than me. I recently tried to get good comparisons of the British and American health systems and didn’t find anything that gave a good, solid overview.

    JD

  683. j ferguson,
    As you are probably aware, there are a few “rough” neighborhoods in Stuart, and so the local hospitals for sure see ‘significant other’ abuse on a regular basis. Which probably makes them more suspicious than they would otherwise be. Of course, there is abuse most everywhere, but the incidence varies a lot.

  684. JD Ohio,
    Here is a list of the ten countries with the highest paid medical doctors: https://medicfootprints.org/10-highest-paid-countries-world-doctors/
    Note that the list is ordered by the income of specialists, not the average of all doctors… for the average, the States is way higher… and remember these are the 9 other countries with the highest pay for doctors. As I said, I have nothing against people trying to maximize their income, I just think that we pay far too much because the entire health care system is set up to be non-competitive…. licencing, prescribing, insurance, medicare, and medicaid all combine to boost doctor’s ability to set high fees. The system is the problem, not the people.

  685. JD,
    “I expect the low paid MDs come from countries that have nationalized health care.”
    .
    Shhhhhh…….there are way too many libertarians on this forum, ha ha. Since almost everyone else runs nationalized healthcare of one flavor or other, this is undoubtedly true.
    I’m sure if you start digging into the details one will find much to chew on, their legal expenses are likely much higher, their assistants cost more, their material costs are much higher, etc. Every part of the system can probably legitimately point to all the other parts of the system as their reason for high costs.
    .
    https://journal.practicelink.com/vital-stats/physician-compensation-worldwide/
    .
    https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make
    .
    https://www.forbes.com/sites/theapothecary/2013/05/28/are-u-s-doctors-paid-too-much/#36b05560d525

  687. Harold, regarding your comment “along the lines of the famous climate energy balance diagrams,” you got me thinking about global systems analysis. And I just realized that healthcare as an industry is unique from any other I can think of in how universally and uniformly it is consumed by the population. In every other industry I can think of a population segment that is preferentially served. Even if one points to the elderly as being served more everyone has elderly loved ones or and aspires to become elderly themselves. I am wondering if this unique attribute has any bearing on historic rationales for nationalizing healthcare. Anyone know or want to guess?
    .
    Mike M.’s Adam Smith quote: “Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to, only so far as it may be necessary for promoting that of the consumer.”
    .
    To me this is talking more about failures in central planning of production than how consumer is king. There is no separation from industries and consumer’s health and wealth for the few exceptions which are already regulated like pollution and addiction. Even these can be equalized by transparency. Sunshine cures many ills.
    .
    The central problem of healthcare is inefficiency. This is cured by transparency of information and skin in the game to use it. Having a central consumer access information clearinghouse would double or triple efficiency by allowing informed choices.
    .
    Lucia, the purpose of my tiers in not just to make it easier for businesses to select plans for employees. It’s because, as a business owner, I have witnessed firsthand in how disinterested and how inept (and annoyed) the average worker is with being burdened by having to make a choice they are unqualified to make despite my composing supplementary illustrations and scenarios. We’ve had more choice (but higher rates) since the ACA outlawed small business group plans. Everyone in my company would rather have had the lower prices.
    .
    Tiers allow easy, fair and transparent regulation, which brings down costs and prices for consumers.

  688. Ron

    Tiers allow easy, fair and transparent regulation, which brings down costs and prices for consumers.

    Repeating this over and over is not remotely like showing government mandated tiers do anything to bring down costs and prices for consumers.

    since the ACA outlawed small business group plans

    So don’t outlaw small business group plans. This has nothing to do with your “17 tiers” limitation.

    I have witnessed firsthand in how disinterested and how inept (and annoyed) the average worker is with being burdened by having to make a choice they are unqualified to make despite my composing supplementary illustrations and scenarios

    This is not remotely a good reason for government mandates that restrict the plans oferred in the entire country to 17 “tiers”. It’s a good reason to give business owner the option to choose the a single plan or set of plans they want to provide as job benefits. Some companies could tailor to their range of employees and different companies would make different choices often according to the mix of employees in their business.

    This wouldn’t be remotely like your tiers which has the government limit the choices.

  689. As has been noted above, the problem with medical costs is the system, rather than any specific part of the system (such as doctors, hospitals, insurers, etc.). The numbers I posted above support that; no one part of the system is large enough to be the cause of either the high costs or the rapid rise in costs.
    .
    I think Adam Smith was prescient when he wrote: ““The interest of [businessmen] is always in some respects different from, and even opposite to, that of the public … ”

    You can replace “businessmen” with “hospitals” or “insurance companies” or “pharmaceutical companies” and this is very accurate. Less so with “doctors” since most doctors care about the well being of their patients.

    Continuing the Adam Smith quote: “… The proposal of any new law or regulation of commerce which comes from this order … ought never to be adopted, till after having been long and carefully examined … with the most suspicious attention. It comes from an order of men … who have generally an interest to deceive and even oppress the public”.

    That is a perfect analysis of Obamacare (we have to pass it to find out what’s in it). That will also happen to any centrally planned market. There will be infinite details in any such plan. Those details will be designed by experts from hospitals, insurers, and Big Pharma. They will NOT be examined with the most suspicious attention. So they will not serve the public interest.
    .
    The current insane medical billing system makes perfect sense. Hospitals want to maximize revenue, insurance companies want to minimize payouts. So hospitals justify their bills by means of minute itemization. It is easy for hospitals to bill enough to cover marginal costs (even when billing Medicare) but hard for them to recover their very substantial fixed costs. So they look for places where they can maximize the markup. The most obvious candidates are things people can’t do much about (the ER), things the insurance company is required to cover 100% (colonoscopies), and direct pay customers who have little bargaining power. It seems that things that you can buy over the counter at the drug store get especially large markups, but I don’t know why they are such good targets for recovery of fixed costs.

    A side effect of the hospital billing system is that is is highly problematic for the direct pay customer. That is a feature, not a bug (unless you are a direct pay customer). The insurance companies like it since it discourages people from not buying insurance. The hospitals like it since they see the uninsured as 30 million potential deadbeats rather than as 30 million potential customers. And the politicians like it, since they are addicted to campaign contributions.

    Government control can restrain costs, but only at the expense of choice, quality, and innovation.
    .
    The only hope I see to really change things is to empower direct pay customers so that they are seen as an opportunity, not something to be avoided. Then there could be a dynamic market that would produce creative ideas that might “infect” the rest of the system. Even without significantly altering the existing system, direct pay customers are a 12 digit market. They are largely avoided (that is starting to change), because of an assumption that they can not pay. One way to fix that is to allow people without insurance to set up Health Savings Accounts (HSA’s) and to make substantial contributions to those accounts. The sum total in such accounts would quickly amount to hundreds of billions of dollars. That should be more than sufficient to attract innovators to serve the direct pay market.

  690. “Government control can restrain costs, but only at the expense of choice, quality, and innovation.”
    .
    Very likely true, but as I mentioned above:
    “Do you think the average poor or middle-class person would rather:
    a) Get modern health care
    b) Get the same amount of health care as their parents’ generation, but with modern technology like ACE inhibitors, and also earn $8000 extra a year”
    .
    So we have had the cost trend going for 40 years now, can eliminating employee inusrance (forcing everyone into the private market), cost transparency, and skin in the game force a reduction in overall costs? Maybe, but maybe not.
    .
    If you are a surgeon who spends all day doing hip replacements then the thing that will force you to drop prices is losing customers due to competition on cost. One of the distinct differences here is people cannot choose to not participate in the market like I can choose to not buy a yacht. Inelastic demand. I’m not an economist, I had to look that one up, ha ha.
    .
    The cost of hip replacement doesn’t change until the material costs for doing so is reduced or enough greedy low cost hip replacer doctors enter the market and get rid of all the greedy high cost hip replacer doctors. Perhaps hip replacing school can be a 2 year program that only educates one on hip replacing.
    .
    A small dent could be made by people waiting longer to get a hip replacement, no doubt a “feature” of nationalized medicine.
    .
    If a magic wand is waved and physician salaries are reduced by 33% would we have a shortage of hip replacers? I doubt it. How about if we reduced it by 90%? Then we will no doubt have a big shortage and those hip replacers will be of poor quality, the talented people will find other more lucrative professions.
    .
    Is the market currently working so as to find the optimum for that cost/value trade off? I very much doubt that.
    .
    This industry is incentivized to keep the current system and to actually make it even worse, and it has for 40 years. I see no other option other than forcing change through external means. Yuck. If someone can tell me how this is going to work some other way, I’m all ears. Healthcare isn’t gasoline (also inelastic demand). Ethics are a much bigger factor here and price controls may be justified.

  691. Tom Scharf: ” If someone can tell me how this is going to work some other way, I’m all ears.”
    .
    What is needed is a space where new approaches can thrive and then spread out to take a larger share of the market. That means, I think, a healthy direct-pay market.

    I put forward a proposal earlier, but upon reflection I think it impractical. Here is a revised version that should be more practical. The idea is to allow room for something new without first destroying what is in place. It should only be the success of the new that destroys the old.

    Allow individuals to deduct insurance premiums, up to some limit, from taxable income. As it is, if your insurance is not paid for by either your employer or the government, you are screwed.

    Treat HSA contributions as insurance premiums for tax purposes.

    Allow people to have HSA’s even if they don’t have insurance. Double (at least) the maximum annual contributions.

    Leave Obamacare in place since low income people won’t be able to take much advantage of the tax deduction. Dare I say “If you like your plan, you can keep your plan”?

    Allow insurance policies that are non-compliant with Obamacare to be sold off the exchanges.

    Exempt people from the individual mandate penalty even if they have non-compliant policies (or just an HSA) provided they spend some minimum amount (income dependent) on premiums and HSA contributions. This is an effective repeal of about 90% of what people hate about Obamacare.

    My idea is that as hundreds of billions start to accumulate in HSA’s, innovators will be inspired to cater to the people who control those funds. Then change can begin.

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