428 Comments
User's avatar
Terence J. Ollerhead's avatar

In Canada, we have had free health care all my long life. I find it nearly impossible to listen to the labyrinthine explanations why the US is the only rich nation which doesn't. The only explanation that makes sense, and this is for many features of the US, not many to its advangage: Canada, Europe, NZ, Australia - let's call then the Coalition of the Sane - believe that the collective is more important than the individual. The US believes the opposite. Hence its bizarre gun laws, health insurance mess, the Constitutional and court messes .... In Canada, your right to own a gun and gun dealers to sell without restrictions is not as important as society's right to be safe, schools to be safe, etc. Same as healthcare. I'm well off, but I am very happy to know that my neighbours, who are not, will not be bankrupted by a pregnancy. or car accident. All of us benefit. It's about us, not me. But you believe the state has no right to make you get a vaccination, though oddly it will make a female on life support for months carry a fetus to viability.

Expand full comment
Michael Happy's avatar

I can't see anything like what might be called an organized sense of the collective good in the United States, which is simply taken for granted in all the other developed nations.

If we're being honest here, a gun has sturdier constitutional rights than an actual citizen.

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

Unless they're also "stockholders of note".

Then it's about equal.

Expand full comment
Michael Happy's avatar

"About equal", but not full equals.

There are more guns in the United States than people, so I guess that makes sense.

Expand full comment
User's avatar
Comment removed
4dEdited
Comment removed
Expand full comment
Michael Happy's avatar

Spam. Reported.

Expand full comment
Frau Katze's avatar

Now there’s another just above it. The report button doesn’t work on an iPhone. Someone please report.

Expand full comment
George Patterson's avatar

As the old saying goes - "We're all equal, but some are more equal than others."

Expand full comment
Michael Happy's avatar

Well, that's a secret hidden in plain sight: it is in fact the American Dream.

Ask the broligarchs.

They know America's finished, so they're making a last smash and grab before the inevitable collapse which they, as "accelerationists", are pushing as hard as they can.

And then it's off to their survivalist bunkers for six months!

Those of us who have not starved to death in the interim or been slaughtered by roving rightwing death squads will be just the right amount of surplus labor, grateful for the pittances offered us.

(I kid, of course, because I love...)

Expand full comment
Pauline Nagle, Ed.S.'s avatar

True! Guns have so many rights!

Expand full comment
Jason's avatar
4dEdited

Right off the bat, Jon Gruber dismisses what should be called 'Medicare For All' as 'BernieCare', while ignoring that every industrialized country in the world has some form of public health care, that the US has public health care already for millions of people in the form of Medicaid and Medicare, and that a public option was part of ACA until 'moderate' Democrats decided to remove it.

ACA has helped a lot of people. It could have helped even more people if it had a public option. It gets really tiresome to hear people say what we can't do in the world's richest country.

Gruber acknowledges that Medicaid and Medicare were fought against at the time and many states were slow to adopt the programs, but he dismissed the expansion of those now-popular programs as not feasible.

Expand full comment
Winston Smith London Oceania's avatar

He wasn't dismissing it. He was pointing out how many Americans would dismiss it - because they're ignorant.

Expand full comment
Sandra Kinzer's avatar

They dismissed it because they fear change…and since Reagan they’ve been told by the GOP they can’t trust the “government.”

If you recall, people’s resistance was to losing what they had, for some promised gov. change.

Not excusing it, just stating the fact that the GOP & oligarchs have been seeding distrust of gov. for generations. Now it is bearing fruit…just like their racism & patriarchy propaganda effort after Brown v. Board.

Expand full comment
Winston Smith London Oceania's avatar

Right. It was a continuation and expansion of Tricky Dickies "Southern Strategy". St. Reagan and his cohorts exploited the ignorance with blatant lies. This was further compounded by reichwing media - which back then was dominated by Limbaugh and Coulter.

And the suckers fell for it hook, line and sinker.

Expand full comment
Frau Katze's avatar

Reagan was a huge influence but they’re currently in the Trump cult.

Expand full comment
Jason's avatar

You're not wrong about Americans..but they also dismissed ACA when it was created as well...and many dismissed Social Security, Medicaid, Medicare with similar arguments (too expensive, takes away my choice, socialism etc)

Expand full comment
Winston Smith London Oceania's avatar

Exactly! Because of sheer ignorance. Now, the same people who dismissed all of those programs actually like them.

Expand full comment
Rex Page (Left Coast)'s avatar

Sheer WILLFUL ignorance. It taka lot of effort to be so uninformed.

Expand full comment
Jan Steinman's avatar

I saw a cartoon that has a senior citizen shouting and waving a sign, "DOWN WITH OBAMACARE!"

Next pane, she was crouched over in pain, saying, "Just don't touch the Affordable Care Act."

Priceless. And so true.

Expand full comment
Jason's avatar

ha yeah - 'BernieCare ' - you mean like the socialist guy? Bad!

'Medicare For All' - you mean expanding a popular program! Good!

also a bit like the Tea Party guy with the sign saying 'Government Out of My Medicare'

Expand full comment
Karen Brenchley's avatar

The "take away my choice" is a big fear, so much so that some (a lot of) people would rather die that be saved by someone else.

Expand full comment
Jason's avatar

its a funny one too, since most people don't really have a 'choice' they just have whatever their jobs gives them.

my job just recently out of the blue downgraded its dental plan, to one my dentist of 20 years won't accept..so my 'choice' is pay full price out of pocket, or find a lesser dentist that take the low-payout plan.

Expand full comment
Edwin Callahan's avatar

We can’t get some sort of universal health care until the current MAGA Reich is destroyed. Maybe then we can have some nice things, after all the necessary punishment, of course.

Expand full comment
Jason's avatar

of course this is true, i mentioned somewhere in here that we will be lucky to have any public health insurance of any sort in a few years at this rate.

Expand full comment
mary thiel's avatar

Yes, that was my interpretation, that he may not be against single payer, but based on past history, the general public isn’t.

Expand full comment
mary thiel's avatar

Great column. Very informative. Thanks.

Expand full comment
Al Keim's avatar

As with fossil fuel health care has deeply integrated investors intent on the preservation of their particular prerogatives:-)

Expand full comment
leave my name off's avatar

Exactly. His numbered bullet point #3. ACA has been a boon for the insurance companies. People receive a form around the same time as their 1099s to reconcile their income vs the paid-in subsidies. The reconciliated separate form sent to the IRS calculates what one owes for over paid subsidies. It only allows for one's income and not what was actually paid in premiums by the individual. I contacted the Health Care Market Place both by phone & certified mail to tell them I no longer qualify and have been sending the full premium to my insurance company, but it is still getting subsidies from the Market Place, which I imagine that the IRS will require I pay back next year. Industry doesn't want the public option. The only reason industry offered health care benefits post WW II is because it didn't want to pay war-inflation level wages and paying for baby deliveries during the baby boom was cheaper than higher wages for the younger adult population then. In actuality, after mass layoffs, industry could quit offering health insurance to new hires and still wouldn't have to pay higher wages. What are discount retailers now going to do if they can't con their low wage employees to go apply for Medicaid? Oh, I guess if they're working, then they're eligible for Medicaid. But if you're in between jobs and Cobra premiums are too high--too bad--no Medicaid for you unless you want to waste your time and drive down competition in the low wage labor racket just to tide you by until maybe-what-if you find another dwindling possibility of a higher quality job with company provided benefits.

Expand full comment
Al Keim's avatar

The intergraded differential of that equation is too difficult for me to follow:-)

Expand full comment
Doug S.'s avatar

IIRC during WW2 there were literal price controls that said that wages and salaries weren't allowed to be over a certain dollar amount during the war, but the people in charge of that said that money that companies spent buying health insurance for workers didn't count towards that. So companies bought health insurance for employees instead of giving them illegal raises.

Expand full comment
leave my name off's avatar

Well, what a convenient loophole, since old people are the biggest consumers of health care and not the parents of the baby boomers after the war!.....there's never insurance/finance PROFIT CONTROLS, only W-2 INCOME CONTROLS!

Expand full comment
Jason's avatar

This is true of course but not a reason to not try or dismiss the possibility.

Expand full comment
Al Keim's avatar

Not dismissed simply explained as to why Berniecare hasn't happened.

Expand full comment
Jason's avatar

I dunno, he sounded pretty dismissive to me. Even calling it 'Berniecare' is typically said as criticism. Maybe I'll listen again.

Still, from what I heard, he also doesn't mention anything about the public option that was in the ACA, then removed...and not by the demand of voters, who generally liked this idea, but of a few 'moderate' Democrats like Joe Lieberman.

I don't suggest it wouldn't have been a political battle. Passing the ACA was too, and was not particularly popular at the time either.

Expand full comment
Al Keim's avatar

You're right ACA was not popular and the botched roll out didn't help. Romney's Massachusetts plan was a handy concept familiar to a MIT professor. Clinton had a plan crushed early in his presidency and that served as a warning to Obama. Berniecare if enacted would be incredibly popular. The discussion seemed to me to be about how to get there.

Expand full comment
Frau Katze's avatar

That’s another aspect of the BBB. Out with solar and wind, back to fossil fuels. Because global warming is a scam(!)

Expand full comment
Al Keim's avatar

Like vaccines and elections:-)

Expand full comment
Glen Beck's avatar

I think Gruber meant not feasible given their political structure framework.

Expand full comment
Jason's avatar

If he only meant that, then why does he not mention the public option that was part of ACA then dropped?

His explanations don't address that, and they don't address how every other industrialized capitalist country has been able to make single payer (or some form of it) work.

Expand full comment
Edwin Callahan's avatar

Because none of those countries are full of Americans. Turns out, Americans come with the occasional drawback, such as stubbornly clinging to what they’re used to

Expand full comment
paulisima's avatar

I think that many Americans has the impression that anything paid for via taxes is "socialist" or "communist" in nature, which of course is why many Americans do not want to pay more taxes than absolutely necessary.

The very same people has no idea as to what Socialism and Communism is all about since neither of these ideologies are mainstream politics in the US (the Democrats generally speaking has a Social Democratic ideology).

Expand full comment
Jason's avatar

..and many oft hose same people will go crazy if their Social Security or Medicare is taken away ...

Expand full comment
Patrice La Belle, M.D.'s avatar

These are the same people who don't realize that their farm co-ops are socialist.

Expand full comment
Frau Katze's avatar

I’ve argued with commenters at the WSJ about single payer (we have it Canada). They’re vehemently opposed. They insist large numbers of Canadians go to the US for healthcare (I’ve never met one and I’m over 70).

Their opposition is implacable. I can see how politically they’d be a big obstacle (they’re mostly MAGA, I might add).

Expand full comment
Jason's avatar

sure, the WSJ is dead set against any social service.

the idea about Canadians coming here for health care is funny. I know many people that have don the opposite..and not just to Canada but flying to Thailand for dental work , or to Mexico, or other places ...

Expand full comment
Patrice La Belle, M.D.'s avatar

It's called medical tourism and is big business in places like Mexico.

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

The Wall Street Journal, other than the editorial page, LOVES to see billionaires getting even richer.

Always has.

Expand full comment
Frau Katze's avatar

I find it’s the editorial side like that. In fact, the news side has a new editor and the MAGAs keep complaining bitterly.

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

Ordinarily, yes.

But the Editorial Page has been a saving grace for many of us, actually speaking "truth to hate".

Some GREAT STUFF here!!:

"Wall Street Journal Skewers Trump’s Tariffs Chaos As A Triple Whammy For Americans

“Welcome to the new tariff economy..." wrote the newspaper's conservative editorial board."

https://www.huffpost.com/entry/wall-street-journal-donald-trump-tariffs_n_67fcdbc1e4b0c8069e856fd2

"'Cue The Meltdown': Wall Street Journal Exposes Trump's 'Biggest' Mistake In Decades

The newspaper said this move by the president is causing the markets to sink and confidence to plunge."

https://www.huffpost.com/entry/wall-street-journal-trump-powell_n_68070546e4b06d0beefd1962

"'Harsh Reality': Wall Street Journal Dunks On Trump In Stinging New Editorial

The newspaper also called out the "MAGA echo chamber" for backing the president's tariffs."

https://www.huffpost.com/entry/wall-street-journal-trump-reality_n_6809e409e4b09e23ad05526e

"WSJ pundits demolish right-wing talking points defending Hegseth: “It all comes back again to this basic point that something's wrong at the top levels”

Editorial board member Kim Strassel: “The president's going to need to engage there, hopefully sooner rather than later, to get this stuff sorted out."

https://www.mediamatters.org/wall-street-journal/wsj-pundits-demolish-right-wing-talking-points-defending-hegseth-it-all-comes

And I find about a dozen more examples just in my History...

Expand full comment
Frau Katze's avatar

True, the WSJ EB is completely opposite to tariffs, I’ll give them credit there.

Expand full comment
M. Layfield's avatar

WSJ will be contorting soon; investors and shareholders will be affected. Did the GOP forget them, no. They never even thought to think of them!

Expand full comment
chris lemon's avatar

Gruber, early on, pointed out a "fact" about the US politics that will probably ultimately end the democracy "experiment." That is, despite the current health "care" system being a convoluted, expensive, poorly performing disaster, the system can't be fixed because the many pigs that have their snouts in the health care trough pay politicians to make sure that the problems aren't fixed. A similar argument applies to the military industrial complex. The political system only reforms in response to catastrophes, but you can't run a superpower with a government that is unable to deliver public goods, except in response to wars or economic meltdowns. As a aside, the current health insurance "system" in the US is a byproduct of companies in WW2 working around wage control rules by offering health insurance. So the economy is being dragged down by an apparently unfixable historical accident.

Expand full comment
John Poole's avatar

There was never a real public option in the ACA... It was written to benefit insurers instead of creating an independent plan.

Expand full comment
Jason's avatar

Nonetheless, insurance companies and their 'moderate' Dem and GOP allies saw to it that even this would not be included.

My point here though was to note that Gruber doesn't mention this at all in his reasons why 'Berniecare' (his words) couldn't work.

Expand full comment
Frau Katze's avatar

There was a good article on this the other day The Bulwark. They trace it back to the “Southern Strategy” and race problems.

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

Hard to argue.

The Southern Strategy is the predecessor to Project 2025.

And very likely the ONLY reason the South is GOP.

https://en.wikipedia.org/wiki/Southern_strategy

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

Actually, it was modified to fit Mitch's plan to cause Obama to be a "one term president".

That plan to only allow an Obama presidency for 4 years, including destroying Obama's legacy, became the GOP's ONLY concern for...8 years.

Expand full comment
Frau Katze's avatar

The insurance companies are the big obstacle. But they’re largely responsible for the high GDP cost of American healthcare.

Expand full comment
George Patterson's avatar

They expanded Medicaid under Obama. At last count, ten States (one fifth of the US) refused the extra money.

Expand full comment
Jason's avatar

True, so, I am not sure what is your point?

Many states also refused to adopt Medicaid when it as first enacted, as is mentioned in this video.

But expanding Medicaid has been a success overall, despite a few states with GOP governors that refused to go along for no good reason other than spite and rigid ideology.

Sanders and others that advocate for Medicare For All have always framed the change as a gradual expansion of the existing program as well. This is another point Gruber does not address here. The proposed change to single payer would be incremental and built on a popular and well-tested existing program.

Of course, right now none of this really matters though, does it? We will be lucky if ACA or any public health care exists at all by the time Trump is finally out of office, assuming he leaves willingly. Instead we will have RFK Jr fitness farms while we look for black market vaccines.

Expand full comment
Frau Katze's avatar

I saw an article at WaPo the other day about a fanily that was charged $1400 for a single vaccine.

Expand full comment
leave my name off's avatar

What is left unsaid is that the state could claw back those Medicaid funds by seizing homes, bank accounts and health care companies will place a lien upon your assets if you have no insurance and their bills are prohibitively high.

Expand full comment
George Patterson's avatar

That may be true elsewhere, but Tennessee laws are reported to be weird as far as that is concerned. Property cannot be confiscated for five years and must be sold for at least the latest evaluation for tax purposes. That has led to municipalities, such as my home town of Knoxville, to become the owners of lots of property that has deteriorated to the point of being unfit for human habitation, but unsalable as a result.

Expand full comment
Winston Smith London Oceania's avatar

You're right about that. However, there's another factor involved: the setup of our political system. Unfortunately, it was designed in such a way as to make it easy for the reichwing to exploit and abuse to make it possible for a small, overpowered minority to rule over the rest of us.

The first part of it is this damned electoral college that makes it possible for someone to win the presidential election even after losing the popular vote - as long as the candidate has enough electoral votes.

The second part of this travesty is the Senate. Every state gets exactly two, no matter how large or small. Thus Wyoming - a state with a population about 1/4 that of Brooklyn NY gets to have the same representation in the "upper" chamber as California, with a population close to 40,000,000 - more than some countries.

That's before taking into account all of the electoral shenanigans pulled by the GOP such as extreme gerrymandering, voter suppression and intimidation, etc.

Expand full comment
Donna McKee's avatar

You are 100% correct. The Electoral College has got to go. Unfortunately, that will take a Constitutional Amendment which can take decades to achieve. And we should pursue it, but we can't wait that long. In the meantime, there are two things we can do now:

1.) Get enough states to sign on to the National Popular Vote Interstate Compact, wherein participating states agree to award all of their EC votes to whichever presidential ticket wins the overall popular vote in the 50 states and the District of Columbia. We are close to achieving that now and only need a few more states to sign on to it.

2.) Ranked Choice Voting can also help with some of the other issues.

However, the extreme partisan gerrymandering needs to be stopped with independent, citizen redistricting commissions in each state; and voter suppression and intimidation, which is illegal, but still goes on, must be stopped. We have a LOT of work to do between now and the midterm elections if we want to preserve what is left of democratic, truly representative, Constitutional government and the rule of law.

Expand full comment
Winston Smith London Oceania's avatar

I'll sign on to that.

Expand full comment
R Hodsdon's avatar

Here's my critique of what I'll call the "Dump the Electoral College" movement: it doesn't provide a guarantee of getting good governance, unless you believe so much in democracy that winning the popular vote guarantees no dishonest, self-serving schemer will ever become president.

I don't think it does give us such a guarantee; bad government becomes less likely, with election by popular vote, but is not a guaranteed slam dunk that our government would be improved if we did away with the EC (and the process of amending the Constitution would itself be fraught with opportunity for error and mischief).

If you consider the Framers' point of view -- not trusting so much in the wisdom of crowds, but valorizing the political experience of an educated elite over the common man -- an Electoral college could act as a backstop to prevent an unfit candidate from being certified for office. Trump was elected with a majority of the popular vote; I consider him unfit for office. People are easily deceived.

Expand full comment
Jan Steinman's avatar

"Trump was elected with a majority of the popular vote"

A *plurality*, not a "majority". He got something like 48.8% of the vote.

Expand full comment
R Hodsdon's avatar

Yes. Deduct 5 points from my score for sloppy writing.

Expand full comment
George Patterson's avatar

The founders were also dealing with horribly slow communications and travel. Much better in that time to have each of the thirteen States send a few "electors" to what was then the central point in the country than have to deal with all the complications of sending all of the ballot boxes there.

It probably would've made the Teamsters happy, though.

Expand full comment
Winston Smith London Oceania's avatar

Good point.

Expand full comment
Rex Page (Left Coast)'s avatar

You are right that something closer to a parliamentary system wouldn’t guarantee good governance, but surely it would make it more likely.

Expand full comment
R Hodsdon's avatar

Rex, I am not sufficiently schooled in political theory to venture an opinion on whether a parliamentary system would be a better guarantee of good governance. I understand, however, that the original 13 colonies had legislative assemblies. Had these been run along parliamentary lines, with members belonging to parties, and the leader of the majority party becoming head of government, that system might have been carried over into the Federal government.

If you recall, however, the Colonies became states, which were jealous of their powers and reluctant to recognize federal authority (especially taxation).

The powers allowed to the Congress and the Executive were restricted to those enumerated in the Constitution, while its checks and balances were designed to ensure that the the new republic had not overthrown one king, only to appoint another.

The President and Vice President, by virtue of being put in office by a vote of the entire national electorate, would be seen as representing the nation as a whole ( 13 states at the time).

Expand full comment
Jan Steinman's avatar

"I am not sufficiently schooled in political theory to venture an opinion on whether a parliamentary system would be a better guarantee of good governance"

Well, first off, Trupm and his entire cabinet would have to come from Parliament, meaning each one of the would have had to be voted in by at least their electoral district.

I think Trupm is the only one in his entire cabinet who has served in public office before… exactly once.

No one voted for any of these bums, except for Trmup himself.

Expand full comment
R Hodsdon's avatar

There are plenty of fools who get themselves elected ( exhibit A is Margie Green, imho). And all of them believe that one day THEY deserve to be Prime Minister. I’d rather have the President free to choose between capable administrators from civilian life.

The Trump cabinet is so outstandingly terrible because Trump chose them, because he is a terrible administrator and all around idiot.

Expand full comment
Rex Page (Left Coast)'s avatar

Yes, I think that’s why we have a presidential system and an undemocratic Senate (though I’m not well-schooled in this matter, either). Also, they were working in an absence of evidence about what might work in government by the people. Nevertheless, it appears now that they made some serious mistakes. That it’s understandable doesn’t make it good.

Expand full comment
Frau Katze's avatar

I thought it was because they were copying Britain: the House of Commons became the House of Congress. The House of Lords became the Senate (elected). The King became the President (elected).

But in Britain the King and House of Lords lost all polical power.

Only the House of Commons remains as the government.

Expand full comment
andré's avatar

A major problem with Electoral College is the "winner takes all" of most states creates "swing states".

A policy that all states use a proportion of the votes to decide the votes related to house seats would still favour the small red states, but would show that big states such as California, New York, Texas & Florida are not only Blue or only Red states.

It would have (probably) shown that Trump won with a very slim margin, similar to his percentage of the popular vote.

This would have weakened his influence over Congress.

Expand full comment
R Hodsdon's avatar

Two reasons Congress had a chance to ditch the Electoral College 60 years ago: institutional inertia and senators' excessive love of speech-making and institutional inertia smothered it.

Today, however, the states have come up with an idea that does not involve congressional action. The National Popular Vote Interstate Compact (NPVIC) is an attempt to sidestep the Electoral College—without abolishing it through a constitutional amendment.

It is is an agreement among participating U.S. states to award all their Electoral College votes to the candidate who wins the national popular vote, regardless of who wins in their specific state.

Once enough states have signed the agreement to reach the winning total of 270 electoral votes, the plan would go into effect. The Constitution gives states the power to decide how to allocate their electors.

So far, the total number of electors for the 17 states (plus the District) is just over 200, so more states would have to join for the agreement to take effect.

SO, why not go all the way and make Presidential elections by popular vote? Well, that would be dandy as long as we don't have to do it by Constitutional Convention, which would open the door to considering all sorts of amendments and back-room deals. Unfortunately, modern-day politicians are not all as able and high-minded statesmen as the group that came up with our original constitution.

Expand full comment
Winston Smith London Oceania's avatar

Of course it won't guarantee of good governance. The problem is the EC allows for rule by a small overpowered minority, AKA, an oligarchy. Doing away with the EC is a step in the right direction to ending that nonsense.

You could argue that, technically, Trumpkopf won a majority of the popular vote, but by a slim - and questionable - margin.

Expand full comment
SgtPepper's avatar

It's race. It's all race. All those countries were over 90% white and had no large minority populations when their social welfare systems were formed in the 20th century. Everything you need to know about America goes back to its slave population and the fact that the white majority does not see the former slaves as equal citizens. That will explain everything you wrote

Expand full comment
Michael Happy's avatar

Yes.

In England, it's class -- still.

In America, it's race -- still!!

Expand full comment
Donna McKee's avatar

Actually, in America, it is both race AND class. Make NO mistake. This is a CLASS war that is being waged upon us. Even Warren Buffet admitted as much. 'Broligarchs' like Musk, Thiel, Sacks, Zuckerberg, etc. are exhibit 'A'. But absolutely, race is used as a wedge and also as a cover by the oligarch class to wage their class warfare. Tragically, it works on racists and low information voters and blinds them to the damage and harm it will do to them and other poor & middle-class people of all ethnicities, themselves included. It is certainly true that people of color and the most vulnerable among us are generally hurt the worst by policies that Republicans have been ramming down our throats for over 4 decades. When will people wake up and figure it out??

Expand full comment
Michael Happy's avatar

I absolutely agree with you. I only make the distinction because in each case the one issue leverages the other.

So in England, class exclusion leverages subordination by race.

In America -- as you've very nicely illustrated -- race is used as a creeping barrage in the class war.

Lyndon Johnson said (I'm paraphrasing), "If you can make the poorest white man feel like he's better than the best Black man, he'll not only give you what's in his pockets, he'll empty them on the spot for you."

That's the dynamic, isn't it?

It's why poor white people in the South most conspicuously vote against their own economic interests. They hate the people -- libtards -- who want to help them because it also means helping Black people, and they'd rather just do without altogether, if that's gonna be the case.

Expand full comment
Frau Katze's avatar

But the English upper classes didn’t try to prevent single payer healthcare.

Expand full comment
Michael Happy's avatar

No, but they did get two-tier healthcare!

There is private healthcare for those who can afford it, which means that the public option is always significantly underfunded.

The English are very good at the bait and switch. After all, they ran an empire that was a viciously cruel criminal enterprise for centuries. The attitude and the practices are baked in.

Expand full comment
Frau Katze's avatar

True.

Expand full comment
Frau Katze's avatar

Should have let the South go. You’d be like Canada now.

Expand full comment
Jennie H.'s avatar

And allowed them to continue to enslave people?

Expand full comment
Frau Katze's avatar

There weren’t good options I admit.

Expand full comment
R Hodsdon's avatar

Frau K - Interesting comment you made about letting the Southern (slave) states leave the Union back in 1861.

There was no provision for a peaceful, legal exit from the Union once a State had entered. The 'free' states would not have readily agreed to a voluntary breakup. And if the CSA had successfully become independent of the USA, it was unclear if the two smaller states would be viable, post break-up, as the USA had only existed for close to 90 years and was still concerned about encroachment in the Americas by European Powers.

By 1860 the Southern plantation economy, which was made possible by its supply of enslaved people working the fields of cotton and tobacco, had peaked and was under threat by increased cotton production in other countries within the British Empire, notably Egypt and India.

Expand full comment
John Keating's avatar

Very well put. We have plenty of selfish jerks in Canada, just like anywhere else. But there is still that collective sense that helping those who need it benefits everyone.

Expand full comment
Donna McKee's avatar

That used to be the case here, too, as recently as the 1990s and early 2000s. But that has all changed since Donald J. tRUmp and the MAGAtization of Republicans and conservatives, in general. I believe is a result of the total information warfare that has been waged upon our population since at least 2015. It emanates from a number of sources: Russian GRU and its assets (social media and You Tube/ internet), right-wing "Christian" evangelical churches/CNP, and literal fake news sources like Fox, OANN, Newsmax, Breitbart, Sinclair, Parler and others. There are literally more fake local news websites now in the US than there are real local newspaper websites. Let that sink in.

Expand full comment
Michael Adelman's avatar

I agree with the overall theme here but it's worth observing that developed nations have many different ways of covering their population (and most of them do involve some amount of private and OOP spending). The ACA is pretty similar to the health insurance systems in Switzerland and the Netherlands with the basic architecture of guaranteed issue, community rating, private plans offering defined essential benefits, and sliding-scale premium subsidies. It works there and (in the states that are trying) it works here. We have a dozen states in the 2-5% uninsured range on par with those two counties and 30 that are under 7%.

One common thread of the Swiss and Dutch systems is that they are of relatively recent vintage (90s and 00s, respectively). A Canada-style system becomes a *much* heavier lift if, instead of building it in the 60s or 70s, you have another couple decades of provider cost growth and people getting used to private coverage and getting rid of all that requires just insane levels of revenue and disruption. So it's not a coincidence that in 2010, the Swiss/Dutch path made a lot more sense.

Expand full comment
Jan Steinman's avatar

"The ACA is pretty similar to the health insurance systems in Switzerland"

I lived in Switzerland for a year and a half.

A *huge* difference between the Swiss system and the US system is that Switzerland spends less than half as much as the US does on health care, even with a private insurance industry.

Interesting that the first place my employer took me was the police, where I was properly registered and warned that if I move, I had to let them know.

The *second* place they took me was an insurance provider. I asked if it mattered much which one I went to; they said no, they're all required to provide the same coverage for the same money.

Expand full comment
Michael Adelman's avatar

I think this illustrates the comparison pretty well. Great comment und ganz toll daß Sie in der Schweiz gewohnt haben!

"Same coverage for the same money" is the result of guaranteed issue, community rating, standardized essential benefits, and premium subsidies. These are pretty similar between the Swiss system and the ACA. There is even a common thread of federalism - Switzerland has its health insurance marketplaces at the cantonal level like our state-level Exchanges (and unlike the Dutch marketplace which is national). Amazingly, I think the ACA subsidy schedule is a bit more generous than the Swiss one (and a referendum to increase the Swiss financial aid came up short last year), but that reflects in part our higher prices.

You also observed a few key differences. Being taken to an insurance enroller right away reflects the way the Swiss cantons (a) vigorously enforce their individual mandate and (b) make affirmative efforts to enroll people. The Swiss system was implemented by an ideologically wide-ranging governing coalition, and there wasn't anything like the kind of massive resistance that some red states put up against the ACA nor the specific resistance to the mandate (the only part of the original ACA that didn't survive). And it turns out that state/cantonal buy in and effort matters a lot in making sure people don't fall through the cracks!

In Switzerland, provider costs and overall health expenditure relative to GDP are a bit higher than elsewhere in Europe but lower than here. And that mostly reflects when countries bent their respective cost curves by implementing their respective comprehensive healthcare systems. The UK is on the low end here having done so in the 1940s; the Swiss did it in the 1990s; and America didn't achieve this until the 2010s. Those extra decades of the cost curve going up are not cheap!

Expand full comment
Jan Steinman's avatar

Ich wohne funfzen monat in Bern. Yea, it was a foreign country!

I rollerbladed to work every day. Most people there had never seen them. A guy at work said, "Have you paid your tax on those?"

"Tax?" I innocently replied, "I didn't know there was a tax on roller blades here!"

He replied, "Everything that is not forbidden is required, and if it is required, it is taxed!"

I was fairly fast, and didn't want to take a chance wiping out pedestrians, so I skated on the street, taking up not much more room than a bicycle. But one bus driver decided I didn't belong on the street, and forced me off the road! I was able to jump the curb, but was pretty shaken, considering how much worse it could have been.

Yea, it was an adventure. Never used health care the whole time I was there. I chalk that up to a 100-gram daily chocolate habit. We don't really have chocolate here. Even Lindt is better there — they ship us their seconds!

Expand full comment
Michael Adelman's avatar

Switzerland has all my favorite things - mountains, public transit, public transit *to* the mountains, chocolate, cheese, and the OG Obamacare. Loved visiting and would love to go back.

Expand full comment
Frau Katze's avatar

Also in Canada it was not a federal initiative. It was done one province at a time and remains provincial to this day.

Why couldn’t one state introduce it? That I don’t understand.

Expand full comment
Michael Adelman's avatar

In terms of why an individual state couldn't do a specifically Canadian-style system - they would face all the same hurdles as the Federal government in terms of the significant revenue required and disruption to existing arrangements, but with the *added* challenge that states must always balance their budgets and that some kind of deal with the Feds would be needed to allow them to redirect revenue their citizens pay into Federal health programs. So the state would need to be willing to raise taxes *a lot* and have a friendly Administration willing to grant innovation waivers. Colorado and Vermont actually both proposed Canadian-style systems ... but in CO it failed badly by referendum, and in VT the proposed tax increases led to the defeat of the Dem governor.

But in terms of getting ~100% coverage of their residents by any kind of system ... states can do and are doing quite a lot on this front. As I noted in the OP, a dozen states have already reached uninsured rates in the low single digits on par with the Swiss and Dutch systems. A lot of this comes down to effort around reaching as many people as possible with ACA Exchange and Medicaid expansion coverage. The most exciting innovations that are now up and running have been state-level Basic Health Plans (in NY and MN) and public options (in CO and WA), both of which make for kind if a Japanese coverage model.

Expand full comment
Frau Katze's avatar

The Canadian ones were all done one province at a time in the 1960s and 70s. To this day, each province does its own.

Expand full comment
John Gregory's avatar

but with a lot of federal pressure for conformity in benefits and a lot of federal money to pay for them. But it's close to impossible for the feds to micro-manage how the money is spent, and there are loud provincial protests if they try.

Expand full comment
Michael Adelman's avatar

Exactly - that was the time to do it. Bend the cost curve back when it was much lower. Raise the required revenue back when provider costs and health spending relative to GDP were far less.

Absent a time machine, our options decades later are just far more limited. Path dependence is real!

Expand full comment
Jan Steinman's avatar

Three cheers for Tommy Douglas! Not many people realize that conservative Saskatchewan was the first province to have universal health care.

Expand full comment
John Gregory's avatar

not so conservative at the time, when the farmers, post-Depression and post-dust bowl (not as bad in Canada as it was in the US) voted for a social-democratic party as government for 20+ years. NOW it's conservative, but not then.

Expand full comment
Jan Steinman's avatar

Wasn't very long ago that Alberta had a "socialist" government, and now they're somewhere to the right of Texas or Florida!

It takes more than a party in power. That's why I used a small "c" to spell "conservative".

Farming jurisdictions far from the coast tend to be small-c conservative, but pragmatic. They can vote for someone who says they'll take care of them when they get sick, and still be fiscally conservative. That's a strength of a multi-party system.

But the US has bipolar disorder. You have to proudly wear a badge, and accept whatever those who print the badges say — even if that means eliminating your export market and taking away your workers.

Heaven forbid that an ag-state Republican wear a Democrat badge! So, they end up voting against their own interests.

Musk just said he's starting a new political party. This should be interesting.

Expand full comment
R Hodsdon's avatar

There hasn't been enough room for a third party in the US to become a permanent, viable force in politics. Ross Perot was a very rich man who did astonishingly well in is 1992 race against George HW Bush and Bill Clinton, but he ultimately failed not only as a candidate but his party also collapsed.

Now Elon Musk is an EXTREMELY rich man, and has already had a close association with government, as a contractor and advisor to Trump. Any party Elon supports could potentially last longer than a few presidential election cycles, but what voters would he get? There are 4 potential sources. Of existing voters, those who have voted Dem or Rep or "other"; and non-voters, both the ones who were eligible but didn't vote, and those who were ineligible (never registered, felons, of underaged). Which group/s would Elon's party dare from?

I expect Musk-endorsed candidates would appeal to many of the younger male voters who supported Trump in 2024.

My guess is, the disaffected or non-MAGA TrumpRepublican party voters. In other words, I think a Musk-oriented party would take more votes from the Republican than the Democratic column, and add in some from the Non-Voter column.

Expand full comment
Frau Katze's avatar

Indeed. It spread from there!

Expand full comment
Anthony Beavers's avatar

I wish people would stop referring to state provided healthcare as free. It's not. The state pays for it through taxing its citizens. Healthcare provided through the state in this manner is far more equitable, far more effective, and far cheaper per capita than the hell hole that is US healthcare. But it is not free.

Expand full comment
Terence J. Ollerhead's avatar

I don't think you need to tell a heavily taxed Canadian about this (one of the highest taxed citizenry in the entire world). Don't be pedantic; nothing is free, certainly no state services. But it is free at the point of delivery, even for those who pay little or no tax. Do you believe that we think public schools are 'free', too ? Of course not.

Expand full comment
Anthony Beavers's avatar

Thanks for conceding my point, although I don’t understand why you’re so miffed over it. My guess is that you got the impression that I am against publicly funded healthcare. If you take the time to read my entire comment, you’ll see that that’s not the case.

And how you got the impression that I think Canadians believe that public schools are ‘free’ from my entire comment read in context is totally beyond me. Oh well…

Anyway, it’s not pedantic to describe things as they really are. It’s just stating obvious truths. One of the problems we have in policy debates in the US is that people don’t look at things as they are, and use language and descriptions that make good sound bites but have no basis in fact. Whenever the left in the US starts talking about free healthcare, the right makes hay while the sun shines by dumping all over that misrepresentation. Why give those a-holes the opportunity to do that?

Expand full comment
Jan Steinman's avatar

Of course, taxpayers in general pay for it.

But it is completely free at point of service, even for someone who had never paid any taxes.

Expand full comment
Frau Katze's avatar

Good point. Cutting out the insurance companies saves a bundle.

Expand full comment
MagnusTraginot's avatar

Yes, there's a pervasive sense in the US that life is a zero sum game, your gain is my loss, etc. Any discussion of "collective" benefits smacks of communism and unfair requirements that the wealthy pay for lazy poorer people. What they don't understand, as you allude to, is that the reality is we are all connected, whether we like it or not. I don't want the neighbor's kid to be dissuaded from getting her medical degree because of cost, because I want someone to have the expertise to treat my kid. And, of course, not all solutions are that the wealthy pay more. We in the US can all pay for medical care with a VAT tax, and control costs by taking control of the inefficiencies in the US medical industry (as they have done in every other advanced country). Of course, that gets us back to the political problem of altering what people have become accustomed to. Which, when you get down to it, gets up back to the zero sum mentality.

Expand full comment
Al Keim's avatar

Well you Canadian's don't have Dirty Harry to look up to just some Dudley Do-right dude.

Expand full comment
Charlie Hardy's avatar

You are so right as an EU citizen l, like you, find the attitude and debate in disUSA on health and social services utterly bizarre. Bismarkian social insurance within a primarily tax funded system is by far the most positive, stable and effective system in these areas in my view. And its about foundational societal leadership well beyond economics even though (as was apparent in this debate) the economic benefits are also very clear.

On one specific point sectoral focussed discussions with a epidiemiologists who are also well qualified health economists is key. These are common complimentary skills in this area and OECD will easily be able to direct you there.

Also l suggest to build associated vignettes (using the above ideas set in the context of pure public health policies/actions) around real people, most importantly in the categories you spoke of, to illustrate and sell these messages even better in practical ways showing at a more personal level and (thus more effectively) the personal, social and economic benefits that can be obtained. Such an approach is as a great way to communicate the positive real world impacts you can achieve, l believe. This must sold hard with clarity in ways public, politicians/ policy makers and business people can identify with and which chime with their drivers and interests within and between these groups proving the great synergies and multiplier self reinforcing benefits that can be realised.

TIME IS short.

The dank dystopian poisonous clouds of dark fascism grow closer, deeper and darker now each and every day as the candle of democracy is stuttering smoking and also growing dimmer daily.

A technology driven feudal medieval dark age awaits if good women and men do nothing!

Expand full comment
Lance's avatar

Wow, I learned a lot! The NIH part was very informative by using return on investment data. We are so foolish condoning the DOGE chopping block. What opportunities we miss and will miss.

Expand full comment
andré's avatar

Exactly. The few times I have visited the US (from Canada) I have had a lot of unsolicited feedback from random sources about how they envy Canada's health system & lack of gun violence.

It shows me that many in the US would appreciate Canada's system.

I suspect it is a militant minority blocking it.

Expand full comment
John Gregory's avatar

there is a very old line (at least in Canada) that Canadians are like unarmed Americans with health care.

these days one would have to add 'and way less likely to fall for MAGA b.s.'

Expand full comment
andré's avatar

We could add, don’t have all those problems with racism.

Expand full comment
Frau Katze's avatar

It largely coincides with MAGA.

Expand full comment
Paul G's avatar

In the U.S. we don't have a healthcare system we have a revenue generating system that does healthcare. As such the the company's (delivering healthcare) income is more important than a patient's outcome. And everything is set up to maximize the former at the expense (literally and figuratively) of the latter.

Expand full comment
Elizabeth's avatar

During the NAFTA, USA corporations argued that Canada's public health care gave their Canadian counterparts an unfair corporate advantage! So, the answer is..

Expand full comment
R Hodsdon's avatar

Well then we get into arguments about the US mortgage interest deduction, which was not offered to Canadian taxpayers. (Terence please correct me if my info is out of date).

Expand full comment
Frau Katze's avatar

Correct. Mortgage interest is not tax deductible.

Expand full comment
Frau Katze's avatar

We in Canada pay for it our taxes, that are noticeably higher here. Their argument fails.

Expand full comment
Sandra P. Campbell's avatar

Terence, you nailed it.

Expand full comment
R Hodsdon's avatar

Terence, thanks for giving us the Canadian perspective on our peculiar institutions down here.

I am an American and I'll jump in here with a comment on rights of the individual. The Declaration of Independence is probably as good a textbook as any for getting at how Enlightenment thinkers conceived of what mattered most when establishing what would be the government of the United States of America.

" We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness—-That to secure these Rights, Governments are instituted among Men, deriving their just Powers from the Consent of the Governed..." etc.

They don't specifically state that individual rights have precedence over the rights of the community, but read in context, that meaning is, as they put it, "self-evident." Nor do they elaborate on what the "just Powers" of government might be.

Taking the rights of the Individual as the starting point for this description of how a political system works (or how an ideal system should work),the Declaration quite sensibly does not enumerate the limitations to these rights.

I say "quite sensibly" because they very quickly move onto a discussion of an individual citizen's duty when those rights are ignored or abused -- a rationale for rebellion against the British Crown. That enumeration of rights had to wait for another 15 1/2 years to be ratified as the Bill of Rights, the first 10 Amendments to the Constitution, in December, 1791.

The determination of what "just Powers" of government may be, and how they are apportioned between states and the federal government, is still being worked out in Congress and the courts.

The first 10 amendments do not simply list a series of rights, but they do so in what I believe was to the authors a logical precedence, with the rights of free speech, etc. being the first. Interesting that they put the right of owning and using firearms to be second. In the wake of a lot and costly fight against the British Empire, having the right to fight back with deadly force was highly regarded, even though it would empower the citizenry with the right to depose their own government.

Expand full comment
Terence J. Ollerhead's avatar

Thank god my country is not tied to a document like the constitution. Just as happy that doctors aren't using medical texts today from 1776. The US isn't in the state it is today by accident; it was led there by the slavish fetishization of the constitution.

Expand full comment
R Hodsdon's avatar

Since the Constitution is the framework ( and English Common Law the basis) on which rests the whole of our national polity, I would say that jurists may find it necessary to alter or construct new interpretations of the document to accommodate the requirements of new legislation.

I would agree that some of our Supreme Court jurists (the "originalists") make a fetish out of trying to read the intent of our long-dead Framers in order to divine the true meaning of the wording in the Constitution; we are not living in the 18th century anymore, as you astutely note, and yet we have managed to adapt to changing circumstances.

On the other hand, living by a consistent set of principles is generally considered to be a good thing.

But then I am neither a lawyer nor a judge.

Expand full comment
Jan Steinman's avatar

"I would say that jurists may find it necessary to alter or construct new interpretations of the document"

Since you quoted the Declaration of Independence, it's right there!

"That whenever any form of government becomes destructive of these ends, it is the right of the people to alter or abolish it, and to institute new government."

I'm just not very clear on how electing either of the pro-growth, pro-corporate, pro-genocide parties is going to "alter or abolish" a system that seems to be working for them.

I'm my no means a Turmp supporter, but he seems to be doing a decent job of "altering or abolishing" the existing government!

Expand full comment
R Hodsdon's avatar

The passage you quote supports the idea that it is right and proper to change the form of government when circumstances dictate. What I was trying to say is that, government may need to revise their interpretation of the Constitution as circumstances dictate, to reform rather than destroy government, and thus obviate the need for revolutionary change.

Expand full comment
Jan Steinman's avatar

The US has the oldest Constitution in the industrialized world.

They are sorely in need of a constitutional convention.

When the Bill of Rights was written, it took a full minute to re-load a musket.

The Foundering Fathers never envisioned semi-automatic weapons that could fire as quickly as you could pull the trigger being constitutionally protected.

Expand full comment
Frau Katze's avatar

Medicine as a practice barely existed in 1776. Single payer healthcare was introduced in the 1960s and 70s (depending on province).

Expand full comment
The Rhythm's avatar

Can you please explain to me WHY Republicans hate Medicaid so much? Is that a failure of basic human decency?

Expand full comment
Michael Happy's avatar

Yes.

Expand full comment
ron katz's avatar

i think alot of people willing to gut medicaid do not believe in their hearts that the government should support those in need. survival of the fittest is their central totem. this is particularly strong in more rural white communities ? indigenous rural groups understand the need for government support, as inadequate as it is.

my family (my tribe) (my community) can handle this among ourselves privately (charity care run by private religious groups not the government) and everyone else does the same or suffers (or fies) unnecessarily from fixable medical issues. it is god's decision who suffers, not me.

i have never been able to have these people understand that our entire current society depends technological progress and it is driven by the goal of all of us having better and better minimum standards and quality of life. it works today through consumerism and public institutions.

as individuals we collectively pay for all this (GDP) during our working years. as children, the accident of birth accounts for too much and our post working retirements are fraught with the spector of death or impoverishment.

Expand full comment
The Rhythm's avatar

My question was rather tongue in cheek rhetorical because I know the answer. Like you say, there are sadly a large number of people out there who believe they are better/more entitled than everyone else. They fail to learn the lessons of history that the type of society they crave inevitably leads to such inequality and repression that they end in revolution. “Let them eat cake”…

Expand full comment
Winston Smith London Oceania's avatar

It's not that they fail to learn the lessons of history so much as it is they have psychopathic tendencies - which includes sadism.

Expand full comment
The Rhythm's avatar

Ok that’s getting a touch extreme now.

Expand full comment
Winston Smith London Oceania's avatar

But is it?

They voted for someone who said "I could shoot someone on Fifth Avenue and still get elected!" Who but a psychopath would even >think< such a thing?

Who would vote for someone like that and who also promised cruelty to the most vulnerable citizens?

Expand full comment
Rocinante's avatar

Honestly, for many it seems to be “survival of the richest,” mixed with “survival of the whitest.”

Expand full comment
Turgut Tuten's avatar

I think your first two paras are on the spot. But then the same people (and others) come and ask for their "pork" and usually get it at the expense of the lesser well off. It's the "me first" US system; in a way it's democracy, except for the distortions in the representative system a commentator mentioned, electoral system, 2 senators for each state, gerrymandering, etc

Expand full comment
I Hate this Timeline's avatar

Racism, sexism, classism, greed and a poor understanding of who will be impacted. 5 reasons pretty much sums it up. You may when about sexism in that but women are poorer than men, are expected to pick up the burden of caring for elders and live longer than men. So the face of elder poverty is expendable women.

Expand full comment
Jim T's avatar

Because it takes your hard earned dollars and gives them to "those people. " When you talk about what motivates the Rs if you don't put race in the equation you are missing most of the story. These are the people who closed polls rather than integrate them.

Expand full comment
Howardsp's avatar

Because they are selfish

Expand full comment
Frederick J Frahm's avatar

In a word, yes, selfish serves as a complete answer.

Expand full comment
Lance Khrome's avatar

Do they even understand that it is those in nursing homes and those receiving home care are receiving three-quarters of Medicaid payment outlays? Yet the bastards get on Fox and blather away about "single guys playing video games in Mum's basement" as those who are "draining the system". What is and what has been the real issue here is lack of strong messaging from Medicaid supporters about exactly who benefits and why, rather than playing defense and getting into mindless polemics regarding — wait for it —

"waste, fraud, and abuse".

As usual, the Right wins the propaganda battle, while the Left loses the public support war.

Expand full comment
leave my name off's avatar

Maybe that $25 billion for rural hospitals will be so that they can hire clerical staff to help prospective & current patients fill out the forms correctly so as to receive Medicaid coverage.

Expand full comment
Frau Katze's avatar

Single guys playing video games all day instead of working—the WSJ had an editorial saying that this describes millions of Medicaid recipients.

Further millions are said to be illegal migrants.

The MAGAs in the comments were going nuts.

Expand full comment
Doug S.'s avatar

As a single guy who does play video games a lot and doesn't have a formal job, I would like to object that I have private health insurance paid for by ACA subsidies, not Medicaid. 😆

Expand full comment
Frau Katze's avatar

No criticism intended. My son was always big on video games.

I’m happy to live in Canada where everyone gets healthcare paid by our taxes. No one has to qualify.

Expand full comment
Doug S.'s avatar

There are plenty of times I wish I was Canadian. Or Swedish.

Expand full comment
Frau Katze's avatar

I appreciate that more than anything. Healthcare should be for everyone. You shouldn’t have to jump through hoops to get it (or be wealthy).

Expand full comment
Thomas Reiland's avatar

The GOP is stuck in the "welfare queen" mentality of the 1980's. They "lift" themselves by putting and keeping others down.

Expand full comment
Seneca Plutarchus's avatar

They need something to cut and can't touch Social Security or Medicare for political reason. I assume they're being paid off by the insurance industry, so they don't touch Medicare Advantage.

Expand full comment
Frederick J Frahm's avatar

Because they were raised to believe in individual initiative over collective responsibility? Somewhere in the Fifty’s anticommunist fright selfless sacrifice became a suspect trait, and empathy an undesirable marker of collectivist feelings.

Expand full comment
George Patterson's avatar

Because it predominately benefits "those" people.

Expand full comment
Adrian's avatar

Yes

Expand full comment
Al Keim's avatar

Bingo

Expand full comment
Robert Duane Shelton's avatar

Don't tune out at the endless discussion of the minutiae of health care. The discussion ends up on science, which is a lot easier to understand. And probably a lot more important. The message is that the Trump Gang is killing the goose that laid the golden egg: American science.

Expand full comment
Winston Smith London Oceania's avatar

Actually, he's killing America itself.

Expand full comment
Jess A's avatar
4dEdited

My biggest fear is Trump's 150 billion (not ONLY 45 like I wrote earlier) ICE money. I'm afraid it will be his own private army and that immigrants will be forced to live in squalor on the tax payer's dollar while security/detention center companies will make a load of money. And that immigrants will be forced to work at close to if not at slave labor for corporations, and that any dissenters, including US citizens, could be at great risk very shortly.

That's the alarm being sounded by some.

Thank you for this post on medical coverage. You always go to the top expert which makes your information the most relevant.

Expand full comment
Winston Smith London Oceania's avatar

It's even worse than that - 150 billion. And you're right, it's to create a "Neu Gestapo".

Expand full comment
Jess A's avatar

Thanks for correcting me.

Expand full comment
George Patterson's avatar

He already has his "brownshirts."

Expand full comment
Winston Smith London Oceania's avatar

Indeed he does! And he's about to get a lot more of them. This Big Atrocity of a Bill gives 150 billion to ICE. It's really, really, appalling.

Expand full comment
John Poole's avatar

Ironic that his ending quip targets the Tea Party... That movement fought Obama on his ICE expansions, which provided the legal basis for everything Trump is arguing now.

Expand full comment
Dirk  Faegre's avatar

One likely possibility: Giving $138B to this agency, when they (only) have $11B now, is a financial recipe for disaster. Whenever people or agencies get an order of magnitude more $$, they have no clue or any experience in how to handle it. They have the thought they now have a bottomless pit of cash and so they can do ANYTHING. And so they try. Chaos and corruption quickly follow. Mayhem is the outcome. It all becomes a massive disaster.

Expand full comment
Rex Page (Left Coast)'s avatar

Republicans thrive on promoting bad governance, then campaigning on government disfunction.

Expand full comment
Michael Happy's avatar

To read Gruber's account of how and why Americans didn't end up with single-payer healthcare -- particularly because they don't adequately understand their own economic self-interest -- is horrifying. The United States has the worst and most expensive healthcare in the developed world. And the cost of a medical emergency has the potential to wipe out most American families financially.

It's not a matter of "There's got to be a better way". There are undeniably proven better ways. Americans just won't apply them.

To be clear: it costs more than twice per capita to deliver healthcare in the US than it does anywhere that has single payer, not everybody gets that healthcare in anything like adequate measure, and most people are going to be out of pocket to access it.

It's an in-broad-daylight example of self-harm.

Expand full comment
Cat's avatar

The biggest obstacle to healthcare and really anything decent in this country is the Republican Party. While we are talking about how to help sign people up for Medicaid (love the Mamdami volunteers idea) they are talking about how to kick people off. It is never about helping people for Republicans. Ever.

Expand full comment
Michael Happy's avatar

The modern incarnation of the Republican party is the Confederacy's revenge on the Union.

It's why the Blue States are made to pay the bills of the Red States but aren't allowed to have nice things for themselves.

Expand full comment
Winston Smith London Oceania's avatar

It's because we have a broken political system. And it wasn't just Trumpkopf who broke it. The Constitution itself has cracks that made Trumpkopf possible in the first place.

Expand full comment
Charles Gutfeld's avatar

You talk about volunteers to reach out to assist people through the Medicare/Medicaid maze. Although it is underfunded, grossly underpublicized and does not go out door-to-door, the program already exists. I am a SHIP counselor (State Health Insurance Assistance Program). SHIP (called by different names in some states) is a nationwide program of federally trained and certified volunteers who counsel people about Medicare and Medicaid options. Unlike insurance brokers, we do not receive commissions from insurance companies for signing people up, so we have no financial bias other than the welfare of the consumer. The initial budget proposals zeroed out SHIP (of course), but it somehow came back and survived intact. It is a small bulwark against what is happening - but it is a bulwark and needs to get promoted at every opportunity.

Expand full comment
Daisymaeqqzz's avatar

As a gig economy worker, I am wondering if incorporating and paying myself a salary is a way to make reporting requirements less difficult. My coworkers are completely freaking out.

Expand full comment
Charles Johnson's avatar

I am afraid Gruber is wrong in his closing optimism. Ever since Lyndon Johnson decided to increase U.S. involvement in Vietnam, I have felt that the U.S. was moving almost linearly in the wrong direction and always thought that the pendulum would swing beck in a more positive direction. I believed that Richard Nixon was the worst thing imaginable, but by comparison with politics today, he looks positively liberal. Reagan still look awful and was the beginning of the movement toward more and more selfish, conservative attitudes in voters. Americans now are being divided into haves and have-nots where the almost-haves are afraid of losing what little bit of wealth they have and are willing to take away what little is provided to the have-nots.. After nearly 50 years of seeing this in the U.S. and being politically active, I left and am now a citizen of Canada approaching my 90th year and increasingly glad that I made the decision to move across the boarder. I share the distaste of most Canadians with the actions of the U.S. Government that is supported by American voters. Things are not going to get better in the U.S. It is going to get worse.

Expand full comment
Diane's avatar

Great interview. Thanks for the transcript !

Expand full comment
Michael Hutchinson's avatar

"The problem with universal healthcare is that people don't want to give up their insurance for some nebulous Berniecare." Spot on. If you ask Americans if they approve of universal healthcare, 70% say yes. But if you ask the follow-up question "You realize this means you too?" then support drops in half, to 35%.

The answer is straightforward. Legislation that would require corporations to offer Medicare as an option to their employees. This would cost the employer the going rate, say $6,000, so no-one can complain that corporations are getting government handouts. Moreover, 1) no senior already on Medicare could complain that "they worked for it," and 2) those employees who want to remain on their private insurance would be free to do so.

Medicare would also be available to the self-employed.

Such a system would save $1 trillion per year, something the corporations would support - see our 2019 book "Healing American Healthcare."

The ACA may be a 3-legged stool - and therefore vulnerable - but is overly complex, and has left 70 million Americans either uninsured or under-insured.

Expand full comment
chris lemon's avatar

US Corporations should support some form of single payer system just so that they can get out of being part of managing the complex nightmare that is the US heath insurance system. Companies in no other country are mired in anything like this mess. Getting rid of the hassle would probably allow corporations to sack a 10th of their HR staff, possibly more. As a bribe to the workers, companies could increase pay by the same amount that they currently contribute toward the employees heath insurance.

Expand full comment
PipandJoe's avatar

Yes, US companies having to foot the bill for insurance premiums puts them at a disadvantage when competing globally.

Also, did anyone realize that Trump just doomed the auto industry that has made a lot of investments to produce EVs by axing the subsidies?

Expand full comment
Jess A's avatar

yes. so did musk. old news.

Expand full comment
Winston Smith London Oceania's avatar

Actually, MuskRat was - and is - totally dependent on those subsidies.

Expand full comment
Jess A's avatar

exactly what I was saying. that's one of the reasons he hated the bill. though I guess there's a space travel tax break somewhere in there.

Expand full comment
Winston Smith London Oceania's avatar

He's been trying to get one, but he might soon be begging to just not be deported.

Expand full comment
George Patterson's avatar

Actually, I read today that it's just the opposite. There's talk about charging launch companies up to $30,000 per launch. I also read that at least one of the European countries is working on the infrastructure to be able to launch their own satellites.

Expand full comment
PipandJoe's avatar

Even Bernie pointed out the cost benefit to business with a universal health plan and yes Tesla will take a hit with the loss of the EV subsidies, but so will the big 3. I did not know Musk as advocating for them as well as himself and Tesla. I don't do X or social media, so I am not up to date on everything Musk.

Expand full comment
Winston Smith London Oceania's avatar

Without those subsidies, nobody would ever have known who MuskRat is. He'd be a dead broke nobody.

Expand full comment
Michael Hutchinson's avatar

This is a win-win for the citizen and also for the corporations. Of course, it will be vigorously opposed by the insurance industry, but this would not be a big deal. The insurance industry is reviled by most Americans.

Expand full comment
leave my name off's avatar

Face it, today the medical & insurance industrial complex is the MAJORITY industry in much of the country.

Expand full comment
Winston Smith London Oceania's avatar

"...companies could increase pay by the same amount..." ha ha ha, that'll never happen! They'd rather pocket it for themselves!

Expand full comment
Rex Page (Left Coast)'s avatar

Yes. Corporate structure enables paying the corner-office executives 500 times more than the average employee. Even JP Morgan famously thought that was an exceedingly bad idea.

Expand full comment
PipandJoe's avatar

Actually, Medicaid is far more cost effective than Medicare based on past research.

A buy-in to Medicaid should be the public option priced at a certain percentage of any income over the qualifying poverty limit.

This would allow people to keep it even as they begin to make more money. They would simply pay a percentage to keep it.

People on Medicare should be allowed to choose the buy-in Medicaid option, as well, instead.

Medicare is now very expensive. I took a huge hit to my wallet when I had to trade my subsidized ACA plan for Medicare when I turned 65 - yikes!

I know low-income seniors have some options, but I want to be able to leave something to my kids and not have to worry about state Medicaid estate recovery issues where they can then take your house when you die simply because you were poor enough to need Medicaid assisted living at some stage. Odd that a supposedly liberal state like CA still does that to people. They also allow hospitals to be exempt in a bankruptcy and allow them to not exclude your home in CA, so you can lose it if you have large medical bills

Tip- if you are running for governor next time, promise to fix all of that as well as undo some of the parent to child and grandchild changes so we can not be so stressed that all one worked for will all be taken away due to illness.

Anyway, with a buy-in higher earners they may decide that X percentage of income to buy in to Medicaid is more expensive than a regular policy and switch, so it would still cover mostly the average and lower income workers who decide to buy-in or who qualify based on income.

Expand full comment
Lee Peters's avatar

The reasoning behind requiring you to spend down your assets like your house is that other taxpayers who may be poorer than you are helping pay for your care. Requiring younger taxpayers and people who don’t have enough net income after taxes to pay for their family living expenses, let alone buy a house, to subsidize the estates of older people is inequitable.

Expand full comment
PipandJoe's avatar

I'm not talking about that. I am talking about estate recovery after you die if you go into a nursing home on Medicaid. They can take the house and other assets to pay for your care. Many states do this.

Is healthcare a right or not?

https://www.dhcs.ca.gov/services/Pages/TPLRD_ER_cont.aspx

Expand full comment
Michael Hutchinson's avatar

Sounds like you have a high income. Medicare is essentially free to middle and low income people over the age of 65. Think of it like a tax. In other wealthy countries, medical provision is taken out of income taxes and everyone understands this. Even in the US, if you have employer-based insurance, this is not free because your corporation is not a charity, so your income is lowered by the amount of the cost of the healthcare they provide (there is no free lunch).

The problem with Medicaid is that most doctors don't take it. So, you get what you pay for.

Expand full comment
PipandJoe's avatar

https://www.dhcs.ca.gov/services/Pages/TPLRD_ER_cont.aspx

if your income is too low applying for QMB can also put you on medicaid

Expand full comment
PipandJoe's avatar

Free?

Sounds like you have never bothered to even look up the cost of Medicare or what it does or does not cover.

Please look it up. Just the base insurance is over 2200 a year and that does not cover prescription drugs or gap insurance and there are yearly caps and no out of pocket min based on income like the aca has

if you apply for QMB it can bump you into Medicaid and then the state can take your home when you die. not worth it.

Medicaid covers far more even if fancy places like Mayo Clinic don't take it, but despite your claims enough drs do but they have to get rid of estate recovery

Expand full comment
Michael Hutchinson's avatar

There's another simple solution: raise taxes on the wealthy and give everyone access to Medicare. It's how it's done in other wealthy countries. Why should any citizen of the richest country in the world have to put up with Medicaid?

Expand full comment
PipandJoe's avatar

Medicaid has no deductibles and no out of pocket costs, no medical bills at all, no surprise bills, so why would anyone put up with Medicare that does not always cover everything? People can go bankrupt even on Medicare, but not Medicaid. The problem is the estate recovery where Medicaid will hijack your estate when you die and take your house - that is if you end up in nursing care and live in certain states like CA.

Expand full comment
Jennie H.'s avatar

Medicaid is very good, better than Medicare. No copay, no deductible, covered all my medications for free, and were reasonable when my doctor had to prescribe something that my current insurance doesn't even have in their formulary.

Expand full comment
leave my name off's avatar

WoW....CA must want the elderly to get out of state & make room for more young tech people! My mom was affluent, but she lived debt-free in rural midwest on her $10,000+/- annual social security income that didn't take THAT much out for Medicare! And she never paid out of pocket. Of course, her then available Plan F annual premiums were $5,000, Plan D premiums were worth it--as she was diabetic with minor cardiovascular issues, and she did pay for a long-term care plan out of her investment income. She was in assisted living for four years due to mobility and memory issues with taking her meds. She spent the last 60+ days of her life between the hospital and in skilled nursing covered completely by Medicare. She would have been happier to have unconsciously passed away during her diabetic episode, rather than those last miserable 60+ days. Staff need to be observant of dietary intake when administering diabetic meds.

Expand full comment
George Patterson's avatar

My Medicare payments are $82.50/month. They are that high only because I was late signing up when I turned 65. My bill every month contains a note that part of the bill is a charge for delayed signup.

Expand full comment
PipandJoe's avatar

"In 2025, the standard monthly premium for Medicare Part B (Medical Insurance) is $185. "

Maybe it depended on when you turned 65?

Expand full comment
chris lemon's avatar

All of these discussions are very informative. Depressing, but informative. However, they're missing the elephant standing in the middle of the hospital lobby, so to speak. The elephant is costs. Absent huge, apparently politically impossible, changes in the US system, specifically reducing the parasitic drag of the insurance industry, and ending the capture of Congress by the pharmaceutical industry, the US will be bled to death by health care expenses. The US wastes about $2trillion/yr on health care, spending about twice per capital what other counties do. This money effectively dissapears, not making any contributions to US innovation, production, education, or anything else. Beyond the direct costs, by tying down armies of fairly clever people to run the Byzantine system, you've even lost out on potentially productive work they could otherwise be doing. There are groups of people in health insurance companies working day and night to figure out optimal ways of denying your claims; surely there's something more useful for them to be doing?

Expand full comment
foofaraw & Chiquita(ARF!)'s avatar

One informative graphic novel on its way!

Thanks to you both. Obviously this topic is badly in need of clarification, and you have done a fabulous job here.

Expand full comment
Sandra P. Campbell's avatar

Excellent discussion - thank you both. Prof. Grueber said yes, he thinks the political party responsible will face consequeces, but if these cuts don't really kick in until AFTER the mid-terms (how convenient), it won't be soon enough. Also, I read yesterday that about 2/3 of voters said they 'hadn't heard about the bill'. Were they living on another planet?? That's almost ALL I've seen and heard.

I'm currently reading Evan Osnos' 'Haves and Have Yachts', which partially answers Prof. Grueber's comment about Josh Hawley and his cohorts. Almost, if not all, Senators are millionaires, if not billionaires. They won't ever need Medicaid, or any other type of public help. Therefore they literally can't conceive of the lives of people who DO need it. It's the worst case of "let them eat cake" I've ever seen.

Expand full comment
Jayne Docherty's avatar

What about a state like Virginia where the GOP put a ticking time bomb in our Medicaid expansion? If the feds reduce their contribution, the program in Virginia ends. How ironic that the party that screams about over regulation in order to appeal to small business owners is using excessive regulation and paperwork to kill healthcare?

Expand full comment
Howard Weamer's avatar

Out hiking yesterday, the idea of making every Democratic party office a hub for aiding those unable to navigate the deliberately obstructionist regulations. Provide transport, coffee and donuts, and volunteers or paid help to get the victims of Republican policy in the door. They'll never forget it. This is a huge opportunity for Democrats to show compassion and humanity.

Expand full comment
Hawkdawg's avatar

I'm straining, unsuccessfully, to extract the promised "not as depressing as you might think" from this article.

Expand full comment
PipandJoe's avatar

John McCain was from a state that had already expanded Medicaid even before the ACA and it was/is a very good program.

They did it by voter initiative, if I recall.

So, he knew what the people of his state wanted and the ACA gave his state more money to keep this program going.

I bet McConnell knew he would be a "no" and was counting on it because they have nothing to replace it with.

Even now, the GOP have postponed the Medicaid cuts until after the midterms because they know it would doom them.

Expand full comment
George Patterson's avatar

Not only would it doom them in the midterms, if the Dems take the midterms anyway, the Reps can blame the whole thing on them.

Expand full comment
PipandJoe's avatar

"In 2025, the standard monthly premium for Medicare Part B (Medical Insurance) is $185. "

Maybe it depended on when you turned 65?

Expand full comment