Mistakes Almost Everyone Makes in Thinking about Health Care

I don’t really want to pick on Robert Frank. I usually enjoy his columns. But in a single New York Times editorial — comparing U.S. and Swedish health care — he manages to repeat just about every major misconception about health economics that you are likely to run into. So let’s do pick on him — for purposes of edifying everyone else.

Cost. Frank begins by telling us that Sweden spends less than half of what we spend on health care in this country. But how does he know that? In every health care system in the world the market has been so completely suppressed that no one ever faces a real price for anything. The conventional method of determining how much is spent in a market is to add up all the individual transactions (price*quantity). But if all the individual prices are phony, summing over them all will produce one big phony number.

As a good economist, Frank must know that the real cost of health care is the value of the alternative uses of the real resources that are used to produce that care. So an alternative to adding up questionable monetary totals is to count real resources. And on that score, the picture looks very different.

For example, the United States has fewer doctors per capita than Sweden has. We also have fewer nurses and fewer medical school graduates. Swedes enter hospitals more frequently than we do and once there they stay longer. On the whole, we may be “spending” less than the Swedes are spending.

Outcomes. Frank tells us the Swedes get better outcomes for the money they spend:

Its infant mortality rate, for example, was recently less than half that of the United States. And males aged 15 to 60 are almost twice as likely to die in any given year in the United States than in Sweden.

But c’mon. The Swedes should have better outcomes than the U.S. population as a whole. I’d be surprised if they didn’t. Here’s a better test: Are Swedish health outcomes better than the outcomes of Minnesotans of Swedish descent? I’m not sure they are.

Efficiency. Frank admires consolidation of the Swedish system, relative to the United States:

In large hospitals, CT scanners and other expensive diagnostic and treatment machines are in nearly constant use, versus only a few hours of weekly use in some small ones.

If he were paying more attention, he would be aware that the U.S. market is consolidating at breakneck speed. But wait a minute. Since when is the existence of unused capacity a sign of inefficiency? At 3:00 AM, there is a lot of idle capacity in a McDonald’s restaurant. But no one ever accuses McDonald’s of inefficient production.

If there is never excess capacity, then a system has no way to respond to changes in demand. If every piece of equipment is in full use all the time, a lot of patients will be waiting for their care — a fact of life for Swedes that Frank acknowledges later on. The real test of efficiency is how few resources are needed to meet changing consumer demand.

Fee-For-Service Payment. Yes, that canard is trotted out once again, and I won’t spend much time on it here. Most services in most markets are purchased fee-for-service. Ever been in a restaurant? Did you pay a fee for each dish you consumed? Or did you pay a flat fee, regardless of what you ate? When the Brookings Institution studied 10 “top-rated” hospital districts, researchers found that some paid fees and others paid salaries to doctors on staff. How doctors were paid didn’t seem to crucially affect performance.

Here is something that should be uncontroversial, however. When government defines the bundles and dictates the prices — leaving practitioners unable to repackage and re-price their services as demand and technology changes, there will definitely be perverse incentives to do things inefficiently.

Non-Profit. Remembering that he is an economist, I can’t believe that Frank actually wrote this:

[U]nlike many American health insurance providers, the government groups that manage Swedish health care are nonprofit entities. Because their charge is to provide quality care for all citizens, they don’t face the same incentive to withhold care that for-profit organizations do.

Earth to Frank: there is no difference between for-profit and non-profit entities in health care. There used to be. But then the non-profits went broke, got purchased or wised up. Here is Uwe Reinhardt on all this.

Evidenced-Based Medicine. Think about how many articles and books have been written about how to make sure doctors only do what is necessary and avoid doing what is unnecessary. The Swedes don’t need algorithms or protocols; they just do the right thing automatically:

The Swedes also provide drugs and other treatments only when evidence establishes their effectiveness. People can spend privately on unproven treatments, but the government refuses to impose their cost on taxpayers.

Why didn’t we think of that?

ObamaCare to the Rescue. Maybe we have thought of it:

ObamaCare also contains many evidence-based provisions for medication and other treatments. But at least in its initial stages, it will not be able to match the cost savings achieved in Sweden.

Spare me. Just about every professional society in this country publishes protocols and guidelines and last time I looked there was no law anywhere that keeps a health plan from paying only for care that follows the guidelines.

Employers Are at Fault. Here is another surprise:

As I discussed in an earlier column, however, such plans are an extremely inefficient way to pay for health care. They arose as an unfortunate historical accident during World War II, when employers used them to sidestep the wage controls that had resulted in extreme labor shortages.

Hey, folks. For better or for worse, employers have been the innovators in health care. They have been out in front of government and the commercial insurance industry and the medical profession. At a minimum, they are not more inefficient than anyone else.

The Market Is at Fault. Here is an interesting idea.

Because of pervasive market failures in private health care markets, this may be the sector that benefits most from collective action.

There may be market failure in health care. But as I documented years ago, this sector is so completely dominated by government failure that market imperfections pale by comparison.

ObamaCare Is the Answer. Did you know that ObamaCare is supposed to make us more like Sweden?

The encouraging news is that the Affordable Care Act was intended to foster the evolution of a new system that can capture many of the gains currently enjoyed by countries like Sweden.

I’m not sure how much Robert Frank actually knows about Sweden. This is what The Guardian wrote back in January:

Despite its reputation as a leftwing utopia, Sweden is now a laboratory for rightwing radicalism. Over the past 15 years a coalition of liberals and conservatives has brought in for-profit free schools in education, has sliced welfare to pay off the deficit and has privatized large parts of the health service…As the state has been shrunk, the private sector has moved in. Göran Dahlgren, a former head civil servant at the Swedish department of health and a visiting professor at the University of Liverpool, says that “almost all welfare services are now owned by private equity firms”…Business-backed medical chains have sprung up: patients can see a GP in a center owned by Capio, be sent to a physician in the community employed by Capio, and if their medical condition is serious enough end up being treated by a consultant in a hospital bed in St Göran, run by Capio. For every visit Capio, owned by venture capitalists based in London and Stockholm, is paid with Swedish taxpayers’ cash.

Comments (114)

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  1. Dewaine says:

    “The Swedes also provide drugs and other treatments only when evidence establishes their effectiveness. People can spend privately on unproven treatments, but the government refuses to impose their cost on taxpayers.”

    How far does this go? I would assume that they have their on version of the FDA, are Swedes allowed to market and sell drugs and treatments not approved by the Swedish FDA? I would love to see that in the U.S. People with terminal illnesses need to be able to try anything. Lives would be certainly be saved.

  2. Ken says:

    Excellent piece. Frank should retract his entire editorial.

  3. Dewaine says:

    “As I discussed in an earlier column, however, such plans are an extremely inefficient way to pay for health care. They arose as an unfortunate historical accident during World War II, when employers used them to sidestep the wage controls that had resulted in extreme labor shortages.”

    So, government price controls created the problem. Yet, Frank admires the idea of a health care system that effectively boils down to an apparatus of intricate price controls?

  4. Buster says:

    I read Robert Frank’s article touting the Swedish health care system. My girlfriend is a consultant and has worked for manufacturers in the Swedish health care sector. When I told her about Robert Frank’s New York Times article, she said the people she consulted for in Sweden told her the Swedish health care system was horrible.

  5. Greg Scandlen says:

    I’m afraid that for the Left it is all politics, 100% of the time. There is no intellectual integrity. They get advanced degrees to cover their political aims. But the thinking is, “How can I use economics (or physics, or engineering, or medicine) to advance my political agenda?” So-called post modernists believe there are no truths, only “truth claims.” So, what you are saying is no more truthful than what I am saying — regardless of any evidence. The Academy is dead.

    • JD says:

      While I agree with the spirit of what you are saying and know that there are people who don’t believe in truth, I don’t think that such a sweeping generalization is appropriate.

      If they don’t believe in ANY truth, then why would they fight so hard (read: lie, cheat and steal) for progressivism? They obviously believe that there is a correct path, a “truth”. I would say that many people (on both sides) are so entrenched in their positions that it would take mountains of evidence to change their minds (myself included). This isn’t necessarily a bad thing. If we all gave up our beliefs based on trending evidence (as opposed to overwhelming evidence), then we would be changing our minds daily.

    • Big Al says:

      Don’t be so glum Greg? I have to agree that ‘Leftists’ use economics, physics, engineering, and medicine to make decisions (political or otherwise). They leave talismans and intransigence to the ‘Rightists’. Remember … nothing is ever “dead”, it simply changes form and energy.

    • Roger Waters says:

      Greg is correct. Having worked in all three branches of the federal government, in both career and political positions, it always amazed me how the Left viewed everything through political lenses and were blind to developing “good policy” separate from the politics. And yes, they don’t believe there are any truths, their “situational ethics” has them pushing their agenda irrespective of any search for the truth. In that context, “progressivism” is not a truth, but rather a fad of theirs, and potentially a slippery slope given the facts and other truths.

    • Don McCanne says:

      Greg says, “I’m afraid that for the Left it is all politics, 100% of the time.”

      But Greg Mankiw, in a new article this month, wrote, “…fundamentally normative conclusions cannot rest on positive economics alone.”

      You can call it politics, but the right, left, and everyone else uses normative economics all of the time. Rigidly adhering to positive economics alone risks ending up with sterile conclusions. The individual, a political animal, really needs to be included in the equation.

      • Wanda J. Jones says:


        “Sterile conclusions…” That’s a pair of words, damning with a label rather than with facts. Rather like a religious creed; don’t bother me with facts, I believe the devil exists.

        Liberals are slippery like that–you can start off with a discussion of how many people will be over 65 in the future compared with how many people will be working and taxed to pay for their care, and some liberal will throw back that the people over 65 paid into Medicare so of course, deserve to get it. That’s sophistry, a goal, but not a realistic strategy. Stay with the real world if you are going to attempt a real world redesign of healthcare. Especially if you are going to design laws that depend, not only on political agreement, but on workability. As Obamacare did not.

        Wanda J. Jones

  6. Saul says:

    “In every health care system in the world the market has been so completely suppressed that no one ever faces a real price for anything.”

    – This is a huge problem with healthcare

  7. Big Al says:

    Doc: “When government defines the bundles and dictates the prices — leaving practitioners unable to repackage and re-price their services as demand and technology changes, there will definitely be perverse incentives to do things inefficiently.”

    Words are funny things. Simply inserting ‘dictates’ instead of the correct term ‘offers’ changes the entire matrix of the business model. Remember, accepting the offer$ of insurers is solely in the purview of the provider. If a provider can’t run their businesses ‘efficiently’ at ‘offered’ rates, they need to refuse the offer.

    Looks like California ACA premiums are reasonable after all. http://www.coveredca.com/news/press-releases/pr-05-23-13-plans-anounced.html

    • Gerald Clarke, M.D. says:

      Exactly – physicians like myself will quit taking the small beans given us by the government, unless we can balance bill the PATIENT – that will bring ‘some’ economic reality into the equation.

  8. Roger Waters says:

    In 2008, between jobs, I was hired by a large multi-national pharmaceutical company to evaluate new areas in healthcare they might wish to pursue. As part of that engagement, I was able to visit and study the Nordic countries and find out why, for example, cardiac disease in Finland had dramatically decreased, arguably correlated to increase in electronic medical record use (1993 to 2003). Turns out it simply was due to a realization they were eating too much red meat and exercising too little, which they changed. But wait a minute, you can’t just change habits like that? Well, turns out Finland, like Sweden, is ethnically and culturally homogenous – 99% (maybe more) are ethnically the same, so they all followed the new recommendations. Then “a light bulb went on,” it seems our diversity is both a strength and a weakness. For example, you can’t prevent ER use in certain cultures when they believe emergency rooms are their primary care portal. So, any comparison between countries should be viewed with skepticism, especially when you only scratch the surface with absolutisms?

    • Stella Baskomb says:

      Can we really argue that people can be smart because of their ethnicity and at the same time believe that it’s a moral failure to argue that people can be dumb because of their ethnicity?

      • Roger Waters says:

        Perhaps my explanation was a little abbreviated. When the Finns said they changed their mobidity and mortality because everyone ate less red meat and exercised more, I thought they were joking. They laughed and said “oh yes, you are from the States, you don’t understand” and they explained their society is extremely homogenous, and everyone did as they were told. Of course, there are probably downsides to homogenaity, just like our diversity has great benefits. It is not smart or dumb, it just is. Furthermore, recognizing access to ER means access to primary care for some people allows us to be culturally sensitive, rather than insisting people should not go to the ER? Perhaps the dumb part is trying to create regulations encouraging ER diversion as that kind of regulation is culturally insensitive?

        • Stella Baskomb says:

          Thanks Roger.

          Based on your experience, the Finns do seem highly community-oriented as do the Japanese and other homogeneous populations. They are more easily governed – or led – however one might prefer to say it.

          I still wonder how the homogeneity of the population can fully explain what’s going on. Why would a homogeneous population necessarily obey their government more than a diverse population? Does that imply that any diverse population will contain people whose culture is to ignore their government? Would “re-education”programs then be appropriate to correct the deviant parts of the population? That gets uncomfortable fast.

          My mom used to tell me that maturity is doing what you should do, without being forced. Maybe the Finns et al are just more culturally “mature” than Americans?

    • Wanda J. Jones says:

      Very wise observation. In a country like the US, where a city like San Francisco can have residents from 182 different countries represented in the school system, it is axiomatic that each group will have a different healthcare culture. Chinese don’t like to be told they have a terminal illness, so everyone is expected to lie to them, including doctors. Some cultures exaggerate their symptoms and over-use medical care. Others are stoic and will not come in until they faint and are carted by their families to the ER. Some believe in treating only the males of the family, not the females. The notion that the writers of Obamacare seem to have is that there can be one pattern of care, one set of protocols, one expected behavior by the patient and family (compliance) is just so untenable as to be laughable. Come out and take a look at our homeless that line up at Glide Memorial for their daily meals; or at the well-fed Montgomery Street financial types, or at the sportsmen braving the weather on the Bay to race dangerous catamarans, or the vastly over-weight Black and Latino teens hanging out at MacDonalds. In our work, we urge fitting the healthcare system and its payment methods to the separate natures of the target groups (non-medical descriptors) and to the risk groups (medical descriptors.) We stay semi-enraged at Obamacare for its central control system, its rigidity, its over-reliance on regulation of the minutest part of the healthcare system, and for its utter unrealistic financial concepts. It’s a command and control model–which will simply drive lower echelons to ignore or subvert it.


      Wanda J. Jones
      San Francisco

  9. Tom says:

    Good piece. It’s important to shed light to those who compare systems within different states. Measuring lots of social systems, spending, poverty, etc, is problematic because we never get the clear picture as one measuring stick can’t get it all.

  10. Sam says:

    Measuring all these things in a health care system…very tough to do accurately. Some general trends may shed light on generalities, but we need to still account the factors that can’t be measured.

  11. Ralph Weber @ MediBid says:

    Spending per capita is very misleading.
    If we break spending into 3 categories:
    3)Private insurance
    And calculate spending per enrollee, rather than per capita, then we see completely different results.
    true, overall spending per capita is over 17%, but Medicare is over 23%….ok, you might say “but that is for seniors, and of course they need more medical care”. Medicaid is over 18%, and the Medicaid population us generally under 65. Private insurance is just over 12%.
    Paints a much different picture.

    • Wanda J. Jones says:

      Thank you–very good new numbers.

      Wanda Jones

    • Don McCanne says:

      “overall spending per capita is over 17%”

      17% of what? When you say, “overall spending,” are you referring to our national health expenditures? Presumably then you mean that our NHE is 17% of our GDP. But then how could Medicare spending represent 23% of our GDP?

      Just asking.

      At least Wanda seems to understand the numbers. Maybe, as Wanda said earlier, I’ve confused my labels with facts, whatever that means.

      • Ralph Weber @ MediBid says:

        Don, good question. I did some extrapolation. I used the GDP per capita, then I took the dollars spent by Medicare divided by the number enrolled in medicare to give me per enrollee spending, then I took that number and divided it into the GDP per capita

  12. Greg Scandlen says:

    Just to be a bit more on-point. Having the U.S. look at Sweden for lessons on doing health care is like Chicago looking to Vermont for lessons on reducing gun violence.

    • Roger Waters says:

      Exactly! Great analogy. Or, perhaps New Hampshire? Maybe even Wyoming?!?

    • Stella Baskomb says:

      “like Chicago looking to Vermont for lessons on reducing gun violence”

      May well be true.

      But why?

  13. Rob Tenery, MD says:

    Checking the demographics, as mentioned in your article, about comparing infant mortality between Sweden and the United States. In 2005, the reported rate was 2.77/1000 births in Sweden and 0.5/1000 in Minnesota.
    That also goes a long way in explaining the sharp discrepancies in the infant mortality rate among different areas throughout this diverse country.

    • Don McCanne says:

      Minnesota at 0.5/1000?

      Try 4.8/1000 in 2003-2005, considerably higher than in Sweden, though on the low end for the United States.


      • Roger Waters says:

        Exactly the problem with trying to get to the truth/facts. The OVERALL infant mortality rate, according to the report you reference, is 4.8 per 1,000 – for everyone. The rate for whites is 4.4 per 1,000. The question here is what is the infant mortality rate for persons of Swedish descent living in Minnesota, a number not revealed in the report referenced?

  14. Frank Timmins says:

    I don’t think there is much mystery as to how Robert Frank can offer a hypothesis that can’t possibly be supported by facts and statistics within his own area of expertise. We need go no further than the “hockey stick” of Global Warming fanatics to find the now widely illustrated propensity of the left to ignore reality in justifying progressive ends.

    Unfortunately it has many times played well with an unknowing public, but as Lincoln said, “You can fool…….

  15. ColoComment says:

    FYI: From the CDC post on international ranking for infant mortality:
    “The primary reason for the United States’ higher infant mortality rate when compared with Europe is the United States’ much higher percentage of preterm births. In 2004, 1 in 8 infants born in the United States were born preterm, compared with 1 in 18 in Ireland and Finland. Preterm infants have much higher rates of death or disability than infants born at 37 weeks of gestation or more (2-4, 6), so the United States’ higher percentage of preterm births has a large effect on infant mortality rates. If the United States had the same gestational age distribution of births as Sweden, the U.S. infant mortality rate (excluding births at less than 22 weeks of gestation) would go from 5.8 to 3.9 infant deaths per 1,000 live births, a 33% decline. These data suggest that preterm birth prevention is crucial to lowering the U.S. infant mortality rate.”

  16. Wanda J. Jones says:

    John and Friends:

    This blog is a perfect illustration of the “lying with numbers” problem we have with formulating health policy in this country. Either the numbers are wrong, mis-understood, off-set by other numbers that are about another topic, or of the wrong meaning for the argument in hand.

    Since there is a lot of passion among the commenters, I have a tiny little hope–could we all collaborate with John to have his organization put together a current atlas of correct numbers and comparisons offset against the ones so often misused by the popular economists of the hour?

    I have a favorite; the international comparatives of longevity, showing the US at 17th. Of course, the numbers used are not comparable, in two ways–our deaths from accidents (auto and violence) are included, which is a comment on society not the healthcare system; and our newborn deaths are included, which they are not in some European countries, who wait for a month to see if the infant survives. When the numbers are “normalized,” the US has the top spot, not the 17th. The fact that this invidious comparison was widely touted during the ACA debates make me think that surely out there somewhere was a bio-statistician in one of our several hundred schools of public health who would object, or a practicing public health officer, or someone from the Centers from Disease Control, or from the health economists who want us to believe their every pronouncement, but there wasn’t. If it came out of the mouth of the government, the argument that the US healthcare system was obviously worse than that of Europe because of differences in longevity was considered valid, but it was not. Also not valid was the basic link of healthcare services and expenditures with longevity, when formal healthcare services affect only about 20% of health status. For crying out loud, why do we let the liberal press continue to perpetrate such infantilization of healthcare reality?

    Speaking of atlases, there is a man in London who has published annual atlases where the numerical differences among countries is depicted by varying the size of the country on a stylized map. Makes understanding the numbers much easier.

    And, coming up, are the egregious confusions created by using the same term, “costs” to denote charges, premiums, total outlay for health services, net revenue per service, and many others. Add to that the collective disdain for fee for service, charging an average price for every enrollee or patient will skew medical decision-making even more mindlessly than FFS does now. Just remember that when a health plan wants to pay providers sme kind of global price, they usually request that they be given an itemized account to compare with what they were asked to pay as it gives them information they don’t get from a sub-cap, bundled price, or monthly membership.

    Anyway, what do people think about this idea–we’ve all got a stake in this crash and burn scenario with the ACA, so shouldn’t we prepare the way for something more realistic?

    Cheers to all…

    Wanda J. Jones, President
    New Century Healthcare Institute
    Sam Francisco, CA

    • Ralph Weber @ MediBid says:

      I always say that statistics are like a lamp post is to a drunk…more for support than illuminaiton

      • Roger Waters says:

        So, shouldn’t we build our own lamp post? I think Wanda’s suggestion is excellent. I’m “in,” when do we start? John??

        • Ralph Weber @ MediBid says:

          We need to examine 5 year survival rates from critical illnesses to truly measure effectiveness of healthcare.

          • Al says:

            Ralph that was done with an international comparison of common cancers in the Concord study. They rated from 1-30 how well each country performed. If one averaged the placements then the US was at the highest end with ~1.4 and Sweden ~7.4. (Cuba excluded by me due to non credible data collection.)

  17. Don McCanne says:

    David Callahan has a great commentary today, not only on Robert Frank’s column on Sweden, but also on an important theme discussed here. Callahan writes, “Ironically, government run healthcare systems are better for free enterprise than those — like the ACA — which impose mandates on employers.”

    Many on the left agree with others here that Obamacare is a highly dysfunctional program. Where we disagree is in what sort of a program would better serve our free enterprise system.


  18. Breck says:

    John: You didn’t explain that metrics such as infant mortality rate are heavily influenced by how we determine when a live birth has occurred and whether or not the mother sought and received pre-natal care. The root of any disparities in the U.S. is that we have larger percentages of individuals with problematic life styles owing to poverty, lack of education, drug abuse, and the like. If we only measure health outcomes for people with similar economic and social circumstances I’d bet the U.S. would come out on top.

    Like most of those on the liberal side, Frank assumes health care is a static entity of which there is a fixed quantity that must be divided up fairly. He doesn’t account for the fact that there is constant change in what constitutes good health care and that the quantity changes with market incentives.

    Thanks for making so many things about health care so clear.

  19. ColoComment says:

    Bravo, Wanda! That is exactly the proper response to claims about internationally comparative health care results, about what is, or is not, included in any discussion about the “cost” of health care, and any other apples-to-grapes-to-tomatoes purported comparisons.

    I, too, kept waiting for someone with the research capability to burst onto the Obamacare legislative scene and cry, “Stop! You are not being accurate in your argument!” But it never happened, and deceptive information is still being referenced without question.

    PS: does the health care industry also include pharmaceutical R&D, and if so, how does one address what I would call “free pricing” in the U.S. v. government controlled pricing in Europe & elsewhere, i.e., freeriding on U.S. pharma?

    • Wanda J. Jones says:

      Yes, it is well-understood that European health systems do take a free ride on US research and pricing. And people persist in urging that the government negotiate prices with drug firms (which they do anyway.) What are the roots of these prices? Why, our system of government funding of research, followed by our government-managed patent system, which for 30 years has patented human genes, to be followed by a Byzantine-era FDA clinical trials process. Each of those processes is flawed by various kinds of inter-agency incest, that is concealed behind a more or less permanent public employee, “cannot be fired” support system. I get really hot when I hear a government employee say the healthcare system is “broken.”

      As I urge in other settings, that the legal framework for healthcare at the state level should be modernized in model laws that can bed adopted by each state, I think it would be a good idea for some very smart cookies to produce a model framework for modernizing the laws that make our pharmaceutical industry so problematic. Who would have an interest in this? Health plans and providers, who are the ones most tagged as bad guys in the cost game.

      Thank you for your response. Did you note that others in this issue do see the value of a new numbers atlas?

      Cheers to all the die hards…

      Wanda Jones

  20. Ralph Weber @ MediBid says:

    Don’t forget big insurance, big pharma, and big hospitals benefit greatly from obamacare. Most mainstream economists will say anything you pay them to say and prop up some stats to “prove it”. Very few are honest when it comes ot healthcare.
    Allow me to illustrate:
    The restaurant association was losing business due to Bloomberg et al, so they hired an economist and lobbyist to fight back. The research economist found that 7 out of every 1,000 people who check into a hospital dies there, while only 3 out of every 10,000 people who visit a restaurant die there. The report reflected that if you get sick, go to a restaurant.
    The above is not a true story of course, but it illustrates how what I said earlier about lamp posts

  21. Wanda J. Jones says:

    To John and All…

    Just a reminder–Obamacare is now 3 months from sign-up day. It will be a debacle. The president is in terrible shape, both at home and abroad. The next two years will make things even worse. One scenario: By the 2014 election, a Republican majority is created in both houses. Obamacare will be in tatters. States will be in an uproar. A bill can still be passed to repeal it, since it will have signed up many fewer than projected, and the costs per person will be untenable. Obama may decline to sign the repeal bill, but there will be enough votes in both houses to over-turn that veto. He will have no political capital left.

    I advise my colleagues who are running healthcare systems or hospitals to plan their ACO strategies to do only that which they would do without Obamacare, and to be wary of entering into bad risk partnerships with HHS, a whirlpool of incompetency in healthcare.

    Anyway, let this be a moment of new leadership in American healthcare; We and our feisty colleagues can craft a new path forward to substitute for Obamacare that will not bankrupt us, yet will provide the healthcare services now missing from the PPACA. To me, a payment arrangement is no guarantee of receiving care, as we have seen with Medicaid and primary care. The PPACA puts us on the road to having the same thing happen with specialists. To me, the simplest, and most direct way to provide services, is to provide them, not simply say we are insuring them. The single most successful service format for under-served people is a Community Health Center, with its sliding scale, public health component, recruited medical staff, reliance on nurses, and location in the midst of the people being served. Why did HHS cut back the funding for 1000 of these two years ago? There’s more–specific design per target group and for selected risk groups, so both short term care and management of chronic diseases can be housed together. (Got plans!)

    Anyway, we have a short time to design a plan that can help carry the right candidates for President, governor, senator, representative, or heads of government departments to a clean sweep election, to tackle not just healthcare but the way the US has been turned into a failed state through debt.

    My husband and I are multi-generational healthcare people and know how complicated it is and how daunting to people not in healthcare. I’m ashamed of how ignorant we have allowed our elected officials to be when talking about this industry; they have done it great harm. The shakeup caused by Obamacare has, indeed, brought people in leadership positions to a state of worry and determination to comply; but it has not necessarily brought them to a state of wisdom about how to take over redesign themselves and do the right thing without the coercion of a Federal risk contract.

    John–What do you think?

    Wanda Jones
    San Francisco

    BTW, I have arranged with my NFP board to go on 20% time so the rest can be spent on direct development and on any political thing I see needs doing. I understand the constraints on those of you who are constrained by the laws surrounding your 501c3 organizations.

    • Ralph Weber @ MediBid says:

      Wanda, What keeps getting missed is the fact that politicians will continue to try to reform “healthcare”, AKA, the financing method of Medical care, rather than Medical care. As long as we allow the tail to wag the dog, failure will continue

    • Big Al says:

      Wanda, I always appreciate a political soothsayer, but you may also wish to tell everyone to prepare for the Dems to take back the house as well for the remaining two years of this administration.
      Never know when you’ve got bad tea leaves.

      I am nearly 60 years old and have never seen a President face so much adversity and obstructionism as has Obama has … nor has anyone done so well to overcome it. I’m afraid you will have to coexist with the ACA for a long long time.

      • Ralph Weber @ MediBid says:

        Big Al,
        I’m also almost 60, and I’m afraid the “tea” from which your tea leaves came had a different name than “tea” back in the era of Woodstock

        • Big Al says:

          Ralph, I chuckle when kids say that current times are the most dire of all times. We made it through the 50’s and 60’s cold wars, Cuban crisis, assassinations and protests, 70’s economic crises, 80’s Social Security scares, 90’s Whitehouse sex scandals, and we’re making a recovery from the Little Bush boat swamping. Currently, unemployment is lowering, GDP still in positive territory, deficit dropping, Medicare and Medicaid bolstered, and mass new access to medical care. Things are looking up every day.

          • Ralph Weber @ MediBid says:

            Al, what is “Bush boat swamping”? Are you referring to swamp boats? Please explain.
            Please describe how you see access to medical care improving.

            • Big Al says:

              Well, swamping the boat refers to starting two wars and not increasing taxes to pay for them; creating Home Land $ecurity dept and not increasing taxes to pay for it; reducing taxes when we couldn’t afford it; and in doing so, sent us on this ‘difficult to control’ deficit upward spiral. Obama’s tax increases, Stimulus, and exiting the wars is finally getting things stabilized … so the boat [the American Economy] didn’t sink.

              35 million people joining the ranks of the medically insured equates to ‘improved access’.

              Hard to argue with success.

              • Ralph Weber @ MediBid says:

                You are really smoking your “tea” arent you. He started 2 wars and deficit spent by a trillion PLUS per year. And in that you take pride? Are you SERIOUS? And putitng 35 million people onto Medicaid does not improve access at all. Man, you are really living in the 60’s. How long have you been this out of touch with reality?

                • Big Al says:

                  Ralph, you asked what I meant by ‘Bush boat swamp’. The references to wars and deficit were under little Bush’s watch, not Big O’s. Big O is righting the ship. Please re-read my post.

                  35 million will not be added to Medicaid. I referred to 35 million that will “medically insured”. They will be added to the ensured rolls of private insurers … as well as Medicaid. With access, they should seek covered preventative service, thereby avoiding acute care needs and government costs.

                  Why do I feel that I am teaching ACA Theory 101?

          • Ralph Weber @ MediBid says:

            Al, you must be very proud of the lies, credit downgrades, scandals, lack of protection of ambassador, giving guns to Mexican drug lords, and all of the other “transparent” corruption your guy has perpetrated and remained standing. He really does have quite a record.

            • Big Al says:

              Lies … please give example of lies.

              Credit downgrades … Boehner holding the debt ceiling hostage instead of accepting Obama’s $4T budget cuts in 2010 was the direct cause of the downgrade. That one was on Boehner and the exuberance of the Tea Party.

              Ambassadors die all the time. If we hold the President personally responsible for them, Regan, Bush Sr., Bush Jr. would be in jail. Please research. This was just Republican pot stirring.

              Fast and Furious was started under Bush Jr. Do you blame him for the idea or do you blame Obama cuz the program finally had casualties that were acknowledged.

              I’m afraid you’ve been listening to too much Hannity or Beck. Remember, they are just entertainers and what they say doesn’t have to be accurate.

              • Ralph Weber @ MediBid says:

                Chris Mathews claiming it was the sun’s fault that obama looked like a complete idiot is an entertainer. The mainstream media does not re[port or inform, you really need an educaiton

                • Big Al says:

                  I do not consider Fox, CNN, or MSNBC main stream. They can be informative when delving into the extremes of politics, but for you to make a blanket statement that “Main Stream Media does not report or inform,” shows blatant disregard for the innumerous journalist and media outlets who endeavor to maintain objectivism in their reporting. Simply because you don’t hear the ringing of the Alex Jones conspiracy chimes , doesn’t make main stream media biased or uninformative.

              • Roger Waters says:

                Point of fact, Ambassadors die all the time – from old age. Very few are assassinated (only one to my recollection in the past thirty or forty years). And none are assassinated when sufficient security is provided (which is an executive branch prerogative). I won’t go into the other factual errors in the statements above, as they appear to be politically charged rather than factually based.

              • Stella Baskomb says:

                Big Al, sticking out his chin, asks: “Lies … please give example of lies.”

                “If you like the health insurance you have, you can keep it.”

                “Clearly the [Boston] police acted stupidly.”

                “No one is reading your email.”

                “Benghazi happened because of an inflammatory video released in the U.S.”

                There’s so much more, but it’s tiresome teaching malfeasance in office, 101.

                • Roger Waters says:

                  President Obama, as the “stationary mandarin” (the famous “you didn’t build that” speech) who feels that government institutions and bureaucracies are the key to growth and not individual initiative supported by a good legal system, civil institutions, and competition. Perhaps not a “lie,” but certainly a different view of the truth? For, in fact, tax dollars are used to build it, and it fails to recognize that roads and infrastructure is built on the shoulders of businesses that finance it. Unless, of course, you wish to build a road or bridge to nowhere?

                  • Big Al says:

                    I am happy that you don’t consider this a lie. Interpretation of statements often depends on the predisposition of the listener. Obama’s ‘different view of the truth’ is that ‘the people are the government, we are the builders’. Roads, bridges, cities, infrastructures are not built by individuals; they are built by everyone, by their tax dollars, their cooperation, and their sweat. Some, taking the statement out of context serves only as political gamesmanship.

                • Big Al says:

                  Stella, welcome to the fray.

                  Definition of Lie: To make an untrue statement with intent to deceive.

                  1) “If you like the health insurance you have, you can keep it.” I am unaware of any part of the ACA which requires someone who already has an existing health insurance policy … to give it up. If an employer decides to change or eliminate their group coverage, or an insurance company drops certain programs … that is beyond the control of the ACT. If your policy does not meet reasonable set criteria, you can still keep it and pay any associated penalties. The statement is not untrue. (0-1)

                  2) “Clearly the [Boston] police acted stupidly.” When police arrest a college professor gaining access to his own home, certainly something seems to have gone stupidly wrong. With the facts Obama had at the time, this was a human perception, not a lie. (0-2)

                  3) “No one is reading your email.” Since it is common knowledge that telephone and internet providers store connection and data (SMDR) information for extended times (billing and abuse reasons), and our (Bush) Patriot Act allows the NSA to acquire and save the information and review it upon warrants … one must be able to reason what the President meant. “No one [legal government representative following legal protocols] is [illegally] reading your email.”
                  Your unfamiliarity with the facts does not equate to an Obama lie. (0-3)

                  4) “Benghazi happened because of an inflammatory video released in the U.S.” Between the 11 th and – 15th of September 2012, there were approximately 40 protests and attacks on diplomatic missions around the world … all precipitated by the video ‘Innocence of Muslims’. I think, with initial information we had, it would not be untrue for the President to make that statement. As time and information changed, the statement became partly true, or at worst obsolete … not a lie. Multiple investigations have supported this. (0-4)

                  Decrying “Liar” simply because one does not understand the facts behind someone’s statements is as bad as calling them narcissistic, Fascist, ignorant, etc. etc. (per other commenter’s) Look with better eyes.

                  • Stella Baskomb says:

                    “Big Al”

                    Obama is not Biden. Your argument might almost fit a buffoon like Biden. But I credit Obama with significantly greater intelligence than that. Obama parses his words carefully and I believe he means what he says.

                    So you go ahead and decide on Obama’s truthfulness based on what you think he means. I’ll continue to decide based on what he actually says – or dances around saying, in his charming, lawyerly way.

                    1. Obama’s “keep it” statements were just another dishonest tactic he used to get ACA passed. ACA itself is, as you point out, the very instrument by which the truth behind Obama’s intended deception is being carried out. Obama’s statement was an intentional, often-repeated lie.

                    2. Obama the “constitutional law professor” shot off his mouth about Boston police based only on a sketchy report of an arrest. As a “professor” he well knew he was wrong to draw any conclusion. Yet he stated his own [erroneous] conclusion anyway. He intended to deceive. He lied.

                    3. “one must be able to reason what the President meant.”

                    You mean, he didn’t lie because what he SAID is not what he MEANT? I think you refute your own argument. I think he MEANS what he SAYS. In this case he meant to deceive. He lied.

                    4. ” Between the 11 th and – 15th of September 2012″

                    All of which took place AFTER the Sep 11 Benghazi event, not before. You simply repeat, and insist on, the Obama lie.

                    “Look with better eyes.”

                    Advice you would do well to take. If Obama were so strictly truthful as you allege, he would not be caught up in so many instances where he is caught double-dealing with Americans. People have begun to notice.

                    PS – “Big” Al I would not be surprised to learn your alias is a lie, too. You’re way overcompensating.

                    • Big Al says:

                      Stella, let’s simplify this for you:

                      1) Per statute, does the ACA prohibit you from keeping your existing insurance plan? Answer=No.

                      2) The Boston police acting stupidly was an ‘OPINION’, of which everyone is entitled. If he would have said that the police acted properly, contrary to his own opinion, then that would have been a lie.

                      3) Is someone reading ‘your’ emails? If you do not know for certain, then decrying liar is out of line.

                      In this age of technology, with billions of people, service providers, companies, agencies, and governments all using the same public forum, it would be naive to think that ‘someone’ might not be reading your emails. However, Obama can only speak about unauthorized access of your emails by Federal Administrative officials.
                      Storage and warranted access of your emails was made legal by ‘our’ Congress and former President.

                      4) Cairo was the first embassy attacked, and it was in protest of the movie. All other attacks followed, either that evening or within a few days. To ascertain and differentiate motives of all protesters and players, at all sites involved, would be difficult, to say the least. The best information was given to the American people as it came in. No cover up was proved … No lies exposed. You are entitled to your suspicions, but again, decrying liar is unfounded.

                      I’ve noticed descent to my opinions and information usually entails numerous derogatory sentiments such as: buffoon, lawyerly way, double-dealing, liar, Fascist, narcissistic, elitist, corrupt, idiot, etc… Is that normally how conservatives argue points; ignore the facts and throw insults?



            • Al says:

              Ralph, there are two Al’s on this list. I think Al came first and then another arrived and he listed himself as Big Al. The two Al’s are 180 degrees apart. One can remember the difference by thinking about the l in liberal. Years ago liberals were different such as classical liberals. Today to separate the two many use a Big L in the word Liberal. That might have been a Bill Buckley convention but I am not sure. You can use an alternate nemonic to remember this Big Lies.

              By the way GWB shut down his version of Fast and Furious because of problems. Obama doubled down when restarting it and had his attorney general Lie about it and then Lied himself.

              • Big Al says:

                Big Al and Al are two peas in a pod. Big Al is more fiscally conservative but Little Al has a better flare for fiction. I was unaware of any charges filed against either Holder or Big O for ‘Lying’ to Congress. Let’s label perceptions … as perceptions, not facts.

                • Al says:

                  Big Al, there is no way you can merge the two of us together. You have no knowledge of what makes one a fiscal conservative. If you did you would be opposing most of Obama’s increased expenditures. Additionally, once again it appears that you are unable to read or understand the English language. There were no claims that charges were filed against either Holder or Obama. In case you don’t realize it people can and do lie even if no charges are brought against them.

                  • Big Al says:

                    Lil Al, I think that I understand your vision of fiscally conservative. You would eliminate deficit reducing programs (ACA) … eliminate programs designed to help the masses (EPA, FDA, DofEd ,TANIF, SNAP, … reduce top tax brackets even though the founders set forth a progressive tax structure and we can’t pay our bills as it is … cut welfare but don’t touch your SS welfare check … is that about right? I’ll stick to fiscally responsible, thank you.

                    When someone accuses someone else of lying, proof is normally used. I thought that you would have been referring to something more substantive (Holder & Obama) than your own disgruntled perceptions. Sorry, I can’t help you there.

                    Since we are only arguing perceptions, are we done flinging crap at each other yet or do you wish to continue wasting bandwidth?

                    • Al says:

                      “the founders set forth a progressive tax structure”

                      Big , Bigger and Biggest Al who is about to burst, Fiscal conservatives do not base their financial security on houses built of cards (like the ACA). We leave that up to foolish people who have a bloated opinion about what they know, but in reality know next to nothing.

                      Apparently you don’t realize the tax structure created by our founders. Go back to school. The ability of Congress to levy an income tax was based upon the 16th amendment which was passed under the Taft administration. You might know him as Big Will, but Big is all you have in common.

      • Greg Scandlen says:

        And I have never seen a president as ideological, partisan, and contemptuous of the opposition as this one. It is a tragedy because this man had an opportunity to do some healing in this nation. Instead he has done just the opposite.

        • Don McCanne says:

          Greg, perspective certainly makes a difference. I am very sincere when I say that I have never seen Congressional Republicans as ideological, partisan and contemptuous of the opposition as the current lot.

          I am not alone. Norman Ornstein and Thomas Mann, amongst many others, seem to share the same view:

        • Big Al says:

          I can’t agree that Big O is contemptuous. He is understanding and gratious when referring to Republican obstructionism as ‘Congress’ in general … It’s uncharacteristic for a grownup to have contempt for a child when the child throws a tantrum. The parent may not approve of the behavoir, and gets things done despite the child’s kicking and screaming, but the parent doesn’t hold contempt.

          Greg, we understand your feelings and everything will be ok honey.

          • Roger Waters says:

            Actually…not contempt. If you really get to know the guy, it is really arrogance. He is very smart, thinks he knows better than anyone else in the room. Problem is that his experience as a “community organizer” is rather myopic. Thus, his intelligence and myopism results in an arrogance that leaves little patience for ideas that are not his own, especially if they come from persons he feels are his ideologic enemies. No room for compromise here, although he will bargain away anything to further his liberal agenda

            • Big Al says:

              Very smart … yes.
              Knows better than most people in the room … yes.
              A Constitutional Professor, Eight year State Senator, Federal Senator … who had the compassion to sit in the trenches of America’s poor for years … is more than qualified to get my respect and vote.

              If you have followed his appointments, you would have found that he places the most qualified in strategic spots. He gets the job done. Are there bumps? Absolutely, but he plays a smart long game. His agenda is for America as a whole. Just because he doesn’t tickle your belly doesn’t make him a villain.

              • Ralph Weber @ MediBid says:

                I’d be surprised if his IQ exceeded 135, and I do not consider that very smart.

                • Big Al says:

                  “The measure of intelligence is the ability to change.”
                  ― Albert Einstein

                  • Roger Waters says:

                    Ok, so I have quietly sat by and said nothing, but given the rhetoric, it behooves me to note that my earlier comment was not vilifying at all. Instead, it appears Al has bought into the political propoganda, rather than knowing the facts. The fact is our current president will be very nice to your face, if you have something he wants (e.g. your vote). If not, he is impersonal, dismissive, elitist, and arrogant. That the press does not make more of this is a good question, and you can draw your own conclusions. Just the facts here, none of the political rhetoric. So please believe whatever you wish, and we’re not saying change is not good, rather the wrong change leads you down the path of perdition. Enough said.

                    • Big Al says:

                      Since you seem to be a character witness for President Obama, I must assume that you know him personally and have intimate knowledge of all of his meetings and thoughts??? If not, wouldn’t you say that your perceptions are simply your perceptions, not facts?

              • Roger Waters says:

                Perhaps you misread my post, smart in this context means cunning. The fact he went to Harvard means he also has a high IQ. What he “knows” better than anyone in the room is that his position is right, irrespective of the rights of everyone else or the diversity of opinion that this great nation was founded upon. That he gets angry when you voice a different opinion shows immaturity and arrogance. His “smart long game” has always been for his own personal gain, to the detriment of others. The fact he has nowhere else to go, it shall be interesting to see how he self-destructs as most arrogant immature people eventually do. BTW, where HAVE all the Statesmen gone?

                • Roger Waters says:

                  My facts come from having worked professionally with almost all the people mentioned in this blog, and gotten to know them personally. That is why your musings are humerous. The political drivel is mildly irritating, but altogether humerous.

                • Roger Waters says:

                  My facts come from having worked professionally with almost all the people mentioned in this blog, on both sides of the aisle, and gotten to know them personally. That is why your musings are humerous. The political drivel is mildly irritating, but altogether humerous.

                  • Big Al says:

                    Then the people mentioned in this blog know the President personally and are privy to his meetings and thoughts? Again, if not, then your incessant name calling is still strictly baseless whining.

                    With all due respect to the good Doctor and the many readers and contributors to this venue, this blog seems to be a vent to blow off steam caused by potential effects of the ACA. Some commenters are more than mildly irritating (Lil Al) and not as humorous as me either. I would appreciate seeing ideas that will improve the ACA instead of just bashing it. It is here to stay, just like SS, Medicare, and Medicaid. Doctors … Heal it. Make it better

                    • Roger Waters says:

                      LOL, my apologies for not being more specific. My professional career in the US Senate and White House writing health care laws and regulations allowed me to work with, and get to know, most all of the political, elected officials mentioned in this blog. My experience also taught me that laws written by young people like me (and never read by people like the Hon. Nancy Pelosi) usually have unintended consequences (please see “The Great Degeneration” by Niall Ferguson for more). And my work has never been with any of the bloggers here, that I can recall, unless of course some of you had meetings with me, but then again “I can’t recall” (famous disclaimer).

                    • Al says:

                      “Some commenters are more than mildly irritating (Lil Al)”

                      When ignorance is exposed the ignorant become irritated. I guess my points weren’t lost.

                      “Heal it.” [the ACA] “Make it better”. The ignorant create a program that cannot work and then rely upon their betters to fix the problems they created (referring to the left and no one in particular).

        • Al says:

          Obama is a narcissistic elitist and probably somewhat of a fascist. His worst trait is he preys on racial hatred and envy. You are right for he was the wrong man at the right place and if he were a better man he could have been great.

          • Big Al says:

            Wow, narcissistic, elitist, fascist … do you own ‘The Dictionary for the Frustrated?’ Impressive.

            Greatness is in the eye of the beholders. Sorry for your perceptions. The 2012 election tallied the perceptions and you were in the minority. There is more greatness to come, so hang in there.

            • Al says:

              Apparently you need a dictionary so you can understand what those words mean. Then you might even learn what greatness is. Right now you sound like a kid voting for who will make the best president for the fourth grade.

              That piece of candy you received sealed your vote.

  22. Big Al says:

    Sorry, spell check … Gracious and behavior.

  23. Wanda J. Jones says:

    Big Al: 25 million under coverage equates to access? NO! There won’t be 25 million and they will not be able to get doctors if they don’t have them already.
    Notice the stats on doctors leaving or not accepting government patients. Don’t swallow the propaganda from HHS–they have not been right yet.

    Wanda Jones

    • Big Al says:

      Wanda, I appreciate your compassion, but shouldn’t we be cautious of guessing what the patient doctor ratios will be … even before exchange implementation? I don’t think we’ll see multitudes of Doctors throwing away their professions just to spite public pay levels. The ACA has provisions to support the education and deployment of new generations of Doctors to deal with the normal and abnormal attrition ahead. The harder you squeeze to keep the status quo, the more that squirts through your fingers. Change is inevitable and necessary.

  24. Al says:

    Don McCanne, you referred us to a commentary by David Callahan. Callahan said:

    “Of those ten countries, nearly every one has a universal healthcare system or mandates that individuals pay into medical savings accounts. Australia and Canada both have single-payer systems.”

    What he said was that the U.S. is different and I thank God for that. If we didn’t have differences Europe would be speaking German for the outlier, The U.S., first had to bail Europe out of its war and then had to feed the people of Europe. Those that drank the Kool-Aid in Jonestown and died were doing nothing more than what Callahan is telling the United States to do now and that is to follow the leader and drink the Kool-Aid. Definitely not a smart idea.

  25. Al says:

    The Con Job

    Big Al writes: “35 million people joining the ranks of the medically insured equates to ‘improved access’”

    Big Al has swallowed the Kool-Aid. This type of access is like selling 300,000 tickets for the World Series at Yankee Stadium. The stadium only seats 50,000 spectators.

    • Big Al says:

      Oh, i get it. We only have enough doctors to take care of the entitled and the impatient. Heaven forbid we all have to wait a little longer for service to accommodate everyone. I’ll take my place in line, thank you.

      • Al says:

        Obama and Obamacare care uses physician hours very injudiciously. I won’t bother to explain why for you do not appear receptive to anything but political drivel that you seem to swim in.

        I will tell you something you might understand. When push comes to shove it will be the poor people left out in the cold. That is what your ideology leads to.

        • Big Al says:

          Lil Al, the poor have been living out in the cold for a long time. The ACA is attempting to usher them through the door, despite your trying to shove it closed and retain your status quo.

          You seem to have the same trouble with math that Boehner has. The ACA L O W E R S the deficit (CBO). As a fiscally reasonable (the term conservative is becoming increasingly embarrassing) person, I get it.

          The ACA uses less tax dollars cost-sharing insurance policies and proactive medicine for the poor … than we now spend on ERs and reactive medicine. What part of that doesn’t equate, lil fella?

          • Al says:

            Big, Bigger and Biggest Al, you are a little bottom heavy and perhaps need to concentrate on quality not size. That Kool-Aid must have a lot of calories while lacking in food for the brain. The original CBO numbers are long past and we are in for a big deficit while the lower middle class’s care is downgraded to a bit above Medicaid. The poor won’t get the benefit despite all the guarantees that cannot possibly be lived up to.

            It’s amazing how you guys pledge to help the poor while your actions cause increasing unemployment and poverty. You have managed to create the largest need for food stamps ever in a country where obesity is a major health threat. It is so amazing that this President will be known as the food stamp President.

            • Big Al says:

              Oh, Lil Al. I guess you still want to play. Ok.

              1)”CBO numbers are long past.” Numbers (requested by Boehner … again) from 6/24/2012 … ACA still shows 109 billion deficit reduction.

              2) “we are in for a big deficit” Deficit is shrinking rapidly.

              3) “The poor won’t get the benefit despite all the guarantees that cannot possibly be lived up to.” Pure conjecture. Time will tell.

              4) “It’s amazing how you guys pledge to help the poor while your actions cause increasing unemployment ….” I’m assuming that you have actually seen the drop in unemployment figures to 7.6% from the high of 10.3% haven’t you? That is called decreasing, not increasing. Your welcome. data.bls.gov/pdq/SurveyOutputServlet?request_action=wh&graph_name=LN_cpsbref3

              5) ” You have managed to create the largest need for food stamps ever in a country where obesity is a major health threat. It is so amazing that this President will be known as the food stamp President.”

              Don’t you wonder how it came to be that so many people qualify for the food stamp program? It’s because of the Bush Recession. Your logic is as sound as blaming Obama because there are too many life boats in the water … just after Captain Bush sank the ship. Amazing.

              That’s in line with Hannity saying that “Obama ‘presides’ over the largest debt know to our country”, but without stating who was responsible for causing the debt … Regan, Bush, Bush. zfacts.com/p/318.html

              If you include me in Obama’s actions … thank you. Stabilized GDP, Lowered Unemployment, turned runaway Bush deficit around, first president to get comprehensive health care passed, extricating us from two insane wars, stabilized Medicare. Don’t even make me send you the documentation. You should throw away your shovel and call it a day while your head is still above ground level.

              • Al says:

                Big, Bigger and Biggest Al, go back to school.

                Play? …with one that thinks our founders created a progressive tax system that was actually created during the Taft administration?

                Your data is wrong and you don’t know how to interpret what you quote nor do you seem to recognize the difference between primary data and secondary or tertiary data. You also don’t know what the unemployment figures mean. Apparently you know nothing of the underemployed nor those that have given up looking for jobs.

                Blind as a bat you continue to blame Bush who is partially at fault, but on his second term Obama now has to take full blame. Your rhetoric is worthless.

                • Big Al says:

                  Lil Al, you are tenacious, I have to admit. I thought you would have been of the opinion that ‘our schools are socialist denims of evil.’ Glad to see that you support the Dept. of Ed. Is my goal to be as smart as you?

                  I give you as much detail as i think you can absorb. Your name calling tells me that you need more information.

                  The 16th Amendment simply addresses apportionment, census and enumeration. Without respect to the innumerous taxing methods used by both the Federal government and by the states prior to 1812, the first federal income tax proposed (by our founders) was during the War of 1812 and based on the Progressive British Tax act of 1798. Subsequent tax acts of 1861 and 1862 … Wilson-Gorman Tariff of 1894 were also progressive in nature. Want me to stop yet?

                  Bush is known for creating the recession … and … situations related to his debacle, which will go on for decades. Obama is known for getting us out of the recession.
                  You need to stop listening to shock radio/tv.

                  • Al says:

                    “Glad to see that you support the Dept. of Ed.”

                    Big, Bigger and Biggest Al, I support education though not particularly the Department of Education which has failed to adequately educate many, including you.

                    “the founders set forth a progressive tax structure”

                    I note how you wiggle and jiggle in an attempt to resurrect yourself by going to Wikipedia or some other source, but you can’t get away from your own words “set forth”. Those two words have a specific meaning as does the term “the founders”.

                    • Big Al says:

                      “I support education though not particularly the Department of Education” Think carefully now Lil Al, why was the Dept. of Ed created? Since the Dept. of Ed does not create schools or dictate their curriculum, their function is to facilitate federal funds requested by the states and to enforce laws passed by our Congress and Presidents. They are simply doing the bidding of the people and safeguarding our tax dollars. Don’t shoot the messenger. One exception: Lil Bush’s NCLB is, however, an inconvenient conservative intrusion though..

                      ‘Founders’ is often used collectively for our elected officials that were prominent in the establishment or continuance of this nation, and is not restricted to the attorneys who’s names appear on the Constitution. However, if you insist on using only signees, Article 1, Section 8, Clause 1 was written by ‘the Founders’ to collect tax revenue. Since one can’t squeeze water from a rock (cash from the poor) tax structures were progressive in nature. You have nothing … you pay nothing, you have a little … you pay a little, you have a lot … you pay a lot. It’s kind of a Global Common Sense thing, you’ll catch on. Your proclivity to deify the original 40 and protest the taxation they set forth in the same breath is not unique, unfortunately.
                      Need any more of my ‘failed’ Dept. of ED education?

                      Yes, you can keep insulting me if it helps you focus.

                    • Al says:

                      Big, Bigger and Biggest Al, first don’t confuse GWB with a true fiscal conservative or a classical liberal. He was neither, but everything he did wrong has been magnified several fold by Obama. GWB seemed like a decent American. Obama based solely upon his own words in his own books ( if there wasn’t a ghost writer) tells us of a man who should never have been President no matter what economic theory he believed in.

                      This is a healthcare list so I don’t want to debate education. However, your belief that the federal government has little to do with education is faulty just like your information on the founders and progressive taxation that began under Taft about 125 years after the founding of the nation. Your present excuse for your lack of knowledge is accepted though incorrect. (Example: Those that have a lot of money spend more, yet a sales tax is not a progressive tax.) I do this to save you further embarrassment recognizing that education isn’t for everyone.

  26. Al says:

    I have noted the use of Al instead of Big Al by more than one writer. I therefore am posting part of my initial response to Ralph to make sure everyone knows the difference.

    Ralph, there are two Al’s on this list. I think Al came first and then another arrived and he listed himself as Big Al. The two Al’s are 180 degrees apart. One can remember the difference by thinking about the l in liberal. Years ago liberals were different such as classical liberals. Today to separate the two many use a Big L in the word Liberal. That might have been a Bill Buckley convention but I am not sure. You can use an alternate nemonic to remember this, Big Lies.

  27. Roger Waters says:

    And by the way, point of fact (from personal experience working in both places), President Bush did not “start two wars.” President’s cannot start wars, it takes an act of Congress to commit troops. And of course, the President can withdraw troops once it is appropriate to do so. That our current President has not kept that campaign promise speaks to the fact that he views everything through a political lens, rather than a principled lens. Not saying other politicians don’t do that, but it appears he does it to the extreme. Translate: where have all the Statesmen gone?

    • Big Al says:

      “President Bush did not “start two wars.” “President’s cannot start wars; it takes an act of Congress to commit troops”

      Oh, you mean that Little Bush was just sitting in his oval office and Congress knocked on his door and said that he was going to war? Wow, my mistake. The President drives the military bus. He drives the bus to any location he wishes (War Powers Act), plays around for 90 days, and then asks Congress if they want to keep gas in the bus or bring it home. Stop playing semantics. Bush’s Wars, Obama is getting us out as quickly and as reasonably as possible.

      ‘Statesmen’, again, are in the eyes of the beholders.

  28. Roger Waters says:

    And, as for “ideas that will improve the ACA,” well, since we had to pass the law to know what was in it, and now that we know what is in it, it seems the most responsible idea that will improve the ACA is full repeal. It has been done before, and it can be done again.

    • Big Al says:

      It looks like we’re the only two left standing, so I’d love to continue the discussion. I normally deal on the theoretical level supplemented with the most reasonable information I can find, so forgive my idealism. I see that you have ‘closer’ experience with DC than most of us, and insomuch, may have personal reason for some of your less respectful comments about the system and President. I can’t debate that.

      I always chuckle when someone uses the Pelosi comment to discredit the ACA. I hope that you are aware she was referring to the fact that the Senate, at the time, had not passed their version of a HC bill yet, so it would be reasonable to see a bill passed first before the two bills could be reconciled and finally ‘see what was in the [final] bill’. The comment taken out of context is disrespectful.

      I’m afraid, at this juncture, full repeal is neither possible nor reasonable. Too many facets of the law are beneficial to the country and the party makeup of DC would have to change dramatically. I don’t think things are moving in that direction. Mandatory participation, exchange pools, provider’s receiving payment on all of their cases, more preventative care for most Americans … is all things that make sense to me. Are these things bad? A totally free market poses difficulties. That is why we are at this point.

      Love you in ‘The Wall’;)

  29. Greg Scandlen says:

    Hey, Big Al,

    Since this is supposed to be a blog about health care, I will confine my comment to that topic. You ask —
    “Stella, let’s simplify this for you:
    1) Per statute, does the ACA prohibit you from keeping your existing insurance plan? Answer=No.

    Actually the answer is clearly YES. If someone has an individual insurance plan that does not currently cover, say, maternity or Rx they will not be allowed to keep their health plan no matter how much they like it. Ditto if someone does not want 100% coverage for preventive care. These are statutory, not regulatory requirements. Add in the regulatory requirements and almost nothing on the market today will qualify.

    • Big Al says:

      Greg, which section of the ACA directly states that you cannot keep your existing policy? None.

      Insurance companies change policy coverage regularly, to add new procedures coverage, to remove covered procedures, to accommodate new regulations, or simply to increase profits. Now, if insurance companies change their policies … for whatever reason … in an abstract sense, you could say that you would not be able to keep your exact same coverage.

      So, unless one is suggesting that Obama meant that no one’s policies would ever change, for any reason, for ever … one would reasonably assume that he meant that the ACA doesn’t legislate you to change your policy; therefore his statement is not untrue and especially not a lie.

      Keep perceptions reasonable.

      • Al says:

        If you like your car Big Al, you can keep it says the gunman carrying an AR-15 as he turns the ignition on. I’ll accept what you say Big Al. But, I didn’t think you wanted to say that the President is nothing more than a car thief.

        • Big Al says:

          Since I’m a telephone technician, and we are discussing whether Obama lied or not, let me rephrase the example. I believe a more accurate analogy would be that if you own an old rotary telephone, and Barry says that if you want it, you can keep it … and it will work; however, the phone company tells you they will no longer support that technology without additional charges. Barry did not lie. Your situation has changed with your provider and you have to come into the 21st century and learn how to use a touch tone phone (DTMF) … or stay with your rotary and live with the situation.

          Now, let’s focus on whether Obama lied or not lil Al, not stray further into ideologies.

          • Al says:

            Big, Bigger and Biggest Al,

            I know this is a challenge for you, but why don’t you tighten up your rhetoric.

            If Barry sold me on his phone company inducing me to change companies while telling me I could continue to use my old rotary phone he would be a liar if after I paid for my service I found out I had to buy a new phone.