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Federalism is your friend

Federalism is your friend

Democrats have controlled the California Legislature for 54 of the past 60 years. Since 2011, that legislature has been paired with a Democratic Governor, solidifying one-party rule. One out of every five Democrats in Congress is from California. Both of the state’s Senators and all of its statewide officials are Democrats. Trump barely polled 30% there.

With that degree of Democratic dominance, consider this puzzle: Why doesn’t California have single-payer healthcare? Single-payer is, after all, the shining dream of American progressives.

Why aren’t blue states doing more on their own to promote the Democratic agenda? It’s a question we should all be asking ourselves, not because single payer or any other Democratic policy goal is such a nifty idea, but because the federal government is so deeply broken.

Trump’s win is a crippling blow to an already badly weakened federal power. Regardless of the fate of Trump’s policy agenda, his election promises a power shift away from Washington. Congress has been one of our most broadly loathed institutions for a decade. Thanks to Trump, the Presidency may never again carry the imprimatur of prestige it accumulated in the decades since Roosevelt. Left, right or center, everyone should be looking more closely at the states for policy direction.

States have done this sort of thing before. Obamacare got its start in Massachusetts. California and Vermont were both actively pursuing single payer reforms before the Affordable Care Act was implemented. Why doesn’t California already have single payer health care?

There are some factors that make it harder to create complex policy solutions at the state level. Particularly in health care, existing federal programs and regulations create a baffling thicket of limitations, bureaucratic choke-points, and outright prohibitions. When California began exploring single payer a decade ago these constraints shut down their efforts.

How would a state level single payer plan deal with Medicare and Medicaid? A state cannot merely universalize those existing programs, but rebuilding them from scratch would be daunting. Trying to work alongside those programs promises endless conflicts, along with duplication of work and, most importantly from a political perspective, duplication of taxation.

Risk tolerance is lower at the state level, thanks to limitations on borrowing power. California, like 48 other states, is barred from running budget deficits. Though states can still sell bonds to fund certain activities, their debt is not denominated in a currency they control. If the eggheads with calculators make a costly error in shaping their state’s single payer health care experiment, they could create severe fiscal pain. By contrast, federal authorities could easily borrow to cover a shortfall while they work out the glitches in a complicated program.

On the subject of those eggheads, the federal government also benefits from a deep talent pool and a long tradition of professionalism. With few exceptions (Minnesota and Massachusetts stand out), state bureaucracies have less independence from political influence and a much more limited well of talent. Scale plays a part in this deficit. A federal agency recruiting from a pool of 350 million people carries some natural advantages over a state-level agency. Beyond scale considerations, history plays a role as well. Many states simply never enacted the strict civil service reforms that have refined the federal bureaucracy for more than a century.

One could argue that these obstacles are all fed and maintained by a single factor. Democrats long ago embraced a governing philosophy that downplayed state power. Blue states almost universally look to the federal government for leadership on key issues. This was not always the case.

States enacted the first laws on child labor, workplace safety, and minimum wages. Entire realms of critical government activity rose in an era of weak federal government. In an era when southern plantation owners blocked the federal government from investing in public infrastructure, states financed the Erie Canal. States were responsible for almost all the infrastructure development that launched the industrial revolution in the US.

Public schools developed to their modern form before Washington took an interest in the subject. Teaching, medicine, law, and legal professions were all crafted into their modern forms at the state level. Before the second Roosevelt Administration, states were the leading source of smart legislation on almost all matters of major importance. Having pressed for generations to strengthen federal power, Democrats now find themselves pinned beneath that crippled leviathan.

Is it better for the federal government to take the lead on matters of major policy impact? In the abstract, perhaps the answer is yes. In practical terms the answer is irrelevant. Whatever the inherent limitations of state level policymaking, that is our only alternative for the foreseeable future.

Though the obstacles are easy to see, advantages that states enjoy in crafting complex legislation are subtle, but decisive. Most important is a state’s superior potential for achieving political consensus.

Basically, it is easier to sell a complex idea to a few people than to a lot of people. The smaller your electoral pool, the easier it is to pass legislation. State politics also benefits from a narrower issue template and greater public trust. That’s how Massachusetts and New Jersey ended up with Republican Governors. Voters are not evaluating those figures on the same, much larger template of issues that influences their votes for Senate or President. A leadership figure who will travel no farther than your state capital is assumed to be more accountable than someone voters will send to Washington. It is often possible to build cross-partisan consensus on state level issues that would be impossible in Washington.

When it comes to cost and scale, California enjoys a particular advantage. California is big and rich, with a deep well of highly-educated talent that would be the envy of many of the world’s largest countries.

Cost is not holding California back from adopting single payer, at least not exactly. California is the country’s wealthiest and most populous state. It has a GDP roughly on par with France and the UK. Single payer may be expensive, at least by some definitions, but the cost doesn’t get easier to bear by adding Alabama and West Virginia to the program.

What makes the cost difficult to manage is the need to integrate with existing federal infrastructure. More to the point, California is already coughing up an enormous chunk of its potential tax base to the federal government. A disproportionate share of that money gets siphoned away to poorer (mostly red) states. In a strange irony, blue states will benefit far more than their red peers from a massive upper class federal tax cut.

That forms an introduction to the strange and counter-intuitive silver lining for the left in the victory of Donald Trump. Republicans will now get their chance to devastate the federal government. They will slash taxes and reduce Washington’s influence in every aspect of American life outside of women’s health and sexuality, which they plan to regulate like a Soviet state-run industry.

Collapsing federal power presents states like California with an opportunity. California has not enacted single payer health care for one over-arching reason – their decision to cede leadership to the federal government.  A collapse of federal power may reinvigorate state efforts to craft and refine smart public policy. In same way Massachusetts inspired the ACA, a new wave of state innovations may spawn an era of policy innovation that could break us out of decades of quagmire. In chaos, there is opportunity. If Democrats ever again want to lead in Washington, let them prove that they can lead in California.


  1. I just posted a comment in Off Topic – ACA – It’s Complicated which bears on this subject. Washington State attempted comprehensive individual health care reform in 1993. The Republicans subsequently repealed the reform. A debacle ensued. The Seattle Times published an article this morning covering the experience. Taxation and the mandates were the big issues.

  2. I couldn’t directly watch today’s “press conference”, but all my various sources confirmed that it was exactly the type of embarrassing clown shown you’d expect. CNN reporter Jim Acosta was threatened with the ban hammer. But given that this ignorant fool isn’t going to give any real answers to hard questions, I have to ask the press “what have you got to lose?” if you do your actual jobs and hammer him with hard questions? If you are there you get no real answers, which is exactly what you’d get if you were banned, or he stopped holding press conferences. Given that he’s a DDoS attack on truth, does access to him really matter as much anymore? I’m truly curious here.

    1. I wish the media would stop covering his tweets. Just.stop. If he says something that is substantive (which rarely happens if ever), report it out. The rest of the stuff – ignore it. The one thing that really stokes Trump is public attention. Well, let’s give him what he deserves not what he wants.

      One thing is certain. In making enemies of the intelligence operation AND the media, he has done himself no favors. He may think this is macho or cute, but these are not the folks you want to piss off. No one is going to want to cut him slack because he has been such an ass.

      Frankly, Trump is merely a distraction from the really serious stuff that we have to pay attention to – what the Republicans are doing. I watched 5′ of Trump’s press conference where he took, btw, only 35 minutes of q & a…the rest of the time was the paid lawyer reading a statement about how he would deal with the trust issue. (He will not set up a blind trust, he will have his sons run his businesses but he has not removed his ownership.) The little I saw was more of the usual “I, Me, My”. The man is so obnoxious I cannot watch him. Trump actually responded to a question that “that is crap”! How very presidential. Contrast this demeanor with that of outgoing POTUS Obama last night. What a contrast….

      Here’s an idea that is floating around the internet which I plan to promote and follow: DON”T watch the inauguration. Instead, tune into another channel and leave the tv on during the entire inauguration event. Not only will this give Trump low ratings but it will boost other channel ratings.

      Creative, no? Fight fire with fire, but fight we must!

    2. Here is an urgent request from a rabbi asking all who can to call their senators on the following:

      “In just a few hours, the Senate will begin hearings on a resolution condemning United Nations Security Council Resolution 2334 – the vote three weeks ago that reaffirmed long-standing international law that Israeli settlements are illegal.
      Please pick up your phone now and call your Senators asking them to vote NO on Senate Resolution 6.”

      1. Here’s a tip if you try to call and the senator’s mailbox is full. Pull up their website, find a major city local office within the state they represent, and call it. You can make the same request/comment to staff, asking them to forward it immediately due to vote proximity. Worked for me with Cornyn’s office in Houston.

        This same strategy can be utilized for other calls we will need to make. Don’t waste your valuable time re-dialing. Get in touch with a local office instead.

  3. The NYT offers seven critical questions that should be asked regarding repeal and replacement of the ACA. Let me be clear: if health care can be improved, it should be, but the goal should be far more than simple cost containment, as important as that is. It should expand coverage and quality along with structural improvements to include streamlined reporting requirements and elimination of onerous, unnecessary regulations. But if the primary goal is only cost control, health care will be worse.

    I find it amusing that the Republicans who were so critical of Democrats for passing the ACA “without their input” (…which was their choice), are now going to use reconciliation to pass their version. Hypocrisy abounds.

    1. Here is a reasonable approach to replacing the ACA. I am not stating that I agree with every component Alexander recommends, but the approach is at least thoughtful and the goal to minimize disruption to the fullest extent possible. The GOP replacement of subsidies with tax credits are not going to be of benefit to most low income people, and removal of mandates in favor of voluntary participation is going to present interesting funding challenges. Of course, there is no assurance that this process will be adopted, nor what the final plan will look like – assuming there is a final plan.

      1. Their “plan” is not a plan. It promises to implement a couple of irrelevant Republican fetishes like bigger health savings accounts, and to not completely blow up Obamacare until there is a replacement, but there’s not even a suggestion of an alternative to the “three-legged-stool” (mandates+consistent pricing+subsidies) that makes the current system possible. Nor can there be, because the alternatives – Medicaid+employer mandates (=Hillarycare), and greatly expanded subsidies – are more leftist than what we have now, as well as considerably more expensive for the Federal government.

  4. California is pretty liberal, but it’s still generally allergic to taxes. It’s not going to get anything like single-payer. In addition, Covered California has been pretty successful and relatively popular. Most likely, if Obamacare is repealed (which is looking less certain as the Republicans start looking at the disaster any repeal will cause), California will just maintain Covered California and its Medicaid expansion.

    The Democrats have already gotten a good reputation for running things well. Things have really improved since they finally got effective control of the government in 2010. Prior to that, our perpetual budget crises were a painful example of how bad supermajority rules are in periods of divisive parties.

    1. ***California is pretty liberal, but it’s still generally allergic to taxes.***

      This is where I need to raise my hand and interrupt you. Perhaps that’s true, however where is it LESS true? This gets to the heart of my point. If I have a policy idea that is too far left and too expensive for California’s electorate, then perhaps I have a policy idea that should be thrown in the garbage.

      If the left has any ambitions about actually implementing some policy ideas someday, I would suggest that present-day California is their perfect proving ground for those policies.

      1. To the CA proving ground comment I offer: compared to what? If the changes to health care are as extreme as described, this might be the perfect time to try an alternative – even if it results in a new tax. CA has been pretty accepting of taxes which have been thoroughly explained and justified. An enlightened constituency is key. If millions of Californians are suddenly left without medical care that they have come to expect, and the GOP begins to brutishly bear down on Democratic power structures on other issues (sanctuary cities, environmental regulations, etc), the time could be ripe to launch a whole new concept. If not CA, where?

      2. Allow me to turn your statement around, Chris. “If I have a policy idea that is too far (right) left and too expensive for (America’s) California’s electorate, then perhaps I have a policy idea that should be thrown in the garbage.

      3. I agree present-day California is one of the top states for implementing liberal policies (I’d say Massachusetts and Vermont are ahead, but CA is way up there). And, actually, we are leading in a lot of areas – minimum wage increases, decarbonization, de-auto-centrism, worker rights, plastic restriction, etc. I saw a list of new initiatives (legislative and propositions) approved in California in the past year and it’s pages long and mostly liberal. At the same time it’s not crazy and in spite of having an almost one-party state traditional political compromises and negotiation between different interests are still going on.

        It’s just that, specifically, on health insurance, California has no compulsion to lead the nation and several things holding it back. First, Obamacare has worked really well here, largely because with the size of the state and some pushing by the state government we’ve ended up with a genuinely competitive insurance marketplace. Costs are under control, and uninsurance is down by 2/3 (better than the nation as a whole and any other state that was doing reasonably well before.) A single-payerish system would probably be better, but it requires jettisoning a system that works *and* having the biggest tax increases ever. You need a big crisis to drive that kind of thing, and we don’t have it; we have the opposite (health care wise). If the Republicans blow up Obamacare the overwhelming desire will be to basically bring it back or keep it going. And finally, we really are allergic to taxes; it’s really hard to get a tax increase through; partly due to constitutional requirements and partly due to attitude (they’ll just waste it, etc.) My city had to try three or four times to get through a bond increase the schools desperately needed, and to get it through it’s just swamped with citizen oversight boards and spending restrictions.

        We *do* have a crisis worthy of attention, and it’s housing. Prices are beyond nuts and homeless encampments are springing up everywhere because even at $15/hour you can’t afford a 1 bedroom here ($1600 a month according to a 2 year old article I found). The politics are painful, of course, because so many voters own the overpriced houses and want prices even higher.

  5. An as of yet unverified report says the Russians have blackmail material over Trump in the form of perverted sex acts involving something called “golden showers”.

    Torn though I am between my insatiable curiosity and my overwhelming concern for my own mental well-being, I simply cannot bring myself to google “golden showers” in the context of it having ANYTHING to do with Trump. It’ll mentally scar me for life, I just know it.

    I. Just. Can’t. Do. It.

    1. EJ

      It’s a harmless act in and of itself, when practised between loving adults. Unfortunately for those people, it will now forever be associated with a very sleazy person.

      I remember when “Santorum” became a popular slang word for what had once been an intimate act between loving couples; all my friends who were into said act got extremely annoyed that it had been associated with him.

      (Don’t Google Santorum. Trust me on this.)

    2. Let’s just say that given Trump’s contemptuous treatment of women, and the fact that he is an extreme bully who has to constantly show his dominance, I would not be shocked if it were true. But that’s literally at the bottom of the list in terms of what’s the most disturbing allegation.

      I had to laugh when I saw the fake news tweet.

      1. I don’t care much if he performs mildly kinky sex acts with prostitutes, but Elliot Spitzer was forced to resign for less. OTOH, the fact that he’s owned by the Russian mob, as shown by the vast tangle of businesses funneling money to him, horrifies me, and yet the public doesn’t seem to care. Go figure.

  6. Speaking of which:

    met with a local branch of Physicians for a National Health Program:

    Have specific action items for my locality which may not necessarily be relevant to any of you, BUT,

    recent events have put them from a small advocacy group into a surge of interest building variously (esp. in blue states). Might be a good time for people here to reach out and ask your own local chapters,

    “What’s the next step?”

    Tipping point, it may be. Probability curves bend for those who apply force.

    1. My brother and his wife are docs. I’ll forward to them and see if they’re familiar with it and what their opinion is. Kind of a medicare for all without all the paperwork and bureaucracy….I’ve read about this before …. someone has posted this from the CA side. Not sure if docs would have same 10% income ability but they would have less intrusion and paperwork.

  7. Wife is an ER doctor, I’m an ER nurse. We moved to NZ 3.5 years ago. Enjoying the nationalized system here. It isn’t perfect, but it sure as hell isn’t the US model. Patient Satisfaction (Press Gainey) drove us out, essentially, although the need for an adventure and something different was our primary motivation.

    “but I think doctors and hospitals should be adequately compensated for their services” I can tell you right now, doctors make a good deal of money, but for crap hours and for dealing with a lot of political bullshit. As well as the ridiculous cost of medical school. That said, the truly undercompensated are the nurses, NA’s, HCA’s, HUC’s, and ancillary staff involved in patient care. The problem is, to give everyone a pay hike, realllllly eats into those non-profit profits lol. Nurses went without raises for two years at one of my former employers, while the CEO made 300+K, with around 200k of bonuses. Healthcare is so big, so overutilized, that in order to keep it solvent and give everyone a fair shake would be impossible. Someone is going to get shafted, no matter what.

  8. Sessions opened up the marijuana genie today – this is not a good thing, but one thing the Democrats should do is not let them turn it into a R vs. D issue – this needs to be a internecine R vs. R and disastrous R vs. People issue.
    Republicans will try to make this a “stoners in basements” story. In response Democrats should shout about kids needing medicine and states’ rights, making those the key issue, not recreational weed in particular. This will drive the Republicans nuts because:
    1. It is stealing their state’s rights “issue” and they will have to engage in some very unconvincing pretzel logic to defend taking medicine away from very visible desperate kids and parents
    2. Their constituents will be calling them directly and they won’t be able to play the “bad liberal” card
    3. It is very likely that a schism will appear in the Republican party between the congress and the Trump-Putin regime that will help the Democrats build a “broken tyranny” message that should be center stage for the next four years
    If Sessions isn’t as stupid as he seems he will try to create a split between genuine medical marijuana and recreational use. This might be effective, especially if he can impose stronger restrictions on getting a prescription (e.g. “I can’t sleep doc” won’t work any longer). Regardless it will require federal prosecutors to be very active within unwilling states, so while the “desperate kids” images might not be viable, the “Federal Government overreach” message will still be effective.

    1. The irony here is the NYT just had a great story about the medical benefits of Marijuana for kids who have seizures that are uncontrolled by any other medication, and Parkinson’s patients, and of course the palliative benefit for pain control for terminally ill and seriously injured people. Try telling parents of kids whose seizures are controlled for the first time in their lives that marijuana is a bad thing……….

      My friend in CO asserts that one of the reasons the Repubs and Dems seem to get along there is due to the legalization of pot. She may be right….Maybe we should slip some drops in the tea of our members of Congress (-;

    1. Super article, future. There are some very good links within the article about work being done by political scientists that log what is happening at the state level.

      That is why we need to pay attention to local and state politics. Democrats haven’t been attentive enough and now many of our states are mimicking our national political scene in terms of party and policies. It is where we need to invest time and energy.

  9. Years ago a boss who previously had worked for Detroit Edison power company told me this story. The company worked hard to keep the car companies energy reliable and economical. You see unlike the majority of us they were big enough to build and operate their own power plants. Not their business but enough nuisance and they could and would.

    States like California are as big as countries as you pointed out. Could be self sufficient if necessary. It would be poetic justice if state rights ended up giving blue America a way to test it’s ideas and bypass the choke hold the old Confederacy has on the Federal Government. Until the rural white vote either gets hurt enough or dies off you most likely are right that blue states are our best hope. Cannot wait for Central and South Florida to get urban enough to out vote rural north Florida along with other rural areas.

  10. This reminds me of a rant that Steve Dutch, retired professor of geology wrote. Steve Dutch is conservative who believes in global warming and he voted for Clinton. His theory is that people are opposed to liberals because there is a lot of stupid petty regulation (like fees for peeling paint) that everyone sees. No one knows anything about global warming but everyone sees low-level stupidity so they assume the high-level stuff is stupid too.

  11. Given that “states rights” have been used so much for evil, I like the thought of now using them for good- come full circle, return balance to the Force, write in the metaphor of your choice. That brings up another question. We have had a series of gentleman’s agreements in Presidential politics, such as you release your tax returns. Obviously boss tweet crapped all over that one and more, and sadly got away with it. If and when rational adults get some power back in the Federal government, it’s time to make that a law (and probably some also make some legislation fleshing out the emoluments clause). But in the meantime, can the states act? Do they have the right/power to pass laws saying your name doesn’t go on our ballots unless you disclose your last 5 tax returns?

    1. “Do [states} have the right/power to pass laws saying your name doesn’t go on our ballots unless you disclose your last 5 tax returns?”

      No. The Constitution lays out the qualifications for President (age 35, natural born citizen, 14 yrs resident). Can’t be changed without a Constitutional amendment.

      1. Yes but state ballot restrictions exist, and SCOTUS hasn’t struck them down. For example Jill Steinand Evan McMullin weren’t on the ballots of all the states. States can demand a certain number of voter signatures for 3rd party candidates. Is demanding financial disclosure really too much of a reach, especially if it applied to ALL the candidates?

  12. Chris, would the Republican plan to block grant medicaid to the states (ostensibly) to allow them to “better” control services/costs offer the flexibility that is presently missing under the contemporary (temporary) arrangement?

    As for medicare – Ryan wants to make the cut off age 55 for current traditional medicare eligibility. He’s getting some push back from his colleagues and so far Trump is silent on this. How/whether he will continue to allow changes to these programs given his campaign promises (social security is next, folks) remains to be seen, but it looks likely that medicaid is cooked. (poor constituency not as threatening to incumbents)

    So, with medicaid block-granted to states, medicare essentially the same via voucherization, would this unleash the ability of CA to “do its own thing”? Do you really believe the Republicans won’t squash CA into the ground if they perceive it threatens their choke-hold on procedures?

    1. It would. That isn’t, of course, the intention. The intention is to eliminate “waste” which in most southern states basically means eliminating medicare and medicaid. But it would allow states like CA, NY and IL to recover control over a lot of the money they currently send to Washington. It would be much easier then for them to implement something like single payer, if they decided to.

      1. “eliminate waste, aka, medicaid and medicare” (-; You nailed it. I am waiting to see someone do the analysis on how states will meet demand in these areas absent sufficient funding support from the feds. Sooner or later, (sooner) cities, counties and states are going to figure out that this is the GOP ponzi scheme…cut federally funded benefits and, lo and behold, either people will go without care, die, or states and counties will have to pony up the difference. The hospitals are going to get hit big time. Of course, given all the major changes proposed, the next shoe to drop is repeal of EMTALA (mandatory requirement to serve indigents seeking medical care in hospitals).

        The other problem will be physicians bailing from serving the medicaid/medicare population due to lower reimbursements. The cascading affect is going to be enormous.

        The bottom line is that more people are going to die due to lack of medical care, not because of their underlying health problem.

        The only hope is for the huge number of people currently enrolled in these programs to speak out. This Kaiser interactive map offers an excellent overview of just what these numbers are and where they are. Constituency matters, IF they speak out. This is so bad, Chris. All of the other dictatorial changes pale in comparison to how the sick, disabled, poor and elderly are going to be impacted.

        Mario Gabelli was on CNBC and speaking up for the changes he sees coming. Or, as he stated, going from socialism to profitability………It’s all in “who” benefits, isn’t it? The others are “hidden figures” who merely take up space.

      2. “Mario Gabelli was on CNBC and speaking up for the changes he sees coming. Or, as he stated, going from socialism to profitability…”

        The idea of profitability being a consideration of whether someone gets health care or doesn’t is obscene.

      3. Apparently, a study has been done by U of Berkeley and George Washington U. and the Commonwealth Foundation on the economic impact on repeal of ACA and replacing it with the most comprehensive plan submitted so far, House Bill #3762, vetoed by President Obama. The study results are linked in the article.

        “Last week, a report from researchers at George Washington University and the Commonwealth Fund essentially repeated the Berkeley experiment for all 50 states. They came to the same conclusion: that repealing the ACA’s health-insurance subsidies and Medicaid expansion in an H.R. 3762-like plan would result nationwide in a loss of around 3 million jobs, $1.5 trillion in gross state products, and $2.6 trillion in total business activity between 2019 and 2023. Because hospitals often absorb the costs of patients who can’t pay, a plan stripping coverage from low-income people would also increase uncompensated-care costs by over $1 trillion for the decade after 2019.”

      4. I agree “profitability” sounds bad, but I think doctors and hospitals should be adequately compensated for their services. I don’t think the medical profession should become a thankless, under-appreciated job, destined for people who do it only for the love of it and then leave when they burn out because of the hard work and low pay (like teachers).

      5. It’s not just about the patient, the receiver of health care. The needs of the provider of health care should also be taken into account, for health care to function properly. It’s a two-way street.

      6. Tutta, of course the whole matrix should be fairly treated. The worst that can happen to an institution is that it can go out of business. The worst that can happen to a person is that they can die. Kind of helps keep the whole fairness thing in perspective. Doctors have the AMA, pharmaceutical companies have their lobby as do hospitals etc. Who lobbies for you and me?

      7. “I agree “profitability” sounds bad, but I think doctors and hospitals should be adequately compensated for their services.”

        Some hospitals are non-profits, and the people who work there aren’t doing it for free. Likewise there are plenty of charitable organizations that pay people to run them. It may be that we need to scrap the idea of for profit medicine, and consider health care a social good, like police and fire protection, the military, and public education, that will need public support. Probably private, i.e., charitable support too.

      8. Bingo! It’s called: universal health care. I am becoming more and more an advocate of socialized medicine or some iteration thereof. Just like when private entitites got into the war game and prisons, profitability results in a different goal, and it is not a human being.

      9. Pressure’s mounting for a quick replace to the repeal set to go this Friday….from Trump and from many in the medical field. Some basic issues need to be resolved and these will take time…(evidently sixteen years isn’t enough time, right!)

        “the four major elements that we have to resolve, we won’t have time to resolve,” Cassidy said. “Those being: What can Tom Price do? How do we pay for it? What is the blueprint or the pathway forward for repeal? We may need something that needs a 60-vote threshold.”

        The danger is if they “rush it” (recall – 16 years of zero action on the subject), they could end up with a situation that would make the horrible roll out of the ACA look tame….Oooh, delicious…except that I don’t want sick people to pay the price.

      10. Tutta, financial support is necessary to maintain a health care system, but profitability, or at least not profitability by itself, is not the only possibility. If profitability is standing between the health care system and people who need care, we need a different financial support approach, otherwise health care is not meeting peoples’ needs.

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