I firmly believe that "single payer" would get a lot more support if people stopped talking about it in grandiose themes and noble vignettes and started talking about it in real terms. All the liberals I know are in heavy favor of "single payer" without any of them knowing what the fuck it is.
HERE'S WHAT THE FUCK IT IS.
I've got a medical facility - Al's Medicine. Al's subcontracts to Betty the Biller and Cindy the Client Specialist. I operate in a state where my medical facility is covered by Medicaid. We also take private (employer-provided) insurance, which is underwritten by the following insurance firms: Q, R, S, T, U, V, W, X, Y and Z.
Al's must sign individual contracts with Q, R, S, T, U, V and W. These contracts are "take it or leave it" binding: they say that for ICD code 1, Q will pay Al's $7.50 but for ICD code 1.000000001, Q will pay Al's $0.00 because fuck you, Al's. Note that Q might pay Joe's $6.50 or $9.50 or pi.ie^2 for ICD code 1. Q is entirely within its rights to do so. Al and Joe, on the other hand, are contractually forbidden from discussing their rates for ICD Code 1. If Q gets wind that Al and Joe know what the other are getting, they can drop both because fuck you, Al and Joe. Also know that Joe might not get anything for ICD Code 1 because Q has decided that all of Q's contracted healthcare clients can drive 75 miles to Al's for those services because fuck you, Joe. Also know that Q can tell Al's they'll pay $7.50 for "services" verbally and in writing, but when the actual contract comes through the actual number listed is $2.25 because fuck you, Al's. Also know that they won't tell you what ICD codes they'll pay for, they'll just say "services" and let you resubmit your bills over and over and over again until you find the ICD code that pays out the most because fuck you. Also know that the ICD code they choose to pay for can and will also change because fuck you.
A few other notes: Al's might have to provide, for example, rhogam shots to prevent babies from dying from blood type incompatibiliy. These rhogam shots might cost Al's $28 but Q is going to pay $7 because fuck you, Al's. If you ever wondered why hospitals charge you $40 to hold your baby it's because they're trying to claw back the $21 the insurance company isn't paying for medicine they're required by law to administer (for example). Also note that your involvement, gentle consumer, starts when you get an "explanation of benefits" from the insurance company listing all the outrageous charges the doctor hit you with. It will provide no explanation. It will show how generous they were in all their disbursements and then show you that your doctor's office is going to bill you STILL MORE MONEY because they're such bloodsuckers.
This is where Betty Biller and Cindy Client Specialist come in. Betty makes 10% by pickaxing all the money she can get out of Q. Betty's whole job is knowing what Q pays out on. Betty knows which ICD codes Q pays out what on, and can turn your "normal child checkup" into 42 different codes that pay the maximum rate Q has contracted to pay. She is literally a medical billing bounty hunter. Betty is the back office side while Cindy talks to you, the client - here's what's coming, here's what it means, here's how to get your insurance to pay for this ahead of time, here's how to get preapproval for that.
For those keeping track at home, billing specialists outnumber doctors 2:1 in this scenario.
Multiply times insurance companies R, S, T, U, V and W, who all have their own rates, all have their own codes, all have their own geographic exclusion areas, and probably have seven or eight sub-plans so that it's not actually "V" it's V.a, V.b, V.c, V.d, V.e, V.f and so on. Suddenly, Betty and Cindy look positively useful and you will pay them gladly because the act of billing for care takes three to four times as many man-hours as actually providing that care. Betty and Cindy make good livings and their existence is entirely parasitic on the insurance companie's deliberately opaque, byzantine and antagonistic reimbursement practices.
Not Y and Z, though. Y and Z contract through Medicaid. Medicaid has no patience for that bullshit. They will pay the following amounts on the following ICD codes. Anybody who contracts through Medicaid bills those codes and gets that money. It is known. Y knows, Z knows, Al knows, Joe knows, and all of Al and Joe's clients can fuckin' look it up. And when Medicaid's reimbursements lag behind the real world, it gets turned into a bill that goes to the legislature that raises the rates for everyone.
Al's, in fact, might get better reimbursements out of Y and Z (because of medicaid) than they get out of Q, R S, T, U or V.
Unfortunately you as a patient don't get your insurance through Y and Z because you make more than the poverty level for your county. You get whatever insurance your job provides, which might be V.c, might be Q, might be nothing because you drive for Uber and fuck you.
As a provider, we get to choose who we contract with. We do not get to choose what those providers pay us. And if 50% of your clients work for Microsoft, you bloody well better be able to take V.c, despite the fact that they reimburse at exactly half what Medicaid reimburses at (which is funny, because all your Microsoft mommies make six figures). R, on the other hand, may decide that they'll never cover you because they have enough of your specialty in network, never mind that the nearest provider is a ferry ride away (because this way they don't have to pay for those services).
As an insurer, you get to decide who you contract with. You can pick the providers that are the stupidest, that will accept the lowest rates, that have the lowest conflict rate of you arguing over charges. And you get to discuss this with the HR reps of companies large and small, none of which have any background in medicine, medical billing, accounting or statistics. To no one's surprise, they choose on price.
But the poor people? They pay what the state says they pay, the insurance companies collect what the state says they collect, and they contract with the providers the state says they contract with.
THEY STILL MAKE MONEY.
They're still private insurance companies, privately managing your health care, privately paying out private doctors. It is not "socialized medicine." It is not "universal healthcare." It is not the National Health Service. The healthcare industry is something like a tenth of the US economy; you're never getting that. But you go single payer and all of a sudden things go from back-room knife fights between Q, R, Betty and Cindy to state-mandated pricing and state-mandated coverage.
My future is tied to health care. I've got more in a medical practice than you have in your house.
And I'm a big booster of single payer.
And so's Aetna, who in this example is R.
I know. And that's why I refuse to humor you.
The difference between being glum about a physiological limitation or not being glum about a physiological limitation is glumness. Worse, the worse your attitude the worse your hormonal and chemical balance. The more you act like a little bitch, the longer you will be a little bitch, the harder it will be to not be a little bitch... physiologically.
Toughen the fuck up. Not because I think less of you but because your strongest ally in this is yourself and you sell yourself short at the drop of a hat.
I had an epiphany maybe three, maybe for years ago. I was running, as always. Up the dune, as always. A mile into my 3-4 mile run, as always, same as it ever was, as I have been doing since 1988.
This dude smoked me. Trotted right on by like I was standing still. Made me feel like shit. Then I thought about it and realized that I was old enough to be his dad. I'd been running longer than he'd been alive.
I was faster when I was younger. But I'm still going. I'm doing pretty goddamn well, thankyouverymuch, and all the shit that holds me back isn't bad enough to hold me back much. I'm healthier than my parents were at my age; I'm healthier than my grandparents were at my age, I'm healthier than my friends at my age.
I'll take it. In the end, we're only competing with ourselves, and we only get to win until we lose. I'll take every win I can get.
It struck me as wanting to be salty, and wanting to yell at someone else about the problems.
both the Democrats and the Republicans have been lying to the poor for decades, but the Democrats kinda sorta feel bad about it. it's that ambivalence that has left them crushed and despondent.
IT'S FUCKING STUPID. There are so many more poor people in the United States than rich people, so if they want power fuckin' rally behind the fuckn' poor people. I'm almost willing to give them a bye over the fact that it used to be hard to scare up individual donors and if you're looking for whales you're looking for the rich by definition but fuckin' Bernie Sanders.
The Democrats should have been just as gobsmacked by Bernie Sanders as the Republicans were by Trump but instead of going "oh shit we have lost our base" they went "it's Hillary's turn damn the torpedoes full speed ahead" and here we were, living in fear of Twitter.
This is insightful. I've experienced it. I have not put my finger on it before but you have the most of it.
I work with a couple die hard conservatives. They are lonely people in Hollywood; there's a contingent to be sure and they're insular as fuck but the overwhelming majority of Hollywood liberals are in fact liberals.
One of the things I've noticed in discussions with them (careful, respectful, well-bounded discussions) is that the conversation is not built around ideas. It's built around factoids. It's built around totems. It's built around memes.
These ideas are not, in and of themselves, coherent components of a greater philosophy. They are not arguments. They are touchstones. They are bookmarks in an internet search of alienation, secret handshakes of cultural identity.
A funny thing happened when Trump won: they got cranky. Keep in mind: I know people who worked with Trump. a lot. Had I gotten here a few years earlier I totally would have been crew on The Apprentice. He's a known quantity around here and yeah - it's a right-wing conservative orgazmotron. But at the same time, with Republicans owning the house, the senate, the executive and the judicial, the world should be perfect, right? But they knew - they knew - it'd be a long way from perfect. Theirs is a philosophy of opposition, particularly here in liberal Hollywood, and it wasn't so much that they were right, it's that everyone else was wrong.
HERE's MY THINKING
We don't drag him along, we live our lives and do the right thing. We don't assail his ideas hoping that eventually something sticks. It's an oppositional mentality and so long as he wants to oppose, it really doesn't matter what he's opposing. They're a tribe that want everyone else to lose. They don't really know what that looks like, but they want it really badly.
This is the way cognitive dissonance works: it starts by feeling uncomfortable so you ignore the sources that assail your worldview. Then it pushes you into an insular place because you're retreating from information. Then you lose sight of reality because you're working so hard to keep up your microcosm. Then one day it snaps - and it snaps hard. And now you're a disillusioned searcher.
Trump and the modern conservative universe is about the purest form of cognitive dissonance challenge you could ask for. He's not a conservative by any stretch. He's leading the party towards the reductio ad absurdum place the liberals always joked about - Trump literally defended Nazis. And they have nothing to build on, and their efforts to tear down are failing.
There's going to be a reckoning. There's going to be soul-searching. And we'll need to welcome them back.
but not yet, goddamn it