Month: June 2009

Middle Aged Sickos

by digby

It’s a good thing we don’t have rationing like all those horrible European countries or people wouldn’t be able to get health care when they need it:

Americans are struggling to pay for healthcare in the ongoing economic recession, with a quarter saying they have had trouble in the past 12 months, according to a survey released on Monday.

Baby boomers — the generation born between 1946 and 1964 — had the most trouble and were the most likely to put off medical treatments or services, said researchers at Center for Healthcare Improvement, part of the Healthcare business of Thomson Reuters.

[…]

They found 40 percent of all households planned to postpone care in the coming three months, with about 15 percent planning to put off routine doctor visits.

People born before 1946 were the least likely to delay care, probably because most can take part in Medicare, the federal health insurance plan for the elderly, the researchers found.

Baby Boomers were four times more likely than seniors to have trouble paying for healthcare, according to the report.

People born after 1984 were also unlikely to put off care, probably because they are too young to need much medical attention, the researchers said.

Income was also a big factor — homes where people made less than $50,000 a year were three times as likely to say they had trouble paying for medical bills as homes with combined incomes of $100,000 or more.

“It is important for healthcare providers, employers and policymakers to consider how the economy and healthcare policies affect demographic segments differently,” Pickens said in a statement.

This is not good. Check out the demographic segments (add 9 years to each one) and consider what the political implications are:

I suppose it’s possible to put off health care reform for 15 more years or so and hope that all us whining boomers will go into medicare and shut the hell up. But the problem is that medicare really is going to go broke if the whole system isn’t reformed. Nobody wants to see the baby boomer cohort retire and decide to devote itself to politics do they? I didn’t think so.

The country cannot ignore the fact that this huge group is getting older and sicker and unless it’s decided to kill us all, health care costs are going to be a dominant discussion for a long time to come. There are too many of us to ignore. It’s got to be now.

Nothing could be more irrational than to not have decent health care for people who are still working but getting older and needing more access to a doctor. It’s insane to have that population at risk. The costs to the economy in the long run are going to be much, much higher if people my age can’t maintain their health.

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Learn, Damn You, Learn!!!

by dday

Something fairly interesting happened today. It doesn’t mean we will get a public health insurance option to compete with the insurance industry, but it doesn’t exactly hurt. Apparently some Democrats thought that if they only watered down such a public option to nothing, they would get that vaunted bipartisan support, and everybody could go back to their districts and claim they did something when they in fact would have done nothing. But as those of us who have been observing this have known for some time, these aren’t your father’s Republicans, or your grandfather’s, or any other relative. They are the rump conservative party, openly hostile to using government for any means other than profit-taking, and preferring to tell their constituents “good luck” instead of making any tangible difference to their struggles. And somehow, Democrats just discovered this.

Some Senate Democrats have considered nixing the public option proposal in order to win Republican support for the bill.

Schumer’s role is important because he had been acting as an intermediary between liberal Democrats and moderates who are trying to strike a deal on the issue with Republicans on the Senate Finance Committee. Of the five House and Senate committees working on health care, Finance is the only one that appears to have a chance at reaching a bipartisan agreement.

Schumer said Finance Republicans had rejected several proposals designed to beef up the suggested nonprofit insurance co-ops. These included setting up a national structure for the co-ops, $10 billion in government seed money, power to negotiate payment rates to medical providers nationwide and creation of a presidentially appointed board of directors.

The Democrats tried to basically bury the public option as long as they could get any manner of support for the weak substitute. And the Republicans wouldn’t budge. Like in 1993, their mission is to kill health care reform, period. Why anyone would think that any alternative would be true is beyond me, but Senate Democrats obviously needed to play Tic-Tac-Toe with the computer endlessly until they realized what a strange game it all is, and that “the only winning move is not to play.” Ezra Klein comes to the same conclusion.

Republicans, (Schumer) suggests, are standing lockstep even against efforts to create a private co-op system that could offer an alternative to for-profit insurance. Their concern with the co-op plan is not that the government would be taking over the health-care system. It’s that the current insurance providers would face unexpectedly aggressive competition in the marketplace. Which raises an interesting, and potentially clarifying, question: Are Republicans in this to preserve the healthy functioning of a competitive private market or preserve the profits of the currently dominant insurance companies?

Further proof of that learning experience came today from Kent Conrad, the man who devised this health co-op plan by throwing a dart against a board, as he appeared to acknowledge its limitations.

The wheels looked to be coming off with health care reform last week. But a poll showing huge public support for a public health care option and a strong bill from the House of Representatives have changed the dynamic.

Schumer and other backers of a public option insist that any plan must be national in scope, have substantial funding at the beginning from the federal government, and include national purchasing power in order to negotiate lower prices.

Conrad ticked off the areas of agreement that were reached Monday.

“National structure: I believe to be effective there has to a national entity with state affiliates and those affiliates have to have the ability to regionalize. I think his concern there can be addressed,” said Conrad. “Second, he believes there needs to be national purchasing power. I think that’s a good point that the national entity would be able to do purchasing on behalf of the state and regional affiliates and on behalf of the national entity itself.”

Now, Schumer’s vision of a public plan is a compromise from the House vision of a public plan, which is a compromise from single-payer health insurance. But things are moving in a better direction today than yesterday, when DiFi flat-out said Democrats don’t have the votes to pass anything.

This teachable moment has a value for those outside the system who want to push for a real public option that can use bargaining power to force competition from insurers. Because now, as Matt Yglesias says, there’s no excuse for Democrats to water down their bills in order to “seek bipartisanship” and make them durable. Republicans have revealed themselves. And given budget reconciliation and the imminent fact of 60 votes in the US Senate, Democrats have nobody else to blame. They can talk about political realities but those have essentially been voted out of existence, with respect to Republicans. Whether it’s because of health industry campaign contributions or a desire to limit competition in small, rural states, a desire to get the glory for saving policy from the brink or just an ideological disinclination, individual Senate Democrats will have the collapse of any health care reform on their hands.

And yes, I mean Democratic senators. The Republicans, with a few possible exceptions, have decided to do all they can to make the Obama administration a failure. Their role in the health care debate is purely that of spoilers who keep shouting the old slogans — Government-run health care! Socialism! Europe! — hoping that someone still cares […]

The real risk is that health care reform will be undermined by “centrist” Democratic senators who either prevent the passage of a bill or insist on watering down key elements of reform. I use scare quotes around “centrist,” by the way, because if the center means the position held by most Americans, the self-proclaimed centrists are in fact way out in right field.

What the balking Democrats seem most determined to do is to kill the public option, either by eliminating it or by carrying out a bait-and-switch, replacing a true public option with something meaningless. For the record, neither regional health cooperatives nor state-level public plans, both of which have been proposed as alternatives, would have the financial stability and bargaining power needed to bring down health care costs.

It helps to have clarity on who is blocking what the public desires. The grassroots will redouble their efforts, doing to the rest of the wayward Democrats what Change Congress did to Ben Nelson. Blue America are lining up a similar pressure Campaign for Health Care Choice on Blanche Lincoln, and you can contribute to that cause at this link.

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Let Them Eat Fancy Feast

by digby

Think Progress caught a great exchange between GOP Representative and a couple of callers on the health care crisis. The first caller was a 60+ year old woman who worked in retail who was complaining that she couldn’t get health insurance because she has diabetes. Here’s Davis’ answer:

DAVIS: Well, Dorothy, let me, let me say a couple things. First of all, you know, I understand the dilemma you’re in. I don’t know if you’ll be able to retire at 62 or not. Frankly, I mean all of our 401Ks are down. I wish I could retire at 62. I think you’re going to find Americans working longer than they had originally anticipated, given the economic downturn and some of the economic realities.

If you can find a job with a major employer, they’re not going to be able to reject you under those cases. I don’t think you’ll find, probably be able to find some health insurance but if its with a small business or you’re going out on your own, it’s difficult at this point. There may be a government plan or private plans that are mandated coming out of this that are maybe able to help you. But diabetes, particularly adult onset, is controllable. If you watch your weight, if you exercise, watch what you eat and, you know, continue I guess in this case to take your medication. I don’t know any reason why you shouldn’t be able to find something out there, but you want to look for an employer that has a health care plan. Good luck.

[…]

CALLER: I’ll make, I’ll make my comment then I’ll get off the phone. Anyway, one of the things that I noticed this morning was Tom’s reaction to the woman who called looking for the job with health care and his final statement was “good luck,” which I think encapsulates the entire Republican party’s attitude towards any problems that are facing the American people today. I also have a master’s degree in economics.

HOST: Did you want to respond to Rick?

DAVIS: Well, congratulations on — well, I wish her good luck at this point. We’ll see what comes out of the health care plan. It wasn’t a “good luck, you’re on your own type of thing.” I think we all feel for people that are in those kinds of positions. But it’s very difficult. When you start having the government take care of everybody with a problem, as I said you’re doing it with borrowed money, what you want to see is — these are not simple solutions. It is progressive to continue to borrow money, to spend to take care of people’s problems. This tends to be a pretty inefficient way of doing things, number one. And number two, down the pike, somebody has to pay for it. I think I’m fairly progressive in my views as well. I was the head of a county government before I came to Washington and had to run it, inherited a pretty big deficit and was selected two years later, after making a number of changes, as the best financially-run county in the country.

So I look at governance as a very very tough business and I don’t think “good luck” was like a kiss off. I would generally say good luck to you as you try to move through this problem. But I don’t know that she can count on Washington to solve it for her. She will be eligible for Medicare in 3 years. And at that point, you can probably get some relief on some of the issues she’s looking for. She wanted to retire at 62 years old. We’d all like to retire at 62 years old, but I’m not so sure government can guarantee that people can just retire at 62 years old or that we should be doing those kind of things and maybe that’s where I part company with the caller.

So this man who makes six figures and is covered for every hangnail until he dies is telling this woman that she needs to find a large employer who will hire a 62 year woman and then keep working (on her feet — that’s what retail usually is) for much longer than she hoped to. Sure, that’s doable. It’s just a matter of finding the right job after all, and who can’t do that? After all the two of them are in the same boat — the coiffed congressman who would like to retire at 62 but lost a bunch of his portfolio in the crash and this 62 year old shop clerk who’s been working at menial, backbreaking labor her whole life. Hey, he found a job with a large employer who covers him (the federal government) why shouldn’t she? He just can’t figure out why she can’t find a plan to cover her like he has.

The truth is that taxpayers can guarantee his health care and pension because he’s so special, no, so superior to people like this caller. The government can ‘t afford to provide health insurance for losers. Only winners like Congressman Davis.

Meanwhile, we have other Republicans declaring war on the seniors. Evidently, they are all a bunch of whiners who refuse to give up their precious entertainment to pay for their medication. Here’s Mark Steyn filling in for Limbaugh today:

STEYN: We’ve still got to do something to plug this little hole in the donut for the prescription drug plans for seniors. Because, heaven forbid, heaven forbid that these seniors, these seniors should have to choose between prescription drugs and Tony Danza doing South Pacific in dinner theater.

I guess they think this is a big electoral winner, but these gasbags had better watch out or they are going to lose the over 50 demographic just like they lost the under 30 demographic.

Conservative politicians and their wingnut welfare queens are just a bunch of heartless, rich jackasses, basically, always have been. But people are no longer quite so sanguine that they’re going to get the chance to be rich, spoiled jackasses too so these lines don’t read quite as hilarious or as “common sense” as they used to. A public servant telling some 62 year old retail clerk that she needs to stop bellyaching and find a job with a big employer so she can get health care is so “let them eat cake” that I can hardly believe he said it. And some overpaid creep calling senior citizens who are living on a thousand dollars a month “spoiled” is just asking for the guillotine, which in America is a metaphor for a tax rate of 90% on any fatuous wingnut gasbag who has the nerve to say something like this after what they’ve done to this country.

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The Old Machine Still Works

by digby

Here’s a perfect example of the Republican Noise Machine successfully working the refs:

Conservatives have been relentlessly attacking ABC’s upcoming health care special, claiming the network is going to try to “help sell” Obama’s health care plan. Diane Sawyer defended the special by saying that the program will include “questions from every single vantage point.” However, if today’s GMA interview with Obama’s health care team is any indication, one group’s questions and concerns with the health care plan may be left out: progressives.

You can see the video, here.

This is how it’s done. The right wing stages a hissy fit accusing the so-called liberal media of being in the tank for Obama. And the so-called liberal media, which is more afraid of being called the liberal media than being seen as corporate whores, stooges or fools, bends over backwards to ensure that every right wing talking point is aired with the authority of Zeus. They will push, they will prod, they will argue the conservative line vociferously, using their status as advocates for “the people” to make it sound as if they are expressing the doubts of the public at large. They will not mention any liberal concerns because as Atrios pointed out with respect to Froomkin’s firing, anyone who has concerns about the super liberal administration’s plans from the left is, by definition, a crackpot communist nutcase.

This will end up being a seminar for the American people to understand why they should believe the Republicans instead of their own lying eyes. Again.

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Leading Questions

by digby

Ed Kilgore makes an interesting point about bipartisanship vs elite village consensus. (He frames it as political bipartisanship vs grassroots bipartisanship, but I think my shorthand is more descriptive 😉

He has said many times that he thought Obama’s spirit of bipartisanship was aimed at the people rather than the political party in DC. I think the jury is still out on that, but for the sake of argument, I’ll agree that’s so. Therefore, his approach to health care should be calibrated to gaining the support of the people, which sounds right to me in any case. Kilgore writes:

[I]t’s worth emphasizing that the two most credible surveyors of public opinion on this subject, the Kaiser Family Foundation and CBS/New York Times, have both found that at least half of self-identified Republicans favor a well-described public option.

So the question must be asked: if Barack Obama wants to conduct a bipartisan approach to universal health care, what does that mean in terms of the public option? Killing or watering down the public option in order to (maybe) attract the support of Sen. Chuck Grassley, and not much of anybody else in the congressional Republican ranks? Or maintaining it to appeal to rank-and-file Republicans, who favor it despite the views of their “leaders” and the polarized atmosphere in Washington?

[…]

I understand that Obama and congressional Democrats may need cooperation from Grassley or a few others for short-term tactical reasons in the Senate. But ultimately, “bipartisanship” on health care may actually mean looking past congressional Republicans and pitting them against their own supporters across the country, particularly on the public option.

Yes, yes and yes. Indeed, if Obama still wants to emulate the great “game changer” himself, Ronnie Reagan, that is exactly what he would do. Reagan used his personal popularity to get rank and file Democrats to support his policies. And he rhetorically always framed his policies as the common sense policies of the everyman out in the country, and then they backed it up with polling that showed that the people trusted him.

Obama can pass health care with Democrats and then legitimately call it bipartisan by citing public support. But he has to not care that David Broder and David Brooks have a hissy fit over it. They do not speak for Americans; they don’t even speak for Republicans on this one.

This is what the bully pulpit is all about. He can take his case directly to the people and if he backs a real plan, with real teeth, he can get it passed, I don’t have any doubts. The party grassroots and the public at large, including a large number of Republicans, are with him. The only people standing in the way are the insiders in the ruling establishment who want to protect the status quo.

The Republicans and the financial elites (to the extent they are distinct) are both on the run at the moment. Their powers are sorely weakened by the messes they’ve created and the public distrust of them as individuals and institutions. There has rarely been a greater need or a greater opportunity for a politician to appeal directly to the people and create a positive, enduring legacy. He can lead the country or he can lead the village on this — it’s all up to him at this point.

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Slow-Motion Avalanche

by dday

This jumped past me last week, but a federal judge ordered John Yoo to testify in a case filed by Jose Padilla, who was held in a Navy brig for years and slowly driven insane under the enemy combatant policies of the last regime. Ady Barkan thinks this could actually provide some accountability.

In 2002, Justice Department lawyer John Yoo wrote a memo recommending that Jose Padilla, arrested in Chicago in the wake of 9/11 and held on suspicion of plotting a dirty-bomb attack, be classified as an enemy combatant. Yoo also wrote memos arguing that American law does not prevent the president from ordering such enemy combatants tortured. This January, after enduring years of abuse in prison, Padilla sued Yoo for violating his constitutional rights.

And a week ago, Judge Jeffrey White ruled that Padilla’s allegations were plausible enough to justify denying Yoo’s motion to dismiss the lawsuit. White was appointed by George W. Bush the year Yoo was writing his memos.

White’s decision is the first of its kind: Until now, although other lawsuits have been brought, no government official has faced personal liability for his role in the torture or deaths of detainees. But it probably won’t be the last. These cases are just beginning to address the fraught questions of justice that have emerged in the aftermath of the Bush era—what atrocities were committed in the name of national security, who bears responsibility, and how should they be punished? Although neither the Obama administration nor most members of Congress want to deal with these questions directly, they’re even more opposed to letting judges (and juries) take a crack at them. Padilla v. Yoo is an example of a surprising development: a conservative judge putting pressure on the Democrats in Washington to create some system of accountability for the Bush administration. It could help spawn more such rulings.

The Obama Administration actually defended Yoo’s plea to skirt testifying in this case, clearly to just close down this issue in the name of moving forwards and not backwards. But White really boxed in the White House now, and every option available to them plausibly leads to more disclosure and more court rulings that would force some measure of accountability. Barkan considers this ruling crucially important, and maybe it is. Remember that Bush lost case after case invalidating his national security procedures, and now Obama has mirrored his predecessor on many of those fronts. Taking the hard line on official secrecy and executive privilege has the benefit of delaying accountability, but as long as there are lawyers willing to seek justice – and there are – they will pursue the avenues made available by favorable rulings. This avalanche may be happening in slow motion, but it’s rolling downhill, and even a crafty efforts from the elites to shield themselves from a reckoning may not be enough to stop it.

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Educators

by digby

Over the week-end I wrote about and linked to Greg Sargent’s piece about Larry Sabato’s personal relationship with former congressman Virgil Goode and how that’s a good example of conflict of interest that defines the ethos of the insider class of villagers. Sabato’s school had been a recipient of many earmarks from Goode over the years and is now struggling since Tom Periello ousted Goode in the last election.

Sabato responded to Sargent’s criticisms today saying that he would do a better job of disclosing his various ties, which is good.

But my criticism actually runs deeper than disclosure. Wouldn’t it also be useful if Sabato jumped into the earmark debate and educated the public about what they are, the good and the bad? He could have done that at numerous points over the past few years as “earmarks” became a proxy for government spending and corruption — and nearly turned the stimulus debate on its head, if you recall.

As a respected academic and political commentator he could have pointed out many times that government spending (earmarks) is often used for important and valuable institutions and projects like his that benefit the locals and the public at large. The phony construct of “objectivity” made it impossible for him to do that, and I would guess that he didn’t want to be seen as some sort of liberal, defending government largesse. But the problem is that unless people like him speak up, the notion that all government spending is wasteful becomes even more entrenched, even to the point where the spokesman for the Republican Party insists that the government spending money on volcano monitoring is some sort of joke.

Over all those years, instead of making a public case for spending that directly benefited his school, he relied on cronyism. And the result is that the new congressman, who might ideologically have been inclined to fund his institution as a matter of public good, had to run as a “reformer” on earmarks and wasteful spending and can’t justify one for Sabato’s institution. Sabato did it to himself.

The system is corrupt because people are not honest about what government does and what the public needs it to do. And the political class is so insular it doesn’t even know when it’s hurting itself.

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When CBO Scores Vanish

by dday

When a partial Congressional Budget Office score revealed that health care would be more expensive than expected and not cover as many Americans, mainly because it was scoring something, you know, PARTIAL, the press had a field day, egged on by Republicans. Hell, they’re still talking about it.

“Meet the Press” has really got to step up its game on the health-care debate. Last week, host David Gregory tweeted “Compelling fact today: dem-wh health care plan would only cover 16 of the 50 mill uninsured. That makes it a harder sell. Info from cbo.” Problem was, his fact wasn’t much of a fact. CBO didn’t score a “Dem-White House” plan. It scored a partial version of the Senate HELP Committee’s plan. The White House wasn’t involved. And nor, for that matter, would that plan have only covered 16 million. The version of the bill examined by CBO was missing the employer mandate and the specifics on the individual mandate. It was missing, in other words, the parts of the bill that would cover people. Gregory was right to say that the CBO score was a setback. But not for the reasons he suggested.

By contrast, over the weekend, that same CBO scored the Waxman-Markey climate and energy bill to determine the annual cost per household of a cap and trade system and a renewable energy standard.

On that basis, the Congressional Budget Office (CBO) estimates that the net annual economywide cost of the cap-and-trade program in 2020 would be $22 billion—or about $175 per household. That figure includes the cost of restructuring the production and use of energy and of payments made to foreign entities under the program, but it does not include the economic benefits and other benefits of the reduction in GHG emissions and the associated slowing of climate change. CBO could not determine the incidence of certain pieces (including both costs and benefits) that represent, on net, about 8 percent of the total. For the remaining portion of the net cost, households in the lowest income quintile would see an average net benefit of about $40 in 2020, while households in the highest income quintile would see a net cost of $245.

In other words, in another partial score, since it doesn’t take into account the benefit of mitigating climate change, low income households would actually benefit slightly from the impacts of the bill, while high-income households would see a fairly nominal cost. Republicans have argued for months that doing anything on greenhouse gas emissions would cost anywhere from $1,600 to $3,100 a family.

I’m going to go out on a limb and suggest that this score will have absolutely no impact on the debate over whether or not we should enact climate and energy legislation. Those who want to cover for polluting industries will still lie that the impact on “working families” will be too costly, and the press will “cover the controversy.” In other words, the CBO only matters when it matters.

Meanwhile, Democrats have, apparently, a global warming denier in charge of the House Agriculture Committee, and he’s doing whatever he can to stop the bill.

House Agriculture Chairman Collin Peterson (D-Minn.) on Friday said climate change bill negotiators are heading back to the drawing board after discussions between Democrats “blew up last night.”

A meeting between chairmen drafting the climate bill and Democrats on the Agriculture Committee “by and large blew up last night” over the issue of offsets, Peterson said.

Specifically, he said, Agriculture Democrats rejected a concept pitched by bill drafters that would set money aside for a new greenhouse gas conservation program tied together with some offsets […]

“We’re back to how do we deal — we want USDA to run our offset program; they want EPA to run it,” Peterson said. “Not that we’re necessarily against the EPA; they just speak a different language. They don’t have the infrastructure out there to deal with us.”

Added Peterson, “I’m tired of this running around in circles.”

Funny, I was about to say the same thing.

I’m beginning to think that humans have a better chance of adapting with gills than adapting legislatively with meaningful climate change legislation. After all, lawmakers have to protect those poor families from getting that $40 in ten years.

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1996

by digby

Over at the Economix blog at the NY Times, Catherine Rampell took a look at the correlation between actual government deficits over the years and how the public perceived them, according to the Gallup poll:

If public worries about the nation’s fiscal health were perfectly related to the nation’s actual fiscal health, these two charts should be near-mirror images of each other.

That is, when the deficit represents a higher percentage of G.D.P. (i.e., the red bars pointing downward get longer), you should see more people naming the federal budget as the country’s most pressing issue (i.e., the blue bars going upward should also get longer).

Read the whole post for a long explanation and many caveats about these numbers and why they should be taken with a grain of salt, even if they are interesting.

I am interested more in the fact that the public obsession with the deficit tracks very closely with the rise of the anti-tax conservative movement, actually peaking at a time when the deficit was in very serious retreat and turning into surplus. Large numbers of people still believed it was rising.

The fiscal scolds don’t stop when the numbers turn around. They keep up the fear mongering because it isn’t really about balanced budgets or paying down debt. It’s about keeping government from bringing positive results to the people. As long as they can keep people focused on debt, whether it exists or not, they always have the rationale to stop any sort of government action that could empower average citizens.

It’s no mystery why George W. Bush was so anxious to spend that surplus he inherited as soon as possible, or why Alan Greenspan actually said that surpluses were dangerous to the economy. Their whole program is undermined if people aren’t living under the impression that the economy is hamstrung by so much debt that the whole thing is in danger of coming apart at the seams if they don’t (perversely) keep cutting taxes and cutting spending. People hear that enough, they just absorb it and it becomes conventional wisdom.

Deficits are an abstract concept that people end up using it as a proxy for “financial responsibility” which is extremely imprecise, since the government is responsible for a whole lot of things besides the budget. But until somebody comes up with something that makes more sense to average folks, the deficit boogeyman will be a powerful symbol that can be used by both parties to keep the government from challenging the status quo.

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Freedom

by digby

Well at least we don’t have long waits and rationing like all those other horrible places:

In Framingham, Dr. James Kenealy, an ear, nose and throat specialist, said his patients increasingly cite copayments as a hurdle to continuing with allergy treatments. The care typically includes weekly shots for several months, with copayments ranging from $20 to $50, per shot, depending on the patient’s insurance plan.

“Probably once a week, there will be a patient deciding to discontinue allergy injections or not pursue that as a therapy because they have high copays,’’ Kenealy said.

Even patients without chronic illnesses are finding themselves in a copayment crunch.

“If you are a family with four or five kids . . . copayments are going to add up,’’ said Worcester family physician Dr. James Broadhurst, noting that children visit doctors frequently for illnesses and preventive care.

Especially in the past year, Broadhurst said he’s encountered more families asking him to treat or prescribe over the phone because they can’t afford the copayment of an office visit.

As part of Massachusetts’ pioneering 2006 healthcare overhaul, the state created the Safety Net program, which helps people of any income pay large medical bills. But it specifically excludes coverage for copayments.

“Oftentimes, these people end up using their credit cards to pay their copays and end up with medical debt,’’ said Kate Bicego, help line manager at Health Care for All, one of the state’s largest consumer groups.

Bicego said calls to the nonprofit group’s helpline are up roughly 65 percent from last year, and many of those seeking help are struggling with copayments and deductibles.

Other countries have systems that prioritize health care treatment on the basis of need — a triage system. We prioritize health care on the basis of who can pay. And in the most perverse form of rationing there is, we make the sickest people have the most difficult time getting access to health care. (The sickest, after all, can’t hold down a job, so the employer based system doesn’t really work for them, at least not in the long term.)

The idea that the US doesn’t ration health care is absurd. We certainly do. We just make people do it to themselves out of economic hardship. I guess that’s supposed to be a tribute to our sense of individualism and personal freedom.

Hey, nobody’s going to tell you you can’t be treated — you made that decision all by yourself when you opted not to have a lot of money. That’s what freedom’s all about. (Unless you’re sick and you want to die, of course, in which case the state won’t let you.)

The debate is really about irrational rationing vs rational rationing — and the US is the undisputed leader of the first method. When we set our minds to it, nobody can be as irrational as we are.

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