OK, so here's my theory on why Paul Krugman, who is of the general type to be drawn to an Obama-type figure (i.e., an academic who can imagine/idealize a politics that raises the level of debate and tries to get past ideology to get to real solutions), is so exercized about his candidacy and is engaged in a one-man show to undermine support for him among Times readers. (Here's the latest offering.) Actually, I can come up with two reasons. In increasing order of importance in his motivation:
1. Krugman has some legitimate gripes with Obama's policy positions, most notably his health care plan. Once his favored candidate (Edwards) went down, he saw it as his job to shake up the Dem race by continuing the fight to put true universal coverage on the table. The same can be said of trade deals, tax policy and others. He wants to keep up his role as a "thought leader" on the left and opposition is simply the best way to be perceived as a leader. This will be especially true if (when?) Obama becomes president. Krugman serves no role if he is always agreeing with the president, thus, he needs to set the stage for an oppositional arrangement now.
2. More than any other columnist or pundit, Krugman loves playing the role of an "I told you so" prognosticator. Consider: Other columnists, like Harold Meyerson and even the more conservative Andrew Sullivan, have taken the plunge in their support for Obama, knowing full well that he could very well flame out when he gets into office. I'm pretty sure they know that his soaring rhetoric and his grand vision may wind up as withered fruit in the face of GOP dirtiness and the cynicism that is our modern life. At the same time, precisely because our politics today has been so sullied and de-legitimized, they are willing to take a chance, they are willing to live on hope for a little while. Krugman, on the other hand, knowing the same thing sees an opportunity to be able to say "See, I knew that Obama was all hot air. He never fooled me." In fact, pending an Obama election, I foresee a Krugman column just about a year from now when he declares exactly so. (And then, I get to say "I told you so.")
Friday, April 25, 2008
Wednesday, March 5, 2008
Morning after thoughts
Tough night for Obama. Hard to say whether it was a good night or not for the Democrats, but I'm inclined to think not.
If I'm a superdelegate, I am feeling no rush to move anywhere at this point. There will be another intense 6 weeks of campaigning to do what it should -- help the American people sort through these two candidates. I feel that, as of right now, Hillary actually has the tactical advantage, and she will solidify that advantage with a win in PA. This race will be determined by the superdelegates, among whom she has deeper and stronger connections. He has a good case to make with regard to a pledged delegate lead that I don't think that Hillary can overcome, but she has a good case to make with regard to her having won almost all of the big states, them having split the purple states, her momentum in finishin stronger, and her maybe being tied in the popular vote. (Obama is only ahead 12.6 mil to 12.1 mil now.) The FL/MI issue could be both her salvation in terms of the numbers or a calamity in terms of how a credentials fight like that could tear the party apart and alienate the superdelegates. I have a feeling she is going to take a softer tone on that going forward without conceding the point.
Hard to know if this is good for the party or not. It's good that Obama is getting a close look. However, I'm not sure if his loss of inevitability will ultimately help him, by testing him against the type of attacks McCain will run at him, or will weaken him, by planting seeds of doubt in people's minds that McCain will later exploit. If I had to say, I think it's the latter. Hillary made some tough charges start to stick against Obama, or at least introduced enough doubt, and these next 6 weeks are going to be at least as hard-fought and nasty as what we've seen before. He's going to be much more nicked up before this is done, and he is going to have to take some of the existential questions about himself (like does he have the experience, who is he really, is there a "there there") head-on now. His answers so far haven't been good enough and/or have been drowned out in the metastory of Obama the rock star.
It will be interesting to watch if McCain keeps going after just Obama or goes after Clinton as well. That will give a read on which is the candidate they'd prefer to face. Dave I know is much more optimistic about the megatrends impacting November than I am. Obama and Clinton are both strong, but flawed candidates. I still think that Obama has enough substance to assuage people's concerns about him in the general and to be a more likely victor against McCain. Clinton certainly stacks up better against McCain on national security, but I still can't get past the fact that so many Americans have visceral dislike for her, which would push GOP turnout and tilt independents away from her. If Clinton does emerge and win in Nov, she will have Obama to thank. The coronation script that her campaign had written was much less effective than the fighter/comeback story she could tell if she gets past Obama.
If I'm a superdelegate, I am feeling no rush to move anywhere at this point. There will be another intense 6 weeks of campaigning to do what it should -- help the American people sort through these two candidates. I feel that, as of right now, Hillary actually has the tactical advantage, and she will solidify that advantage with a win in PA. This race will be determined by the superdelegates, among whom she has deeper and stronger connections. He has a good case to make with regard to a pledged delegate lead that I don't think that Hillary can overcome, but she has a good case to make with regard to her having won almost all of the big states, them having split the purple states, her momentum in finishin stronger, and her maybe being tied in the popular vote. (Obama is only ahead 12.6 mil to 12.1 mil now.) The FL/MI issue could be both her salvation in terms of the numbers or a calamity in terms of how a credentials fight like that could tear the party apart and alienate the superdelegates. I have a feeling she is going to take a softer tone on that going forward without conceding the point.
Hard to know if this is good for the party or not. It's good that Obama is getting a close look. However, I'm not sure if his loss of inevitability will ultimately help him, by testing him against the type of attacks McCain will run at him, or will weaken him, by planting seeds of doubt in people's minds that McCain will later exploit. If I had to say, I think it's the latter. Hillary made some tough charges start to stick against Obama, or at least introduced enough doubt, and these next 6 weeks are going to be at least as hard-fought and nasty as what we've seen before. He's going to be much more nicked up before this is done, and he is going to have to take some of the existential questions about himself (like does he have the experience, who is he really, is there a "there there") head-on now. His answers so far haven't been good enough and/or have been drowned out in the metastory of Obama the rock star.
It will be interesting to watch if McCain keeps going after just Obama or goes after Clinton as well. That will give a read on which is the candidate they'd prefer to face. Dave I know is much more optimistic about the megatrends impacting November than I am. Obama and Clinton are both strong, but flawed candidates. I still think that Obama has enough substance to assuage people's concerns about him in the general and to be a more likely victor against McCain. Clinton certainly stacks up better against McCain on national security, but I still can't get past the fact that so many Americans have visceral dislike for her, which would push GOP turnout and tilt independents away from her. If Clinton does emerge and win in Nov, she will have Obama to thank. The coronation script that her campaign had written was much less effective than the fighter/comeback story she could tell if she gets past Obama.
Friday, February 8, 2008
We Could Write for the NYT, Too
Here is what David Brooks had to say. Mirrors much of what we both said about why more educated folk can feel safe to attach themselves to Obama. And we don't even have to get all corny with some fake interview shtick.
Thursday, February 7, 2008
Yes. He. Can.
Interesting video. I had read about it but hadn't watched it. Thanks for passing it along.
I hear both of your responses. I think there has been a long-unquenched desire on the left for "the next Kennedy", an inspirational leader who speaks about something bigger than ourselves, takes the high ground and still can win elections. And I think, particularly after 2004, there is a huge swath of this country that just feels completely shut out of the power of decision-making and is ready for that to end. Obama definitely faces the "where's the beef" test vs. both Hillary and McCain. I think he would play up the policy differences more so in the general election, but will have a big hurdle to get over on national security. (BTW, Wes Clark could be a strong Veep contender for either candidate.) But I don't see that translating into a broad suspicions of him as some kind of cult-like leader. We are far too much of a youth-obsessed society for that meme to catch up.
Personally, I'm not getting caught up in the whole Obamania thing. I support him because I think the country's political atmosphere has become too corrosive in ways that are preventing us from finding common sense solutions to pressing problems and also in ways that are detrimental to our democracy and our civic life. Also, I don't know that I'm a believer in the power of any politician to "make us a better people". I think there will always be better and worse angels of our natures, and politicians should be focusing on setting up structures to let the better angels of our natures ultimately prevail, and avoiding appeals to fear and prejudice. I think that Kennedy was more a creature of his times rather than the major shaper of what the 1960's became. (Demographics, economics and the Vietnam War did that.)
BTW, apropos of your concerns, I have a new theory about the split in supporters for Hillary vs. Obama. I'd call it trust. Blacks, young people and higher ed junkies feel like we know Obama because he is one of us. We know where he is coming from and see him as a member of 'our tribe'. To others (Hispanics, Asians, older people, white under $50K earners), he is an unknown newcomer, but they trust Hillary because they have known her for 15 years and have seen what she and Bill have stood for and done.
And if you don't like that theory, here's another one, based on Maslow's hierarchy of needs. If your basic needs have been taken care of, then you can look for someone to provide less material benefits like uplift and you can afford to take more of a chance. If you're worried about your basic needs, you're not looking to take any chances and want someone who can promise to protect you.
I hear both of your responses. I think there has been a long-unquenched desire on the left for "the next Kennedy", an inspirational leader who speaks about something bigger than ourselves, takes the high ground and still can win elections. And I think, particularly after 2004, there is a huge swath of this country that just feels completely shut out of the power of decision-making and is ready for that to end. Obama definitely faces the "where's the beef" test vs. both Hillary and McCain. I think he would play up the policy differences more so in the general election, but will have a big hurdle to get over on national security. (BTW, Wes Clark could be a strong Veep contender for either candidate.) But I don't see that translating into a broad suspicions of him as some kind of cult-like leader. We are far too much of a youth-obsessed society for that meme to catch up.
Personally, I'm not getting caught up in the whole Obamania thing. I support him because I think the country's political atmosphere has become too corrosive in ways that are preventing us from finding common sense solutions to pressing problems and also in ways that are detrimental to our democracy and our civic life. Also, I don't know that I'm a believer in the power of any politician to "make us a better people". I think there will always be better and worse angels of our natures, and politicians should be focusing on setting up structures to let the better angels of our natures ultimately prevail, and avoiding appeals to fear and prejudice. I think that Kennedy was more a creature of his times rather than the major shaper of what the 1960's became. (Demographics, economics and the Vietnam War did that.)
BTW, apropos of your concerns, I have a new theory about the split in supporters for Hillary vs. Obama. I'd call it trust. Blacks, young people and higher ed junkies feel like we know Obama because he is one of us. We know where he is coming from and see him as a member of 'our tribe'. To others (Hispanics, Asians, older people, white under $50K earners), he is an unknown newcomer, but they trust Hillary because they have known her for 15 years and have seen what she and Bill have stood for and done.
And if you don't like that theory, here's another one, based on Maslow's hierarchy of needs. If your basic needs have been taken care of, then you can look for someone to provide less material benefits like uplift and you can afford to take more of a chance. If you're worried about your basic needs, you're not looking to take any chances and want someone who can promise to protect you.
Obamania
Don't know if you've seen this video, but I had two opposite reactions to it, one immediately following the other. My first reaction was largely positive. I felt like this video encapsulates exactly how Obama really has captured the spirit of this time -- an amalgam of media and pop culture and politics and public sentiment that is more about mood and aspiration than about politics. This is why he got my vote -- not because I think he will be better, but because he has the potential to make us better. Hokey, I know, but I figured that after the worse administration in American history, perhaps this wasn't a bad risk to take.
My second reaction to the video, however, was much less favorable. Indeed, I suddenly had an urge of suspicion and fear that I hadn't felt before. Suddenly, Obama felt too cultish, too hucksterish. My thoughts even skipped to the Manchurian Candidate. I think the media are beginning to feel this way, too, and, if the drumbeat grows louder, it could definitely take the shine off. We shall see which perspective flowers over the next few days and weeks, but, for the first time, I'm thinking that my second reaction might just be the dominant one.
My second reaction to the video, however, was much less favorable. Indeed, I suddenly had an urge of suspicion and fear that I hadn't felt before. Suddenly, Obama felt too cultish, too hucksterish. My thoughts even skipped to the Manchurian Candidate. I think the media are beginning to feel this way, too, and, if the drumbeat grows louder, it could definitely take the shine off. We shall see which perspective flowers over the next few days and weeks, but, for the first time, I'm thinking that my second reaction might just be the dominant one.
Wednesday, February 6, 2008
Start flexing those toes
I love the news about how motivated the Dem base is compared to the GOP, but I think that recent history has shown that Presidential elections are much more about personalities than parties. McCain will have broad appeal across independents, and I don't know how much concerns about his conservative cred will suppress GOP turnout, especially if the alternative is Hillary. The vote will be about the future, and we're not running against Bush this time.
Re: the class splits in the Dems, that's very interesting. I think that Obama is running more of an "intellectual" appeal. Plus, there has been some commentary that lower-middle class voters have a greater identification with the Clintons and their struggles and attacks they have sustained. Plus, racism can play a part in the primaries as well as in the general.
Re: the class splits in the Dems, that's very interesting. I think that Obama is running more of an "intellectual" appeal. Plus, there has been some commentary that lower-middle class voters have a greater identification with the Clintons and their struggles and attacks they have sustained. Plus, racism can play a part in the primaries as well as in the general.
Tanned, rested and ready
Thx for providing the impetus for reviving the blog!
I hope you're right. Hillary/Obama would clearly be the dream ticket. Hard to say how it would go down. I'd have to think that Obama would prefer not to be asked. I think he would chafe under Clinton for 8 years, and while it may be the dream ticket for an election, I don't see them working well together. But, if Hillary asks, I think he has to say yes. Interesting to ponder whether she would ask. It reminds me of 2000 and Gore, in that Hillary will have to decide whether it's more important to win or to do what she wants.
But I'm more concerned about nastiness precluding this and tarnishing them both. I don't see big policy differences between them, and if it's not quite about character, it's about tarnishing each other with the brushes of 'too inexperienced' vs. 'more of the same'. I don't see future debates being that illuminating, and we'll have to deal with moderators continually baiting them.
I will take a look at those exit polls and get back with my thoughts. One comment (re: IA, actually) that I thought was right on is that Obama is doing well in places with almost no blacks or with blacks making up a majority of Dems, but not with the in between states. This would track with the belief that white-black tensions are higher when the races are actually in contact with each other. It's a lot easier to not be prejudiced in theory than in practice.
I hope you're right. Hillary/Obama would clearly be the dream ticket. Hard to say how it would go down. I'd have to think that Obama would prefer not to be asked. I think he would chafe under Clinton for 8 years, and while it may be the dream ticket for an election, I don't see them working well together. But, if Hillary asks, I think he has to say yes. Interesting to ponder whether she would ask. It reminds me of 2000 and Gore, in that Hillary will have to decide whether it's more important to win or to do what she wants.
But I'm more concerned about nastiness precluding this and tarnishing them both. I don't see big policy differences between them, and if it's not quite about character, it's about tarnishing each other with the brushes of 'too inexperienced' vs. 'more of the same'. I don't see future debates being that illuminating, and we'll have to deal with moderators continually baiting them.
I will take a look at those exit polls and get back with my thoughts. One comment (re: IA, actually) that I thought was right on is that Obama is doing well in places with almost no blacks or with blacks making up a majority of Dems, but not with the in between states. This would track with the belief that white-black tensions are higher when the races are actually in contact with each other. It's a lot easier to not be prejudiced in theory than in practice.
And Another Thing...
This is why I continue to remain pretty upbeat about the Dems prospects in the fall. Even if there is a lot of dirt thrown during the general, the GOP is suffering voter fatigue, the Dems are enjoying a resurgence. The dirt will hurt both candidates and might suppress turnout, but the Dems are starting so far ahead of the GOP that they have some room to lose voters and still come out ahead. Even if McCain is able to peel away some independent votes, I think the Dem base is sufficiently strong -- and, frankly, McCain's sufficiently weak -- that I am not terribly worried. I know in politics anything can happen and this is why I continue to keep my fingers crossed. But, as I've noted before, I don't see the need, as I have in the last two elections, to cross my toes, as well.
One More Observation
A quick scan of some exit polls on the Dem side reveals that Obama consistently pulls in a majority of college graduates and Hillary a majority of non-college graduates. My own little theory on this gap -- which, coming from someone with a postgraduate degree, might come across as patronizing and for that I apologize -- is that those who feel more comfortable with the nuances of policy (read: more educated class) are more willing to accept someone who speaks in less specific, but posits a larger theme to tie together his views. Those who are less comfortable with the details of policy are more eager to put their trust in someone who has a very deep knowledge of the ins and outs of the policy maze. Thoughts?
Interesting Times, Indeed
Last night I heard the faint cries of our lonely blog page, "Why do you ignore me so? Why does no one take me seriously?" Oh, wait. I think that was Mike Huckabee.
In any event, I thought that this discussion deserved to be preserved in a format other than e-mail. So, here is what Eric wrote: "This is rapidly becoming an illustration of the putative Chinese curse "May you live in interesting times." This is going to drag on for a while. (While you can make a case that keeping the Dems in the spotlight longer is a plus for us, I see more downside to upside of stretching our conflict out. Not every debate is going to be the lovefest that the last one was, and the media loves conflict.)One reflection and one request. The reflection is how odd it seems that the margins of victory in different states were so wide on both sides. Besides CT and MO, every other state seemed to have a 10+ pt gap. Any theories? (Besides the racial one which does seem to explain the deep Southern results.) Was there an explicit strategy on Clinton's side to go after the big states and by Obama to go after the smaller ones? Didn't see any coverage of this beforehand.The request is to send along any consolidated exit polling that you find. I'll be very curious to see the racial/gender/age vote splits, either national or state-by-state."
And here is my response:
I think the drawn out campaign is good for the Dems. They have both gotten sharper and smarter by riffing off each other. I also think that there is still overwhelmingly positive feelings about both and the more that the media show them, the more voters realize that there is a better way. Another consequence, I believe, is that a drawn out contest will likely push Hillary -- if she is the ultimate winner -- to pull in Obama as the VP, which I think would be a very positive development. Typically, you don't want your VP candidate to outshine you, but I do think it could work in this case. In a sense, Obama would help to offset Bill's looming shadow by demonstrating that a Hillary administration is something totally new from her husband's.
As for the large margins of victory, I simply cannot explain the phenomenon. (The GOP experienced a similar thing, even with a three-man race!) Perhaps this is a question for Malcolm Gladwell. After all, it does seem to be a case of reaching a "tipping point" that just pushed an overwhelming majority to vote with a certain candidate. For me, the strangest contrast is that Hillary won TN by 30 points, but lost MN by 30. I think this Super Tuesday and this whole primary season has bestowed political scientists with a huge gift. I could imagine whole careers being built on this one election. The exit polls (which are available here: http://www.msnbc.msn.com/id/21660890/) give a good place to start the analysis.
So, what next? Does the Dem campaign get nastier? Signs are there that it will. (See the fight over health care.) At the same time, perhaps this is my Panglossian view, but I do think that even if it turns nasty, both candidates will be able to maintain a general perception that they are fighting over policy, not character -- unlike the GOP -- and this will ultimately serve the party well. We shall see.
In any event, I thought that this discussion deserved to be preserved in a format other than e-mail. So, here is what Eric wrote: "This is rapidly becoming an illustration of the putative Chinese curse "May you live in interesting times." This is going to drag on for a while. (While you can make a case that keeping the Dems in the spotlight longer is a plus for us, I see more downside to upside of stretching our conflict out. Not every debate is going to be the lovefest that the last one was, and the media loves conflict.)One reflection and one request. The reflection is how odd it seems that the margins of victory in different states were so wide on both sides. Besides CT and MO, every other state seemed to have a 10+ pt gap. Any theories? (Besides the racial one which does seem to explain the deep Southern results.) Was there an explicit strategy on Clinton's side to go after the big states and by Obama to go after the smaller ones? Didn't see any coverage of this beforehand.The request is to send along any consolidated exit polling that you find. I'll be very curious to see the racial/gender/age vote splits, either national or state-by-state."
And here is my response:
I think the drawn out campaign is good for the Dems. They have both gotten sharper and smarter by riffing off each other. I also think that there is still overwhelmingly positive feelings about both and the more that the media show them, the more voters realize that there is a better way. Another consequence, I believe, is that a drawn out contest will likely push Hillary -- if she is the ultimate winner -- to pull in Obama as the VP, which I think would be a very positive development. Typically, you don't want your VP candidate to outshine you, but I do think it could work in this case. In a sense, Obama would help to offset Bill's looming shadow by demonstrating that a Hillary administration is something totally new from her husband's.
As for the large margins of victory, I simply cannot explain the phenomenon. (The GOP experienced a similar thing, even with a three-man race!) Perhaps this is a question for Malcolm Gladwell. After all, it does seem to be a case of reaching a "tipping point" that just pushed an overwhelming majority to vote with a certain candidate. For me, the strangest contrast is that Hillary won TN by 30 points, but lost MN by 30. I think this Super Tuesday and this whole primary season has bestowed political scientists with a huge gift. I could imagine whole careers being built on this one election. The exit polls (which are available here: http://www.msnbc.msn.com/id/21660890/) give a good place to start the analysis.
So, what next? Does the Dem campaign get nastier? Signs are there that it will. (See the fight over health care.) At the same time, perhaps this is my Panglossian view, but I do think that even if it turns nasty, both candidates will be able to maintain a general perception that they are fighting over policy, not character -- unlike the GOP -- and this will ultimately serve the party well. We shall see.
Wednesday, September 19, 2007
A Partial Answer
I realize I have been wholly delinquent in getting you an adequate response to your counter-challenge to me: how exactly are you going to sell universal, government-run health care? Mostly, I have not responded because I've been terribly busy and just haven't found the time to give a well-reasoned (or, at least, semi-coherent) response. (Indeed, this post is written at the expense of doing mywork and, so, I'm afraid, will be shorter than it should be.)
In part, though, the delay in response is because I've been stumped. I mean I still firmly believe that a single-payer system represents the best policy from a practical and fiscal point of view. It contains the greatest potential to curb price rises and to expand access and, in turn, to increase the health of our nation. Yet, rational solutions to complex problems, sadly, aren't all they're cracked up to be in this country (or really anywhere, I suppose, but right now I'm picking on us). Too many conflicting interests mean that policy becomes one giant compromise, rather than one coherent, Pareto-optimal strategy. (I know my use of the term "Pareto-optimal" is somewhat imprecise here, but...)
If compromise is the MO of the nexus between politics and policy, then, how is a radical solution like single-payer supposed to come to fruition? Well, as I struggled with this question, a funny thing happened. Some lady named Hillary (or something like that) showed one way of how to make 75% of the ideal sound like a reasonable compromise to all interests. Her plan of mandated coverage operating within the private insurance system -- which is based largely on the Massachusetts model -- gets us entirely to one of the goals (universal coverage) and, at least puts us on the path towards the second (curbing rising costs). Not that she would ever admit this, but I do think that her plan also prepares the groundwork for moving toward single-payer because it includes a public-private competitive component. If consumers have the option of choosing either a private or government plan that are placed on equal footing, my guess is that, over time, the government plan is going to become increasingly attractive, while the private plans -- with much larger overhead -- are going to wither on the vine.
Anyhow, the bottom line is that at this stage, I'm willing to accept the HRC health care policy -- or something very close to it -- as what is feasible at this stage in the political life of our nation and, then, as time wears on and private insurance seems increasingly flawed relative to a public system, we'll begin to see an opening for single-payer coverage. (By the way, the other two major Dem candidates propose plans with similar elements, but, IMO, Clinton's is the most complete and the only one to consider seriously the matter of the second goal of curbing costs.)
I realize that there is a lot to unpack in this statement and I regret I don't have time to do it now, but suffice it to say that in this election cycle I'm content to go for a 75% solution to begin to shift the policy debate and seek a more complete change in the future.
In part, though, the delay in response is because I've been stumped. I mean I still firmly believe that a single-payer system represents the best policy from a practical and fiscal point of view. It contains the greatest potential to curb price rises and to expand access and, in turn, to increase the health of our nation. Yet, rational solutions to complex problems, sadly, aren't all they're cracked up to be in this country (or really anywhere, I suppose, but right now I'm picking on us). Too many conflicting interests mean that policy becomes one giant compromise, rather than one coherent, Pareto-optimal strategy. (I know my use of the term "Pareto-optimal" is somewhat imprecise here, but...)
If compromise is the MO of the nexus between politics and policy, then, how is a radical solution like single-payer supposed to come to fruition? Well, as I struggled with this question, a funny thing happened. Some lady named Hillary (or something like that) showed one way of how to make 75% of the ideal sound like a reasonable compromise to all interests. Her plan of mandated coverage operating within the private insurance system -- which is based largely on the Massachusetts model -- gets us entirely to one of the goals (universal coverage) and, at least puts us on the path towards the second (curbing rising costs). Not that she would ever admit this, but I do think that her plan also prepares the groundwork for moving toward single-payer because it includes a public-private competitive component. If consumers have the option of choosing either a private or government plan that are placed on equal footing, my guess is that, over time, the government plan is going to become increasingly attractive, while the private plans -- with much larger overhead -- are going to wither on the vine.
Anyhow, the bottom line is that at this stage, I'm willing to accept the HRC health care policy -- or something very close to it -- as what is feasible at this stage in the political life of our nation and, then, as time wears on and private insurance seems increasingly flawed relative to a public system, we'll begin to see an opening for single-payer coverage. (By the way, the other two major Dem candidates propose plans with similar elements, but, IMO, Clinton's is the most complete and the only one to consider seriously the matter of the second goal of curbing costs.)
I realize that there is a lot to unpack in this statement and I regret I don't have time to do it now, but suffice it to say that in this election cycle I'm content to go for a 75% solution to begin to shift the policy debate and seek a more complete change in the future.
Monday, September 10, 2007
Does 300 million count as a crowd?
This poll from the NY Times shows that the American people, as a whole, are frequently wiser than the pundits on TV, or the politicians with their gamesmanship. While I love vocal democracy and the passion of MoveOn.org and their ilk, the mainstream Democratic candidates and Congressional leadership are doing well to avoid being overly influenced by those on the left.
BTW, while we mull over health care with all deliberate speed, what do you think about Patraeus' testimony?
BTW, while we mull over health care with all deliberate speed, what do you think about Patraeus' testimony?
Wednesday, August 29, 2007
Ping. Pong.
This is fun, in addition to being tough. I think that right now, health care is one if those areas where "only Nixon can go to China". I like your pro-business rationale for single payer, but I just think it is a bridge too far for the American people right now. 1993 really poisoned the well for single payer. Socialized medicine, another big government program, and truly massive tax increases -- the talking points for the right wing echo chamber are very well rehearsed and have a ready audience. There is no way to get this through on a bipartisan basis, it's way too easy for the Republicans to parody, and it is a giant risk for the Dems to take in an area that isn't a crisis in people's lives. It is probably the best solution, if designed correctly, and it could be a political winner for the GOP in 2008 or for the Dems in 2016, but I don't think it is for the Dems now. Politics (and this exercise) is the art of the possible, and I can't see the Dems being able to pass this.
But let me give you a chance. Tell me the legislative/political steps by which you think single payer could pass in the next 4 years. Convince me that it's possible. :)
BTW, I really like the MA plan. If the goal is 100% coverage, that is probably the most effective way to get it done that is broadly acceptable. BTW, I am very concerned about the law of unintended consequences. It's a practical reason to be very cautious about a wholesale reinvention of 15% of our economy. Those MA pols are pretty clever? Who was the gov. who did that?
But let me give you a chance. Tell me the legislative/political steps by which you think single payer could pass in the next 4 years. Convince me that it's possible. :)
BTW, I really like the MA plan. If the goal is 100% coverage, that is probably the most effective way to get it done that is broadly acceptable. BTW, I am very concerned about the law of unintended consequences. It's a practical reason to be very cautious about a wholesale reinvention of 15% of our economy. Those MA pols are pretty clever? Who was the gov. who did that?
Luddites unite (right after the anarchists)
The site totally messed up the format of my last post. I e-mailed it directly to Dave. If any one of our multitude of readers wants to see it, s/he can e-mail me directly. We'll continue the rest of the discussion on the blog.
Data Dump
Thanks for the compliment, and I'll take a longer read through your post for us to discuss. But to react to your first two paragraphs, reading poll results is as much art as science, so each of us can find different facts out there to support our reasoning. Below are some I just found. (One of them is quite old, but I believe that a more recent poll would should similar results.) Looking at the polls further, I still read this situation as similar to how I think people see education -- country in crisis, but I'm doing OK, thanks; and I think the country's ambivalence towards NCLB and federal involvement in local education would be reflected in a wellspring of opposition to any specific plan that would involve lack of personal choice due to more federal involvement in health care.But I was very surprised in the last three polls below by the extent to which people expressed support in general for more radical health care solutions. (In the 2nd to last poll in particular, I'd be interested to hear the results if the question was phrased in terms of "increased taxes" instead of "increased spending".) More to follow, but these provide some interesting food for thought.
28% Support Democrat strongly 11 Support Democrat, not so strongly 14 Support Republican, not so strongly 43 Support Republican strongly 2 Neither (Vol.) * Both (Vol.) 2 Don't know/Refused [Question ID: USGREEN.07DCJUL.R073] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
24% Support Democrat strongly 13 Support Democrat, not so strongly 17 Support Republican, not so strongly 43 Support Republican strongly 2 Neither (Vol.) * Both (Vol.) 1 Don't know/Refused [Question ID: USGREEN.07DCJUL.R074] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
19% Very satisfied 30 Somewhat satisfied 21 Somewhat dissatisfied 28 Very dissatisfied 2 Don't know/Refused [Question ID: USGREEN.07DCJUL.R048] Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
48% Very satisfied 33 Somewhat satisfied 9 Somewhat dissatisfied 9 Very dissatisfied 1 Don't know/Refused [Question ID: USGREEN.07DCJUL.R049] Data provided by The Roper Center for Public Opinion Research, University of Connecticut. "Overall, how confident are you that your health insurance for next year will meet the healthcare needs of you and your family?"Base: Will have employer-sponsored health insurance next year
Note: Percentages may not add up exactly to 100% due to rounding. Next, thinking about the campaign for the presidential election in 2008, which one of the following health care issues would you most like to hear the presidential candidates talk about and focus on in any health reform plan they may develop?...Expanding health insurance coverage for the uninsured, reducing health care costs, improving the Medicare prescription drug benefit for seniors, improving the quality of care and reducing medical errors, reducing spending on government health programs like Medicare and Medicaid Subpopulation/Note: Asked of Form 1 half sample |
32% Expanding health insurance coverage for the uninsured 31 Reducing health care costs 13 Improving the Medicare prescription drug benefit for seniors 11 Improving the quality of care and reducing medical errors 7 Reducing spending on government health programs like Medicare and Medicaid 2 None of these (Vol.) 1 Other issue (Vol.) 3 Don't know/Refused
| Survey by Henry J. Kaiser Family Foundation. Methodology: Conducted by Princeton Survey Research Associates International, May 31-June 5, 2007 and based on telephone interviews with a national adult sample of 1,203. [USPSRA.062007HTP.R03] Data provided by The Roper Center for Public Opinion Research, University of Connecticut. |
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: The best way to lower health care costs is through government intervention. Second statement: The best way to lower health care costs is through more choices and competition....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
27% First statement strongly
9 First statement not so strongly
13 Second statement not so strongly
45 Second statement strongly
1 Both (Vol.)
1 Neither (Vol.)
3 Don't know/Refused
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time to establish a Canadian-style national health care system that provides affordable health care for all Americans. Second statement: We can improve our health care system through incremental steps without taking radical measures that will result in a government takeover....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
40% First statement strongly
13 First statement not so strongly
14 Second statement not so strongly
29 Second statement strongly
1 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R066]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| All Health-Related Questions from this Survey |
Democracy Corps Poll [May, 2007] Survey by Democracy Corps. Methodology: Conducted by Greenberg Quinlan Rosner Research, May 29-May 31, 2007 and based on telephone interviews with a national likely voters sample of 1,000. Likely voters are registered voters who voted in the 2004 election/weren't registered/ineligible/too young to vote and said they are probably or almost certain to vote in the 2008 election.
| (Now, I'd like to rate your feelings toward some people and organizations, with one hundred meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and fifty meaning not particularly warm or cold. You can use any number from zero to one hundred, the higher the number the more favorable your feelings are toward that person or organization. If you have no opinion or never heard of that person or organization, please say so.)...Single-payer health care system...Give...single-payer health care system a rating, with 100 meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and 50 meaning not particularly warm or cold. (If Don't know, ask;) Would you say you are unable to give an opinion of...single-payer health care system, or have you never heard of...single-payer health care system? Subpopulation/Note: Asked of Form A half sample Mean = 45.1 |
16% Warm 51-100
24 Cool 0-49
25 Not particularly warm or cold 50
35 Never heard of/Don't know/Refused
[Question ID: USGREEN.07DCJUL.R030]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| (Now, I'd like to rate your feelings toward some people and organizations, with one hundred meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling and fifty meaning not particularly warm or cold. You can use any number from zero to one hundred, the higher the number the more favorable your feelings are toward that person or organization. If you have no opinion or never heard of that person or organization, please say so.)...Canadian-style health care system...Give...Canadian-style health care system a rating, with 100 meaning a very warm, favorable feeling, zero meaning a very cold, unfavorable feeling, and 50 meaning not particularly warm or cold. (If Don't know, ask;) Would you say you are unable to give an opinion of...Canadian-style health care system, or have you never heard of...Canadian-style health care system? Subpopulation/Note: Asked of Form B half sample Mean = 48.9 |
34% Warm 51-100
32 Cool 0-49
14 Not particularly warm or cold 50
20 Never heard of/Don't know/Refused
[Question ID: USGREEN.07DCJUL.R031]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about the country as a whole, would you say you are satisfied or dissatisfied with the quality of health care in this country? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form C half sample |
19% Very satisfied
30 Somewhat satisfied
21 Somewhat dissatisfied
28 Very dissatisfied
2 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R048]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about your own situation and your own family, would you say you are satisfied or dissatisfied with the quality of health care you receive? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form C half sample |
48% Very satisfied
33 Somewhat satisfied
9 Somewhat dissatisfied
9 Very dissatisfied
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R049]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about the country as a whole, would you say you are satisfied or dissatisfied with the cost of health care in this country? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form D half sample |
5% Very satisfied
18 Somewhat satisfied
32 Somewhat dissatisfied
42 Very dissatisfied
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R050]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Thinking about your own situation and your own family, would you say you are satisfied or dissatisfied with the cost of health care? (If Satisfied/Dissatisfied, ask:) (Is that very or somewhat?) Subpopulation/Note: Asked of Form D half sample |
18% Very satisfied
25 Somewhat satisfied
24 Somewhat dissatisfied
32 Very dissatisfied
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R051]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Which of the following do you agree with most?...One: On the whole, the health care system in America works pretty well but some changes are necessary. Two: There are good things about the health system in America, but some major changes are needed. Three: America's health care system is so inadequate and has so many problems that we need to completely rebuild it. Subpopulation/Note: * = less than .5%. |
20% One: On the whole, the health care system
in America works pretty well but some changes
are necessary
55 Two: There are good things about the health
system in America, but some major changes are
needed
24 Three: American's health care system is so
inadequate and has so many problems that we
need to completely rebuild it
* Other (Vol.)
1 None (Vol.)
* Don't know
[Question ID: USGREEN.07DCJUL.R052]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Now I'm going to read you some pairs of statements about your own health care priorities. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right....First statement: Lowering health care costs is the more important thing to me. Second statement: Improving quality is the more important thing to me....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form C half sample |
32% First statement strongly
9 First statement not so strongly
14 Second statement not so strongly
38 Second statement strongly
4 Both (Vol.)
1 Neither (Vol.)
1 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R054]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
2
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time to establish a Canadian-style national health care system that provides affordable health care for all Americans. Second statement: We can improve our health care system through incremental steps without taking radical measures that will result in a government takeover....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form A half sample |
40% First statement strongly
13 First statement not so strongly
14 Second statement not so strongly
29 Second statement strongly
1 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R066]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| (Now I'm going to read you some pairs of statements about health care reform for the country. After I read each pair, please tell me whether the first statement or the second statement comes closer to your own view, even if neither is exactly right.)...First statement: Now is the time for single payer health insurance that is funded and administered by the US (United States government. This Canadian-style system would guarantee affordable health care coverage for all Americans and reduce costs by streamlining the administration of health care. Second statement: We need to make changes to our health care system, but we cannot put it in the hands of the government. While health care accounts for 15 percent of our economy, a government takeover is a radical move that will reduce quality of care and eliminate a patient's choice of doctor....(If First/Second statement, ask:) Do you feel that way strongly or not so strongly? Subpopulation/Note: Asked of Form B half sample |
29% First statement strongly
17 First statement not so strongly
14 Second statement not so strongly
35 Second statement strongly
2 Neither (Vol.)
3 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R067]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
| Would you favor or oppose a proposal that provided every American with health insurance, even if it meant your taxes or health care premiums would increase as a result? (If Favor/Oppose, ask:) Do you feel that way strongly or only somewhat? Subpopulation/Note: Asked of Form A half sample |
27% Strongly favor
27 Somewhat favor
16 Somewhat oppose
27 Strongly oppose
4 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R068]
Data provided b
| Let me tell you about a proposal to reform the health care system in this country. This plan would use what some people call a single-payer health care plan. Under this plan, you still would be able to see your own doctor, just like under Medicare, but the federal government would pay the health care costs for all Americans. This would require a significant tax increase, but all of your current health care costs and insurance premiums would be covered by the government. Having heard this, do you favor or oppose this proposal? (If Favor/Oppose, ask:) Do you feel that way strongly or only somewhat? Subpopulation/Note: Asked of Form D half sample |
25% Strongly favor
29 Somewhat favor
12 Somewhat oppose
29 Strongly oppose
5 Don't know/Refused
[Question ID: USGREEN.07DCJUL.R072]
Data provided by The Roper Center for Public Opinion Research, University of Connecticut.
Health Care: A Much Different Answer
I am beginning to realize just why this little project I have gotten us into is, in fact, deeply challenging. You and I, two reasonably intelligent adults who share many common beliefs about the proper role of government and of what constitute our major problems of the day, still adopt fundamentally different approaches to one of those major problems. Usually, I tend to disguise my conclusions of an argument until the end so that I can build to it, but let me make an exception in this case and start at the end and then walk through the logic of my thinking-- to use the term liberally -- all while trying to address the points you raise in your post. So, here's the bottom line: I think the only adequate solution to the health care challenge is to move to a single-payer system. Now, let me explain why.
I'll start by challenging your starting point. You claim that most people are satisfied with their own health coverage, but complain that the system itself is broken. I actually think that most people believe the system is broken AND that their own coverage is both unsatisfactory (or at least frustrating) and -- to one degree or another -- at risk. (By the way, the one group for which the complaints about health care system are lowest is among the elderly who benefit from a single-payer system.) If one starts with this premise, it is a lot easier to argue that radical change (though I wouldn't use that term to sell the plan, of course) is needed. I totally agree that single-payer is easily parodied and has lots of interests arrayed against it, but I also think that the reasons why it is not so far fetched to consider is that (a) a majority of the public is already accepting of single-payer of one form or another and (b) the largest interest of all -- buisness -- is quickly coming to the conclusion that the current system where buisnesses are largely responsible for paying health care costs is unsustainable.
Taking these points in order, consider this poll from CBS, where two thirds say that they believe that there should be universally guaranteed health care and that only 8% want the whole system to stay the same and fully 36% want a total overhaul. I know that these type of polls are not totally reliable because they are conducted in a political vaccuum where people only imagine a best-case scenario without considering all the potential downsides, but still, it seems to me that the public is primed for a total re-thinking of the ways in which health care coverage is delivered in this country.
The second point, in my mind, is more important. You argue in your post that we need to avoid making this about covering the uninsured because -- by and large -- the uninsured don't vote. On this I agree, but rather than aiming to satisfy/appeal to the middle class, I think instead that the whole issue needs to be framed as one that supports business growth. This is an argument that has even broader appeal and, actually, is even more accurate. Until we figure out a way to enable buisnesses to get out from under the burden of rapidly rising health care premiums, economic growth is threatened. When compainies like GM, IBM and GE are paying billions every year in health benefits for their employees, they are looking to stop the bleeding. The best way to stop it is not to stem the rise of health care premiums, but to throw off the burden all together. I suppose these large companies could simply refuse to pay premiums any more and risk losing vast numbers of employees, but a much more reasonable solution is to get some other big entity to pay. Enter the U.S. government.
This argument, by the way, to me represents the true $800 screwdriver. When GM is about to enter contract negotiations with the UAW and the main issue on the table is how to cover the rising health premiums -- not wages, not work conditions, not retirement benefits -- then it seems that the general public will begin to appreciate the scope of the problem.
Now, as to how to implement. This, I grant you, is a bit tricky not so much because the idea is flawed, but because you can't very well propose a plan that -- as attractive as it might be to many -- wipes out an entire industry (HMOs). I was going to propose that we need an interim phase where coverage is universal and that the cost burdens are shifted from business to the government, but that preserves the role of HMOs to manage individual plans. I suppose this is the route that Massachusetts has taken. (Details here.) We'll have to see how this plays out. It will certainly help with one of the main issues -- coverage -- but I find it hard to believe that it is going to make much of a difference on business growth matter and, so, does not represent a long-term solution.
Instead, I think we need a plan that simply sets the goal of universal health care coverage by the U.S. government as a goal and builds in a phasing in period where essentially Medicare extends its coverage to ever-greater age range. Coverage should begin first with 0 - 18 and then, for example, could add people within five-year age range increments each year over the next several years. This phase-in period would then give time to (a) HMOs to adjust their services to supplemental coverage -- much as they do for the over-65 set now; (b) the government to build up the systems needed to vastly expand and, as you rightly suggest, streamline the coverage and delivery of health care in several ways (electronic record-keeping, standard-setting, etc.); and (c) buisness to adjust salary structures to accommodate the sloughing off of paying health care benefits. On this last point, I would suggest that any good plan also has to have some regulation built in for how businesses shift monies from paying health care premiums to increased salaries that is fair to both employer and employee.
As for the issue of choice, I've never understood this problem. If every doctor accepts the same payer, then presumably patients would have more -- not less -- choice than they do when some doctors now accept patients from some plans and not others. There would be less choice for doctors, I suppose, but I think it is possible to build in some safeguards to insure that payments are fair and that there is limited abuse. As for rationing of certain procedures, this may be a real problem, but think it will be relatively limited and, if we are able to spread health care dollars more equitably, then it will actually make other problems like better technology driving up costs less dramatic. We could also build in some incentives for getting more primary care doctors into practice to build in more gate keepers into the system
A final detail point about how we pay for all this. Coverage is paid for by an increase of taxes to both employers and employees/taxpayers, but these increases, I am assuming, will be lower overall than current taxes + health care premiums. Even if the total tax/health care burden is reduced by 10% overall, it seems a no brainer. My guess, though, is that there will be even more savings than that, however. I am not sure, but I would think that covering the uninsured will do much to drive down costs. After all, if the uninsured currently use expensive ERs as their primary form of care and do not take preventive health seriously then it just makes sense that they will spend less as individuals with access to regular health care and, so, costs for the whole system will fall, as well. I know that Massachusetts is counting on this phenomenon to kick in. Also, eliminating HMO bureaucracy from the mix is bound to reduce overall costs.
To wrap up, I am both optimistic and pessimistic. On the latter point first, considering you claim that a single-payer system is a non-starter in your view, I'm not sure you and I are going to come up with some consensus plan that satisfies both our perspectives and if we can't do it, then I fear that no one can. If we cannot reach some national compromise, we'll be stuck with some variation of the same mess we are in now. At the same time, I have become increasingly persuaded that we are approaching a crisis moment. As many are fond of saying, the Chinese word for crisis is a combination of the words "risk" and "opportunity". I believe that as the crisis looms larger, the U.S. will simply have to take a more risky, but opportunity-filled step of completely overhauling the health care system. With all due respect, anything else just tinkers around the edges and leaves us in the same sorry state we're in now.
One final -- and tangential -- point that I was going to include in a separate post, but may as well throw it in here since it stems directly from yours. Your notion that there should be a set of industry-based standards of care is, in theory, good, and should defintely be explored within the context of a single-payer system, but I also think that you both overestimate and gloss over the capacity of medicine to adhere to standards. On the one hand, medicine is as much art as science. There may be certain standards of care, but as I see up close, there is also a fair amount of guess work and gray areas that simply cannot be regulated from afar. There may be room for standards, I suppose, but doctors also operate on a case-by-case basis and make decisions with individual patients and so such standards may not be possible to implement absolutely in practice. On the other hand, doctors also can fall into the habit of operating by rote and misdiagnosis or mistreat some condition because they are looking at the problem in a particular way or with a particular set of experiences. Standards may act only to exacerbate such tendencies and may, in fact, make things worse, not better.
I guess that, ultimately, our debate will continue. I only wish that the debate in the wider public sphere would continue with even a modicum of the respect and earnestness we are trying to exhibit here.
I'll start by challenging your starting point. You claim that most people are satisfied with their own health coverage, but complain that the system itself is broken. I actually think that most people believe the system is broken AND that their own coverage is both unsatisfactory (or at least frustrating) and -- to one degree or another -- at risk. (By the way, the one group for which the complaints about health care system are lowest is among the elderly who benefit from a single-payer system.) If one starts with this premise, it is a lot easier to argue that radical change (though I wouldn't use that term to sell the plan, of course) is needed. I totally agree that single-payer is easily parodied and has lots of interests arrayed against it, but I also think that the reasons why it is not so far fetched to consider is that (a) a majority of the public is already accepting of single-payer of one form or another and (b) the largest interest of all -- buisness -- is quickly coming to the conclusion that the current system where buisnesses are largely responsible for paying health care costs is unsustainable.
Taking these points in order, consider this poll from CBS, where two thirds say that they believe that there should be universally guaranteed health care and that only 8% want the whole system to stay the same and fully 36% want a total overhaul. I know that these type of polls are not totally reliable because they are conducted in a political vaccuum where people only imagine a best-case scenario without considering all the potential downsides, but still, it seems to me that the public is primed for a total re-thinking of the ways in which health care coverage is delivered in this country.
The second point, in my mind, is more important. You argue in your post that we need to avoid making this about covering the uninsured because -- by and large -- the uninsured don't vote. On this I agree, but rather than aiming to satisfy/appeal to the middle class, I think instead that the whole issue needs to be framed as one that supports business growth. This is an argument that has even broader appeal and, actually, is even more accurate. Until we figure out a way to enable buisnesses to get out from under the burden of rapidly rising health care premiums, economic growth is threatened. When compainies like GM, IBM and GE are paying billions every year in health benefits for their employees, they are looking to stop the bleeding. The best way to stop it is not to stem the rise of health care premiums, but to throw off the burden all together. I suppose these large companies could simply refuse to pay premiums any more and risk losing vast numbers of employees, but a much more reasonable solution is to get some other big entity to pay. Enter the U.S. government.
This argument, by the way, to me represents the true $800 screwdriver. When GM is about to enter contract negotiations with the UAW and the main issue on the table is how to cover the rising health premiums -- not wages, not work conditions, not retirement benefits -- then it seems that the general public will begin to appreciate the scope of the problem.
Now, as to how to implement. This, I grant you, is a bit tricky not so much because the idea is flawed, but because you can't very well propose a plan that -- as attractive as it might be to many -- wipes out an entire industry (HMOs). I was going to propose that we need an interim phase where coverage is universal and that the cost burdens are shifted from business to the government, but that preserves the role of HMOs to manage individual plans. I suppose this is the route that Massachusetts has taken. (Details here.) We'll have to see how this plays out. It will certainly help with one of the main issues -- coverage -- but I find it hard to believe that it is going to make much of a difference on business growth matter and, so, does not represent a long-term solution.
Instead, I think we need a plan that simply sets the goal of universal health care coverage by the U.S. government as a goal and builds in a phasing in period where essentially Medicare extends its coverage to ever-greater age range. Coverage should begin first with 0 - 18 and then, for example, could add people within five-year age range increments each year over the next several years. This phase-in period would then give time to (a) HMOs to adjust their services to supplemental coverage -- much as they do for the over-65 set now; (b) the government to build up the systems needed to vastly expand and, as you rightly suggest, streamline the coverage and delivery of health care in several ways (electronic record-keeping, standard-setting, etc.); and (c) buisness to adjust salary structures to accommodate the sloughing off of paying health care benefits. On this last point, I would suggest that any good plan also has to have some regulation built in for how businesses shift monies from paying health care premiums to increased salaries that is fair to both employer and employee.
As for the issue of choice, I've never understood this problem. If every doctor accepts the same payer, then presumably patients would have more -- not less -- choice than they do when some doctors now accept patients from some plans and not others. There would be less choice for doctors, I suppose, but I think it is possible to build in some safeguards to insure that payments are fair and that there is limited abuse. As for rationing of certain procedures, this may be a real problem, but think it will be relatively limited and, if we are able to spread health care dollars more equitably, then it will actually make other problems like better technology driving up costs less dramatic. We could also build in some incentives for getting more primary care doctors into practice to build in more gate keepers into the system
A final detail point about how we pay for all this. Coverage is paid for by an increase of taxes to both employers and employees/taxpayers, but these increases, I am assuming, will be lower overall than current taxes + health care premiums. Even if the total tax/health care burden is reduced by 10% overall, it seems a no brainer. My guess, though, is that there will be even more savings than that, however. I am not sure, but I would think that covering the uninsured will do much to drive down costs. After all, if the uninsured currently use expensive ERs as their primary form of care and do not take preventive health seriously then it just makes sense that they will spend less as individuals with access to regular health care and, so, costs for the whole system will fall, as well. I know that Massachusetts is counting on this phenomenon to kick in. Also, eliminating HMO bureaucracy from the mix is bound to reduce overall costs.
To wrap up, I am both optimistic and pessimistic. On the latter point first, considering you claim that a single-payer system is a non-starter in your view, I'm not sure you and I are going to come up with some consensus plan that satisfies both our perspectives and if we can't do it, then I fear that no one can. If we cannot reach some national compromise, we'll be stuck with some variation of the same mess we are in now. At the same time, I have become increasingly persuaded that we are approaching a crisis moment. As many are fond of saying, the Chinese word for crisis is a combination of the words "risk" and "opportunity". I believe that as the crisis looms larger, the U.S. will simply have to take a more risky, but opportunity-filled step of completely overhauling the health care system. With all due respect, anything else just tinkers around the edges and leaves us in the same sorry state we're in now.
One final -- and tangential -- point that I was going to include in a separate post, but may as well throw it in here since it stems directly from yours. Your notion that there should be a set of industry-based standards of care is, in theory, good, and should defintely be explored within the context of a single-payer system, but I also think that you both overestimate and gloss over the capacity of medicine to adhere to standards. On the one hand, medicine is as much art as science. There may be certain standards of care, but as I see up close, there is also a fair amount of guess work and gray areas that simply cannot be regulated from afar. There may be room for standards, I suppose, but doctors also operate on a case-by-case basis and make decisions with individual patients and so such standards may not be possible to implement absolutely in practice. On the other hand, doctors also can fall into the habit of operating by rote and misdiagnosis or mistreat some condition because they are looking at the problem in a particular way or with a particular set of experiences. Standards may act only to exacerbate such tendencies and may, in fact, make things worse, not better.
I guess that, ultimately, our debate will continue. I only wish that the debate in the wider public sphere would continue with even a modicum of the respect and earnestness we are trying to exhibit here.
Subscribe to:
Posts (Atom)