Equal Opportunity Reviewer Bashing

I am similarly displeased by this review from the left of another "What's the matter with the Democrats" book, "The Argument" by Matt Bai. A few points:

1) Michiko reviews far, far too many contemporary political books. And her "reviews" are rarely more than summaries of the key points from the books with a few illustrative quotes, followed by some like-minded piling on against the Bush Administration.

2) I'm very tired (as has previously been documented, as my friend Ted knows) of the self-serving reviews within the Times of books by NY Times writers or which have previously appeared in a different form in the Times. These books should appear in a "Noted for your Information" column, as the Times has shown no ability to conduct reviews for these books which are either fair or useful for their readers.

3) I haven't read Bai's book, but I've read almost all of his NY Times Magazine pieces, and this book is so clearly a compilation of the past 4 years of this reportage. Maybe Bai is hoping that no one has noticed, but the political world has changed just a bit since 2003. How can any serious reviewer can not point out how dated the book is? This is yesterday's first draft of history, which isn't too different from what is lining today's litter box.

BTW, the Salon review of the book includes this great quote.

One of my favorite stories in "The Argument" features Democratic Congressional Campaign chairman Rahm Emanuel, another ambiguous figure -- Bai seems to like him, even though he's a message-agnostic, win-at-any-cost pol from Chicago -- blowing up after having to sit through a work session on crafting a coherent Democratic appeal. Told that it's not enough to simply attack the Republican Congress (which is the whole point of Bai's book), Emanuel snarls: "I have my knee on their vertebrae, and I'm not going to let up on the pressure until I hear the vertebrae snap."

I don't know the date of this quote, but it could be anytime from 2006 until now. Emanuel is right and wrong at the same time. We'll find out in Nov. 2008 if he was more right than wrong. (It's a little bit like the difference between Hillary and Obama. BTW, I would love to sit in on the uncensored conversations that he and Obama have. Same city, same generation, and seemingly such a different approach to politics. Would be fascinating.)

Attack of the smug

Though I appreciate the diversity that David Brooks brings to the NY Times Op-Ed page, and he frequently makes some interesting points (which are just as frequently expanded way out of proportion to his supportive evidence), this "review" is Exhibit 28 in why he infuriates me. And the editors thought he would write a fair (and meaningful) review of this book, Why?

Go Team!

I didn't mean to leave you speechless, Dave. Well, good thing we have 15 months to go before we give these ideas to the next Democratic President. :)

While it's a pretty safe assumption that Dems will be less aggressive and strategic in responding to spurious claims than the right, I think that Drum is off-base here. Dems still have a winning hand on the Iraq issue. It's was a war of choice, George Bush's choice, it's going badly, 70%+ of Americans want it to end and for us to bring our troops home. Bush and the GOP have been dead wrong on every aspect of the war, from choosing to fight it to how they fought it to telling the American people for 4 years that it was going great. Bush is desperately grasping at anything he can to rebuild some support for the war, but Vietnam is a distraction. We should keep focus directly on this war, which is a disaster for everyone and is Bush's fault. (And I like your line. That kind of dismissal of this attempted sideshow is perfect.)

The problem we all have is that Colin Powell was right, and, to some extent, Bush was right. We broke it, we bought it. Maybe 2-3 years ago it was accurate to say that much of the violence in Iraq was spurred by the American presence, and therefore our departure may have been an improvement for Iraq. But now, with a full fledged, low-level civil war underway, it seems hard to argue that the Americans are not a stabilizing force in the country and that, at least in the short term, you'd see an upswing in violence were we to leave.

This is a very tough one. There's a reason why the objective function of the Baker-Hamilton report seemed to be an outcome that would have broad bi-partisan support among the U.S. public and preserve some of our dignity rather than one which would be the best for the Iraqi people.

Worst. Foreign. Policy. Debacle. Ever.

We Interrupt This Discussion...

I know I have lamely shirked my responsibility to respond to your thoughtful post on health care. I promise that I will, but wanted to get your thoughts on this idea that Kevin Drum proposes.

What is the proper reaction to the president's latest salvo at undermining all that is good and noble about simple truth? Do we ignore the inanity of the claim that Vietnam could have been won and we are in the same situation now in Iraq so that we prove its inanity by ignoring it or do we actually try to counter the fantasy by bombarding the public with a dose of reality? I'm actually inclined to take the middle ground between the choices. How about dismissing the claim not with an argument, so much as with a snarky comment like, "If the president really wishes to associate his war with the ten years of failed military and political policy of Vietnam, that is his choice."? If Kevin really wants us to fight back against the right, then we need to sound as arrogant and cavalier as they do.

What say you? Talk truth, ignore fantasy or talk trash?

Health Care - The Answer :!*)

OK. I’ve been thinking about your health care challenge over the last week or so. I definitely view this as a work in process, to be improved by our mutual contributions. Let me lay out a framework for how I’m thinking about this, then work up to a policy solution and a way to package it.

The landscape on this issue is not as politicized as some. To the extent that it is, the groundwork is laid along the usual lines of the Dems as the mommy/big government party - wanting to make sure that everyone is covered and healthier and eager to see the government expand deeper into all of our lives to accomplish this - and the GOP is the daddy/small government party - wanting to see people take responsibility for their own health, trusting the free enterprise system to solve social problems, and wanting a relaxation of the government's role in the sector.

Currently, I'd say most Americans feel about health care similarly to how they feel about education. Everyone says it’s a crisis, so it must be, but my school (or coverage) seems to be pretty good. To the extent that there is a problem, people would describe it differently. Some point to 50 million uninsured, some point to the hassles of those with insurance and the evils of HMOs, some point to the toll that health care spending is putting on American companies, some point to the wasteful spending, with primary subproblems within that being too little spent on prevention, too much spent on insurance and unnecessary procedures, too much spent on paperwork and processing, too much spent on pharma, too much spent on the last 3 months of life.

One issue with taking the lead in trying to solve health care is that no one can agree on what the problem is. So, first you've got to convince the majority of the American people that what you say is a problem is really an important problem, then you've got to deal with everyone trying to tear down your solution.

There are a few traps for the Democrats to avoid. First, they have to avoid single payer. The entrenched interests against it are too many, it’s too easy to parody as socialist (or worse, French) and there is not enough of a sense of crisis for people to support a revolution in our health care delivery and payment system. Second, you have to avoid anything that would restrict or ration care at the top end, for the same reason. Third, you have to avoidance making 'universal coverage' your rallying cry. The middle class doesn't care, many uncovered people could afford coverage but choose not to buy it, and the working poor are outnumbered and under-registered.

So, what do you do? First, you focus on the issues of the middle class and the economy. Then you focus on cost and quality. We’re not getting what we pay for. Increasing technology is decreasing costs in computing, home electronics and telecommunications. Why is it increasing costs in health care? And why aren’t we healthier when we are paying so much?

To step back, why do people buy insurance? Typically, it's to avoid risk. Maybe there is only a 1/1000 chance of your house burning down this year, but that outcome is so catastrophic that it is worth paying 1/500th of the value of your house each year for fire insurance. So, it's worth paying $5000/year for health insurance to avoid the 1% chance of having to pay $250,000 in health costs which would be bankrupting. For health insurance, there is another, somewhat paradoxical reason to buy it. Humans are notoriously poor at making trade-offs between the present and the future. Even while we know that eating fatty foods will clog our arteries in the future, we often don't pass up the KFC for the big salad. In terms of health, that means that people will put off that check-up at their doctor and stay home to watch Big Brother instead. So, it makes sense to have pre-paid insurance so the check-up is free and more people would go than if they paid the actual price. The downside of insurance is what's called moral hazard. If I know that I have collision insurance in my rental car, I may drive a bit more recklessly than if I knew I was liable for any scratches. (The health care world is filled with enough other economic inefficiencies to fill about a dozen PhD theses.)

So, here are some attractive principles to start with that make sense and would appeal to the American public. I’ll build my policy and packaging suggestions from these:

1) People need catastrophic insurance. They want it and need the security of knowing that they are not one illness away from bankruptcy
2) People need choices. You only can go to this one doctor and have to pay huge to go out of network is a non-starter
3) Squeezing cost out of the system is good, if it doesn't hurt quality or personal choice.
4) Americans like technology and they like progress. Any system has got to encourage technological advances
5) Health care should be affordable for the average American
6) Single payer is a non-starter
7) The focus of reform efforts should be on things that make life better for the middle class
8) There is lots of room for quality improvement in American health care
9) You shouldn’t have to pay a lot to get high quality. People get it with Toyota and Target.

So here are some components of a solution that should be sellable. I'll think about the packaging of this a little later.

1) Implement voluntary, industry based standards organizations with incentives to join. Government imposed standards are easy to attack. Industry driven standards work very well in the technology/telecommunications fields and are harder to criticize from the right. There should be standards of care for say the 10-20 most common/expensive complaints/procedures/ conditions. The AMA and hospital associations, etc. should get together to agree on these standards of care, convened by the government. Health care providers should be judged based on how well they meet these, and there should be a financial incentive (but no requirement) to do so.

2) Tort reform. This is an issue to take away from the GOP and it reinforces the message of controlling costs (even though it’s probably not a big component of that.) A couple of things I’d suggest. First, all MDs or HMOs should be exempt from liability when they follow the standard of care guidelines above. Second, there should be a declining, sliding scale for legal fees. Third, punitive damages above a certain amount go to a central fund not to the plaintive.

3) There should be differential Medicare reimbursement rates based on efficacy. Providers meeting the standards of care above should be reimbursed at a higher rate. New drug reimbursement rates should be keyed to how much of an improvement the drug is over the previous therapies. Perhaps MD’s or hospitals should receive some kind of incentive based on how often they prescribe generics when they are available.

4) Tax advantages should be available for companies and individuals that follow these “more effective” plans. This should help lift the burden on companies facing foreign competition and make it easier for uninsured Americans to buy plans.

5) There should be an industry based standard for electronic medical records. Not a standard software, but a standard dataset and flows. This is a huge savings opportunity and a great way to use standards to help a whole community. (It's like defining a standard rail track gauge in the olden days.)

6) Cover all kids. This is just a no brainer. (I'm not up on the details of the current proposals for this.)

7) Create attractive national policies for individuals not covered from work to buy into. These should be offered by private companies, and giving people a choice of different tiers. The baseline ones should be low cost, cover preventative care for free, give $ back for healthy behaviors, have high deductible but good catastrophic coverage.

In terms of messaging, I think these are the kind of messages we should use:

• Health care is becoming unaffordable for the average American
• We need to make sure health care is affordable for everyone
• We can get higher quality at lower cost
• We will use market based solutions to fix market failures
• American ingenuity will help us make sure that all Americans have the best health care in the world

Also, to drive the cost point home, we need to find our $800 screwdriver -- the sticky example of just how broken the system is. And we should make the point that these changes will be revenue neutral at all levels of government. The federal government will spend more on tax breaks for these “approved” plans, but it will reap savings in Medicare and Medicaid spending, and the state and local governments will save a lot in these two areas.

To wrap up this mega-post and return to its political possibilities, the left wouldn’t like this plan because it doesn’t provide universal coverage. The right wouldn’t like it because it will increase federal spending and also injects these standards organizations into the marketplace. The pharmas won’t like it because they will have to show greater efficacy for their drugs to get maximum reimbursement. I’m not sure how the AMA and hospital groups would react. Getting them inside the tent on the standards of care setting is key. (But that process will be hellacious.) Individual doctors may object, saying that the government is telling them how to practice medicine. (In reality, the government is just setting different reimbursement rates based on the scientific recommendations for standards of care.) Insurance companies should like the electronic medical records and the additional tax incentives, but may have issues with selected standards of care.

For middle class consumers, I think this issue is winnable in this presentation. They would be told that their own health care costs will start to decline and that the government is reining in costs overall. Not exactly the most powerful rallying cry, but I think it is still a compelling message for how they benefit and how the country benefits, which is what was missing in the compromise immigration bill.

Your thoughts?

See you in a week

Good choice. Health care is a bit easier than some, because it's less ideological than many of the other issues (though the GOP tried to change that in 1993). But it's harder than others because it's not nearly as clear what the "right policy answer" is. (I consider defining the goal as "universal coverage" to be part of the Dems problem, but I'll get back to that in my next, longer post.)

BTW, I'm realizing that you really are much more cynical than I am. I'd say that on an issue-by-issue basis, 50% of success in gathering public support is having a good solution to an issue that matters to people, and 50% is how it is framed and presented (by both sides). So, I see a big part of our exercise to be coming up with smart, workable solutions. The rest (which may indeed be harder) will be informed by these interesting insights and a little strategic thinking on our part. (That's where your cynicism will come in very handy.)

Have a great time this week on vacation, and I'll post something here over the next week for you (and others) to react to.

Leading Off...

Well, it seems that there are a couple of ways to go here. We could start easy and then tackle more difficult issues -- not that any issue is really easy -- or we could try to tackle the bigger, more complicated ones first and then the "simpler" ones can flow from there. I'm inclined to adopt the former approach, so here goes.

Health care. This is shaping up to be perhaps the number one domestic issue of the campaign. It is also an issue that is prone to a lot of myths, in part because everyone has had personal experience with the health care system and, as human beings, we tend to extrapolate from personal experience to the whole, and in part because it is so easy to lampoon and propagandize. Just yesterday, for example, Guiliani came out with his health care "plan" and it is based entirely on the principle of not turning our healthcare system "French". All objective analyses, of course, point to the French system as essentially equal to ours in quality -- and superior in some areas -- that costs 40% less, but those inconvenient facts shouldn't stand in the way of good old American exceptionalism and a little French-bashing, to boot.

So, then, what is a good solution? For so many reasons, there is no way we can hope to replicate the French system -- French doctors earn a lot less, for example, and the AMA would never allow that to happen -- and we don't want the British system which actually is worse than the U.S. in many areas in delivering services. Yet the current American system of a patchwork of private insurers which only partially cover people and, often, only the healthiest people, is, to use one scholar's term, "sicko." How do we get to universal coverage -- which I do think must stand as the only really acceptable goal -- without making it seem like socialized medicine? Notice I use "seem" in the last sentence. Smart people know that the best-run health care system in the country is run by the govt. in the VA and that the group least likely to complain about health care coverage is the elderly who have Medicare. This then is all about marketing, not about facts. But that is the point of this whole exercise anyhow.

Good luck.

Oh, Great. Another Gauntlet :)

What a bracing and stimulating idea, Dave. You're on. I don't think this work is easy by any means, but I think it is doable, within the constraints you laid out. Let's take one issue at a time. (As even doing one well would be a worthy accomplishment.) Select one to start with from the following (or add your own):

Fighting fundamentalist Islamic terrorism
Immigration
Globalization
Climate change
Entitlement insolvency
Education
Health care
Abortion
Moral issues/strengthening families
Farm policy
Government spending
Taxes
Estate tax
Economic growth
Regulation/tort reform

The Samuelson article was interesting. I don't know too much about his other writing, but this seemed reasonably on target. (Though I think there probably has been a lot of serious work on this issue by a various of groups, all bound and gathering dust on staffers' shelves somewhere.) It's always easier to make big changes after a crisis, so this topic remains the "third rail" of American politics until either people understand there is a coming crisis (do we need to watch "An Inconvenient Lockbox" before that happens?) or if a politician has the courage to upset the status quo to try to solve this proactively. Or until two verbose bloggers solve the country's problems with enough time left over to catch the ballgame tonight. :)

Addendum

Usually I find Robert Samuelson to be maddeningly "even-handed" in his discussions of policy, refusing to acknowledge that Republican (or Democratic) ideas are just a sham, but this strikes me as a pretty good idea, in general, and not just on the big issue he suggests. Perhaps if our experiment fails, we could get something like this started.

Throwing Down the Gauntlet

OK, big shot. So let's put this blogging thing to good use. If you think it is actually possible to message smart policy in easily digestible and attractive ways, let's get started. Over the next few days (or weeks, whatever), let's take on a series of issues and actually put language around some sound policies that might also have some life on the campaign trail. In other words, let's try to inch Democratic candidates closer to a real agenda, while, at the same time, making that agenda marketable to the broader public.

I still contend that when it actually comes down to engaging in this work of messaging, it is incredibly difficult and, frankly, is much easier when you actually don't care about policies that will really have a positive impact. That said, I am willing to give it a try, if you are. (There is no way I could do it alone, but I think a bit of back and forth has a better chance of producing something useful.)

Let me propose a couple of groundrules for this little exercise. First, you need to come up with a pithy slogan that accurately captures the essence of the policy AND that the general public can resonate to. (After all, if we are going to effectively counter the GOP, we need something that can counter something like "lower taxes and less government," etc.) Second, you need to lay out at least a few key principal policy points that (a) demonstrate a reasonable amount of depth and move beyond platitudes to real change proposals, (b) are feasible, both financially and politically, (c) are "simple" enough that they can be readily understood and (d) effectively point out where the opposition is wrong and why this policy approach is superior. Perhaps it is unfair to place such a high bar, but, IMO, unless you can satisfy all these criteria, we'll be in the same place we are now.

Since I proposed the groundrules -- which you can push back against, if you think they are too constraining or misguided -- you can pick the issue(s). Off we go...