Hacker makes the definitive case.
Tag: "health care"
I was fortunate enough to be part of a group of journalists and bloggers invited to meet with President Clinton at his offices in Harlem this afternoon. The main subject was the Clinton Foundation, but as one would expect the conversation ended up being quite wide-ranging. There was lots of interesting stuff, but perhaps best was Clinton’s argument for being very bold on health care. Clinton identified four major ways in which the current context differs from the one he faced in 1993:
- A different psychological and political landscape. Because, as Clinton noted, Democrats in Congress had stopped Reagan’s strongest anti-government from being enacted, stated Republican retained a popularity that, after 8 years of Bush (much of it under unified government) they no longer do. Knee-jerk anti-government opposition won’t be nearly as effective. And, of course, Obama has larger and more liberal majorities to work with.
- Obama doesn’t have the same budget restraints. Clinton, having barely gotten a minor tax increase through Congress, wasn’t in the position to raise taxes. Obama will have more options, along with a political context much more receptive to spending increases (although of course this window will close shortly, making quick action on health care essential.)
- Obama doesn’t have to deal with a Republican Senate leader running for President. The famous letter from Bill Kristol to Dole played a significant role in killing Clinton’s proposed reforms, although Dole might have been willing to cut a deal in different circumstances.
- Health Care has gotten even worse. Since the GOP killed reform, American health care has continued to get more expensive while failing to even come close to universal coverage and failing to produce outcomes any better than countries that provide care to more people for less money.
I might quibble with #3 — while of course this precise factor shouldn’t be an issue, it looks like most Republicans in Congress plan on being just as obstructionist. The other 3 points are certainly valid, and for this reason Obama needs to be aggressive rather than living in fear of the failure of reform that happened under Clinton.
From a strategic perspective, Clinton said that it was smart for Obama to try to get 60 votes rather than using reconciliation, to preserve his relationship with Congress for other issues. However, that doesn’t mean “giving away the store”; if the only way to get a good bill — i.e. universal coverage combined with policies that will contain spending — is a 50%+1 vote, then that’s what Obama should do. I think that this is right (and if Obama attempts to get a more bipartisan bill, this would also contain the political damage if he needs to do it with a simple majority.)
Well, this isn’t surprising. Hopefully, this time parochial interests won’t trump the compelling public interest, although given the extent to which American political institutions favor the former I’m still not inclined to bet on it.
Matt Yglesias points out he doesn’t really think that raising sin taxes will reduce health care costs. And he doesn’t make that argument in the post in which I attributed it to him, although he does link approvingly to people who do.
As Matt Weiner notes in the comments to my post, I over-interpreted what Yglesias was saying — he was arguing that “sin taxes” are a desirable way to raise revenue to pay for health care, and may well improve public health in the bargain. I’m more skeptical than he is about the latter point, for reasons I reference in my original post.
But my real concern is an argument that shows up all over the comments to Matt’s post, and, somewhat more significantly, is implicit in such pronouncements as Obama’s preposterous claim during the presidential campaign that rolling back obesity rates to 1980 levels would save Medicare a trillion dollars.
That argument is that people get sick because of lifestyle choices, which means that being sick is your own fault, which in turn means that “forcing” me to pay for your health care means I’m being forced to subsidize your bad lifestyle. This argument isn’t completely false, but it wildly exaggerates the extent to which “bad” lifestyle choices are responsible for health care costs. (As I pointed out in the context of cigarette smoking, it’s not even clear that a healthy lifestyle produces a net health care savings to society in comparison to a less healthy one). And it’s fueling such dubious innovations as quasi-mandatory “wellness programs” for employees
In other words, the really invidious effect of this argument is that it provides yet another handy excuse for not socializing the cost of health care, since needing health care at all, in the most extreme version, becomes a “choice.” And it’s disturbing how many people buy into some version of that claim.
This Yglesias post reflects a group of beliefs regarding public health that tend to cut across ideological lines, probably because they resonate with some deeply embedded cultural puritanism that affects both the right and the left in America.
To simplify somewhat (but not much), the argument is roughly that health care costs so much because people get sick, and people get sick because they have bad habits. So the key to cutting health care costs is to get people to behave better.
Right-wingers tend to frame this argument in terms of “individual responsibility,” while lefties are more prone to blame structural factors, but in both cases the solution to the problem is the same: get Americans to stop stuffing their fat lazy faces with “junk food,” soda, alcohol, and cigarettes, so we can get health care costs under control.
This argument is wrong-headed on a whole bunch of levels. In particular it assumes that people get sick primarily because of their lifestyle habits, when in point of fact people get sick mainly because they get old. And old peoples’ health care costs a lot. But an even bigger problem is the assumption that improving peoples’ health means their health care will end up costing less.
Indeed, consider the one item on this agenda that would actually improve public health: decreasing smoking rates. It’s far from clear that decreasing cigarette smoking would actually save health care costs. It may well be that the improved health quitting smoking produces decreases costs in the short run, but increases them in the long run, because non-smokers live so much longer.
As for the other stuff, it’s been 90 years since Prohibition and the spiritual descendants of Carrie Nation are very much with us. When a smart guy like Yglesias simply assumes that alcohol consumption is a net negative to society it’s easier to understand how this nation’s insane drug policies remain so difficult to reform. It should be unnecessary to point out that alcohol seems to have a markedly beneficial effect on the health, even narrowly defined, of moderate drinkers. This doesn’t even take into account that drinking produces enormous amounts of pleasure, which of course is why the puritans hate it so much. Surely that should count for something. Drinking also generates considerable social costs, but to assume without argument that America would be a better place if people drank less is completely unwarranted.
As for soda and “junk food,” Barry Glassner’s The Gospel of Food is a nice introduction to the moralistic hysteria surrounding these subjects. In any case the notion we can cut health care costs significantly by getting people to drink less soda and eat fewer Doritos is unsupported by any evidence.
The bottom line is that health care costs have risen so much in large part because health has improved so drastically in America. 100 years ago life expectancy was 50, most diseases were basically untreatable, and health care costs were really low. Getting everybody to stop smoking, give up the demon rum, and eat like Alice Waters isn’t going to return us to that utopia.
One thing of note to add to this analysis of the Swiss health care system is that, as Ellen Immergut has pointed out, Switzerland is comparable to the U.S. in having an unusually large number of veto points that gave particularly high levels of power to minorities with a vested interest in the status quo. This isn’t to say that things will play out in the same way (the institutional structures are still different), and Matt is right that the Dems should be pushing a public option as hard they can. But it’s possible that something like the Swiss system is the most viable means of health care reform in the short-term. This is highly suboptimal, but if it’s intelligent in the details it could certainly be a major improvement over the status quo.
Long-time readers will know I agree entirely with this:
So that’s the context in which to ask whether or not it makes sense to have a supermajority requirement for many Senate votes. I would say “no.” Even absent the filibuster, our system would still feature an unusually large number of veto points, especially when you take our unusually robust system of judicial review into account. The supermajority requirement is at odds with our basic democratic norms, you’d be hard-pressed to come up with an example of it ever actually being used to protect the interests of some kind of put-upon minority, and I see no empirical reason to think that our systematically larger number of veto points is producing systematically better results than you see elsewhere. On the other hand, there’s good reason to believe that the large number of veto points makes it easier for narrow interest groups to block public interest reforms.
In terms of Matt’s question about the originality of Tsebelis’s argumemts, I don’t mean it as a criticism of his excellent book to note that this point has been made convincingly by people working in the historical institutionalist tradition as well as rational choicers. Most relevant to the Obama administration is the analysis of scholars like Ellen Immergut and Sven Steinmo, which demonstrates how the chances of achieving major health care reform diminish greatly with additional veto points. Talk about how American doctors and insurance companies oppose health care reform doesn’t explain much in itself, because these groups pretty much always oppose comprehensive reforms everywhere. The difference is that the American system allows representatives of these interests to block even popular reforms much more easily.
For this reason, it’s good that Pelosi is taking away tools allowing for minority vetoes in the House of Representatives, and it’s black comedy for Congressional Republicans to claim that making it more difficult to quietly thwart majority-favored legislation without an up-or-down vote is a blow to “transparency” and “fairness.”
This abominable rule shouldn’t survive the first week of the Obama presidency; the fact that it will — because reversing it takes a good bit of time and squanders resources that could be devoted to other tasks — it’s precisely the sort of thing that puts the lie to the polite notion that we should “disagree without being disagreeable.”
The country is being managed for the time being by people who would be instantly tossed into the ocean if our democracy permitted such an entirely reasonable solution to be put to a national plebiscite. And yet here they are, providing legal cover for the tiny percentage of health professionals who would rather adhere to religious superstition than do their bloody jobs. Moreover, they did so in the face of overwhelming professional condemnation of the proposed rules during the public comment period, and they issued the final regulations late enough that they’ll take effect two days prior to the end of the Bush administration. Being “disagreeable” with the people who created and supported these changes is quite literally the least they deserve. These people don’t care about effectively running a government, and of course they never have. But now that the end is near, they’re ripping out the drywall and stripping the wires, fastening laser printers to their backs, and loading up the service elevators with everything that isn’t nailed down.
Family visitation and work commitments meant that I didn’t see any speeches at the GOP convention last night; I can’t say I was terribly disappointed. Nonetheless, I did look at some transcripts and clips. We could do this all day, but consider the density of lies and nonsense packed into this sentence:
[Obama's] plan will force small businesses to cut jobs, reduce wages, and force families into a government-run health care system where a bureaucrat…
… where a bureaucrat stands between you and your doctor.
There are a couple of obvious lies here: Obama’s plan specifically exempts small businesses from contribution requirements, and he’s not proposing British-style socialized medicine. But what really kills me is the idea that in the current American system no “bureaucrat” will stand between you and your health care. I hate to break this to McCain — whose immense wealth and government benefits mean he doesn’t have to deal with this — but private insurance companies all invest in large bureaucracies whose primary purpose is to stand between you and your doctor.
Further proof that the Bush administration thinks it is above the law, or that the law is just not worth following: according to the government accountability office (GAO) the administration’s push to restrict the use of S-CHIP funds to cover people above the poverty line was in violation of federal law.
The legal opinion, requested by a bipartisan pair of senators, lambasted the president for vetoing Congress’s twice-passed expansion of the SCHIP health care program, which provides health insurance for kids whose parents are too wealthy to get Medicaid but too poor to be able to afford private health insurance. Congress twice approved more money for SCHIP, and BUsh twice vetoed it, mongering fears about socialized medicine.
So there we have it. 70,000 fewer kids insured than would have been possible plus a violation of federal law for good measure.
(via Bitch PhD)
If, like me, you’ve ever wondered what it would be like to cuddle up on a drugged Glenn Beck’s chest while he gurgled cryptic aphorisms about health care and compassion, consider this vlog a belated holiday gift.
Between hits of oxy, Beck suggests that his surgery gave him the opportunity to reassess the nation’s health care system — thoughts he vows to share with his seven or eight viewers on Monday’s show. I won’t be watching, but I’d be surprised if Beck didn’t remind the world once again that Hillary Clinton’s health care proposals are worse than Hitler’s.