The interesting thing about the lead opinion is that it was written by Laurence Silberman, a judge with impeccable conservative credentials. As Jon says, it’s a straightforward but very strong opinion, and he’s particularly good on the meaningless of the “activity/inactivity” distinction.
Tag: "health care"
I strongly recommend John Sides’s post, and for that matter I also strongly recommend On Deaf Ears and the Strategic Presidency, the most essential readings about the presidency this side of Nuestadt and Skowronek.
One thing I should add is that — while public opinion is something that quantitative methods are especially well-positioned to evaluate — I would never say that a behavioral social science study is the God’s truth. I definitely think that careful case studies that show what seems to be the general trends of the data not applying are important. The impossibility of definitively testing historical counterfactuals and isolating causal relationships makes even the best studies potentially limited. But one reason I believe Edwards is correct is that he not only has the data to support his hypotheses, he has a much more convincing theory than the Cult of the Bully Pulpit people. Most importantly, people who believe in the power of messaging to achieve short term results have never dealt convincingly with the fact that 1)most people don’t pay attention to presidential rhetoric, and 2)the people that do are generally high-information voters with strongly entrenched partisan and ideological commitments. Arguments in favor of the power of the bully pulpit, conversely, in my experience tend to involve pundit’s fallacies, unconvincing ad hoc explanations for obviously disconfirming cases, and other signs of a bad argument.
I haven’t read the Canes-Wrone book, but for similar reasons I find the idea that the appropriation process is an exception to the general rule very plausible. Whether it’s actually rhetoric or messaging per se doing the work I don’t know — perhaps she has convincing data on this point — but certainly a president can be expected to have more leverage in a context where legislation has to be passed. With something like the ACA (or Social Security privatization or whatever), the president’s leverage is inherently constrained by the fact that Congress can just walk away from the table.
Which, speaking of theory and counterfactuals concerning the ACA, is the heart of the issue. The next person who can explain what leverage — via messaging or anything else — that Obama had over Evan Bayh, a greasy conservative not running in a state where Obama isn’t especially popular anyway and beholden to corporate interests for his future career, will be the first. The Green Lantern position seems to be that it’s massive failure of available powers that Bayh, Nelson, Lincoln, Lieberman et al couldn’t be made to support a much more progressive bill. My position (which is ironically sometime portrayed as Democratic apologism) is that it’s increasingly amazing in retrospect that Reid and Obama got these people to vote for anything.
On the monetary side are even worse than ours.
In a bit of black comedy, on the other side of the page, Ross Douthat argues that the Obama administration did not pivot quickly enough to austerity. Really. In its way, you have to admire this bit of hackwork:
Finally, instead of pivoting from the Recovery Act to deficits and entitlement reform, the Democratic majority spent all of its post-stimulus political capital trying to push both a costly new health care entitlement and a cap-and-trade bill through Congress. Both policies were advertised, intermittently, as deficit reduction, but neither came close to addressing the real long-term drivers of the nation’s debt.
So, on the one hand, the ACA is “costly.” On the other hand, he doesn’t actually dispute that it would control health care costs, but apparently it is “costly” because it wouldn’t, in itself, reduce the long-term structural deficit problems it would be crazy to focus on in the midst of horrible unemployment. Hacktacular!
It’s a bit of an upset, but good to see the 6CA panel do the right thing. It should be noted that while both majority opinions do an excellent job of attacking the bad commerce clause arguments underlying the challenge to the ACA, James Graham’s dissent does a good job of self-refutation. Consider this passage:
Here, Congress’s exercise of power intrudes on both the States and the people. It brings an end to state experimentation and overrides the expressed legislative will of several states that have guaranteed to their citizens the freedom to choose not to purchase health insurance. The mandate forces law-abiding individuals to purchase a product – an expensive product, no less – and thereby invades the realm of an individual’s financial planning decisions. (“Neither here nor in Wickard had the Court declared that Congress may use a relatively trivial impact on commerce as an excuse for broad general regulation of state or private activities.”). In the absence of the mandate, individuals have the right to decide how to finance medical expenses. The mandate extinguishes that right.
Graham starts off with policy arguments that are irrelevant — the fact that the ACA “brings an end to [some] state experimentation and overrides the expressed legislative will of several states” means nothing in itself, since all kinds of valid federal legislation does so, and the stuff about state legislatures suggests that Graham stopped reading the Constitution before he got to Article VI. But the real key is the last sentences, which suggest that what’s at issue here is not really federalism but a desire to return to a radical Lochner-era liberty of contract — a state mandate, after all, would also “invade the realm of an individual’s financial planning decisions” and “extinguishes the right to decide how to finance medical expenses.” And at this point, the whole shaky edifice collapses, because in fact Lochner hasn’t been good law for many decades, and as Graham concedes the federal government could clear create a more centralized and government-controlled system than the ACA does, opening up the frightening possibility that the U.S. could cover more people for less money like every other major liberal democracy.
The quality of the opinions arguing against the constitutionality of the ACA we’ve seen so far have been remarkably bad, but in part that’s because the argument itself is inherently weak. The only coherent argument against the ACA requires reading quasi-libertarianism into the Constitution, a long-discredited project that has vanishingly tiny amounts of political support.
Over the past couple of years four people I’ve had some sort of relationship with were diagnosed with pancreatic cancer, so I’ve gotten to know more than I ever wanted to know about this especially terrible disease. It’s estimated that about 43,000 Americans will be diagnosed with pancreatic cancer this year, and around 38,000 will die from it. The most common form of the illness remains almost incurable, with a five-year survival rate of less than 5%. Only 20% of cases are diagnosed soon enough to allow for anything other than palliative treatment; this “lucky” minority undergo a grueling operation (the so-called Whipple procedure) that produces a median increase in life expectancy of about a year. Pancreatic cancer is usually a disease of old age: the average age at diagnosis is 73, and America’s aging population has seen a steady increase in its incidence, to the point where it is now the fourth-leading cause of cancer death. (For similar demographic reasons it is beginning to become much more common in the developing world).
Recently I looked at the data from a couple of major academic medical centers who specialize in the Whipple procedure, and I was struck by, among other things, how many of these surgeries are done on patients in their 80s. The ethics and economics — or perhaps the economic ethics — of performing this surgery on very elderly patients in particular are troubling. For all patients, the median survival after the Whipple procedure is about 18 to 24 months (for patients who don’t receive the surgery because their cancer is too advanced it is around six to ten months). But these medians are age-adjusted rather than absolute. In other words, median survival is measured relative to the overall mortality rate in the patients’ age cohort. Since an 85-year-old man without pancreatic cancer has about a 50% chance of dying over the next five years, to say that the five-year survival rate for 85-year-olds undergoing the surgery is 20% means that 90% of these patients will be dead within five years. (And this is assuming that the mortality rate from the surgery and its aftermath will not be higher among the very elderly than among patients in general, which seems like a very optimistic assumption).
How much do these treatments cost? The standard treatment protocol includes post-surgery chemotherapy, and sometimes radiation treatment as well. Re-hospitalization is very common as most patients will suffer a recurrence of the disease within a year or two. In sum, treatment costs can easily exceed six figures. Indeed treatment costs are often high even in the context of the large majority of cases in which surgery is not an option: palliative chemotherapy regimens that have some value in lessening suffering but that generally extend life by no more than a few weeks can cost thousands of dollars a month.
All this raises difficult issues. On the one hand, any time anyone raises the question of whether the cost of keeping very sick people alive for a year or two longer via extremely expensive treatments should be socialized, someone is sure to start shouting about “death panels” and the like. On the other, it’s not as if there are easy answers to the dilemmas these situations raise. After all, a small minority of people live for several years, and on rare occasions even a decade or more, after undergoing the Whipple surgery. Furthermore even if purely palliative treatments are quite expensive, we’re (still) a rich country. As a society should we be less willing to spend money on lessening the suffering of the dying than we are on, for example, building yet more big beautiful bombs? Furthermore some of the money spent on pancreatic cancer ends up funding clinical trials, which at least hold out hope for developing better treatments.
Of course another issue is why these treatments, whether potentially curative or merely palliative, are so expensive. What do rich nations with more just and efficient health care systems than our own, i.e., all of them, do when confronted with the dilemmas that diseases like pancreatic cancer engender? (I have no idea).
In the end we can’t pay for everything, but our current health care “system” pays or doesn’t pay for things in ways that have little apparent relation to justice, efficiency, or any other value beyond the continuing enrichment of those who benefit from the present state of affairs.
Bobo engages in his trademark style of argument, focusing on abstractions and ignoring evidence about whether or not markets actually work for a given problem. Cohn does a good job pointing out the problems, and I think the most important one is near the end — the comparison with other countries. Brooks asserts that “there is no dispositive empirical proof about which method is best.” But the policies of virtually every other country in the world give us the chance to compare a relatively “free market” in health care to more state-oriented approaches, and the evidence is unambiguous. The “free market” delivers coverage to many fewer people for more money, and usually far more money. Although Brooks likes portraying debates between an imaginary ‘Burke” and “Rousseau” while casting himself in the former position, in this case it’s Brooks who’s ignoring all the empirical evidence to cling to his abstract beliefs about the benefits of markets. And he does this despite the fact that — between the inelasticity of demand, lack of informed consumers, and strong incentives insurers have to deny coverage to vulnerable groups — there’s no good reason to expect health care markets to work even in theory.
Joe Nocera’s pleas to accept the Ryan plan as a conversation-starter notwithstanding, there’s no conversation less in need of starting than the conversation about how to reduce Social Security and Medicare benefits. It’s hard to think of another topic Beltway pundits are more likely to talk about. Nor can you contribute to the conversation with a worthless plan.
Let’s also be clear who started this. It is true that there’s an enormous amount of waste in the American system, and the example of virtually every other liberal democracy indicates that we could cover more people for less money by reducing or eliminating the role of private insurers. But, of course, even the cost reductions in the ACA — which were modest because of the need to buy off stakeholders created by the Madisonian system — were deemed by the GOP in 2010 as getting the government into your Medicare. The “leave Ryan alooooone!” argument is a plea for unilateral disarmament…against people who are ideologically opposed to the New Deal/Great Society social contract and aren’t honest. I’ll pass, thanks.
Watching Paul Ryan earlier today talking at the Peterson Fiscal Summit I was amazed by the number of times he said the word “Mediscare,” which is a conservative jargon term for telling the truth about proposals to eliminate Medicare.
Mr. Ryan may claim — and he may even believe — that he’s facing a backlash because his opponents are lying about his proposals. But the reality is that the Ryan plan is turning into a political disaster for Republicans, not because the plan’s critics are lying about it, but because they’re describing it accurately.
Take, for example, the statement that the Ryan plan would end Medicare as we know it. This may have Republicans screaming “Mediscare!” but it’s the absolute truth: The plan would replace our current system, in which the government pays major health costs, with a voucher system, in which seniors would, in effect, be handed a coupon and told to go find private coverage.
The new program might still be called Medicare — hey, we could replace government coverage of major expenses with an allowance of two free aspirins a day, and still call it “Medicare” — but it wouldn’t be the same program. And if the cost estimates of the Congressional Budget Office are at all right, the inadequate size of the vouchers — which by 2030 would cover only about a third of seniors’ health costs — would leave many if not most older Americans unable to afford essential care.
I’m also amused that Karl Rove has decided to advocate the same political strategery as Col. Mustard. Trying to find the “right messaging” for a plan to destroy Medicare to fund massive upper-class tax cuts is like trying to find the right metrics to show that Melky Cabrera is the greatest player in baseball.
I think this is an important point: arguments that various Democratic proposals on health care were once “Republican proposals” are misleading, in the sense that it’s not as if Republicans enacted them when they controlled government or anything. It’s misleading to imply that the Republicans favored even modest health care reform in any meaningful way.