…matters if the Supreme Court will uphold it. I continue to think that this is very unlikely, and if they did it would probably produce a better health care policy anyway.
Tag: "health care"
The post below reminds me that I had been meaning to blog about these Dana Milbank speculations about how Clinton might have been better. He bases this around some discussions with Clinton campaign operatives — let’s call them “Park Menn.” Exactly how would she have been better? Rather than going the route of dead-enders who assert that this life-long DLC centrist would have been the new Eugene Debs had she prevailed in the primaries, Mr. Menn argues that Clinton would have been better…by being much worse:
Clinton campaign advisers I spoke with say she almost certainly would have pulled the plug on comprehensive health-care reform rather than allow it to monopolize the agenda for 15 months. She would have settled for a few popular items such as children’s coverage and a ban on exclusions for pre-existing conditions. That would have left millions uninsured, but it also would have left Democrats in a stronger political position and given them more strength to focus on job creation and other matters, such as immigration and energy.
So we’re supposed to believe that Clinton would be better because she would have abandoned the only chance to significantly reform health care for decades, and in the kindest construction would have urged passing a slightly more protective band-aid in the form of a 90-day foreclosure moratorium. (Not necessarily a bad idea, but…then what? How many of the people who were foreclosed after day 91 would have been enthusiastic Clinton supporters?) And all of this based around the highly implausible idea that trying and failing to pass health care reform would be political gold for the Dems? Sure.
But while the sheer awfulness of Clinton’s top non-brain trust underscores that it is extremely unlikely that she would have been a more progressive president than Obama, I also don’t believe Mr. Menn when he claims that she would have been much worse. Giving away the show, although Milbank doesn’t notice it, is the assertion that Clinton would have settled for “a ban on exclusions for pre-existing conditions.” The obvious problem, as Clinton correctly said throughout the campaign, is that you can’t pass such a policy without a more comprehensive plan including an individual mandate, because it would completely blow up the insurance industry. Which is why Obama inevitably adopted Clinton’s position, and one reason why the ACA isn’t going to be repealed. So while I can’t prove that Clinton wouldn’t have foolishly abandoned health care reform, the word of her advisers on the subject couldn’t be less credible.
Conservatives have made a concerted effort to portray public opposition to health care reform as an ideological rejection of liberalism and government. The truth is that people who don’t have government health insurance support the Affordable Care Act. The only opposition comes from people who already benefit from single-payer health care. They’re not opposed to government health care — they’re worried that providing health insurance to others will come at their expense.
To make an additional side point, It’s not just that the Palin’s “death panels” line was making up something that doesn’t exist. As sophisticated conservative philosopher Ray Stevens inadvertently pointed put, the underlying premise of Republican discourse about the ABA was that the government should keep its grubby paws of people’s taxpayer-funded single-payer healthcare.
Friday will be the girl’s first birthday, and in honor of one year as a parent I thought that I would toss together a few things I wrote on the topic (some from way back) and try to make a series of it. The first installment has to do with health care; the wife’s pregnancy was the first time that I had to deal at length with America’s health care bureaucracy. We also had to deal with the fact that my wife changed jobs shortly before the birth of the girl’s, meaning that we needed to shift between health care providers. This post is more about health care than fatherhood per se, but the experience of having kids brought me to a series of revelations about our health care system.
So, last June I was a more or less happy human being with health care supplied by the University of Kentucky. We knew that my wife would soon leave her job, and we knew that pregnancy often involves a variety of health complications, so I decided to change from the cheap-but-adequate plan to the expensive-but-a-good-idea-if-you-might-get-sick plan. I discovered in the process of making this change that, because of a computer error, I’d actually been uninsured for about a year. Fortunately, I failed to get sick. In any case, I filled out the form and added Davida to the plan. When the little dependents arrived, I added them to the plan. Shortly after the LIFE CHANGING EVENT, we moved to Baltimore for the wife’s new job. The insurance plan offered by the University of Maryland was marginally better than the long distance plan offered by UK, so we switched the wife and kids to UM, while I stayed at UK. This required numerous additional forms. In January, we moved back to Ohio, and switched back to the UK plan, incurring reams of additional paperwork. Finally, in May we arrived at the “Open Enrollment” period at UK, in which I was able to change from the super-expensive plan back to the reasonably-priced plan.
Now, all of this sounds reasonably easy and straightforward; however, anyone who’s ever actually dealt with the multiple bureaucracies that make up the US health care system understand that the story could never be so simple. Every change involved negotiation with at least two, and often three, bureaucracies. The first interactions with UK were difficult, but went very well once someone at UK HR took an interest in our case and effectively became an advocate. This person (who deserves nothing but our eternal thanks) really went the extra-mile, giving out her office phone number so that we could have pharmacists call her in order to find out how much our prescriptions should cost. Had we not been so fortunate in finding someone interested in helping us out, we might have been in real trouble.
We had lots of other interactions with these bureaucracies, and not all of them went as smoothly as the UK…
Trying to get ahold of your insurance company means negotiating a bewildering maze of phone trees and webpages. I use Humana, but I don’t have any reason to believe that any other insurers are any different. The key point to remember is that your insurance company DOES NOT want to talk to you. Maintaining a call center is expensive, and the company will undertake whatever means it can in order to force you onto an automated system or, barring that, attrite you into submission. Moreover, the question you have, if answered properly, might cost the company money. This is bad, and the insurance company is going to do its darndest to make it difficult for you to get the information you need. On a couple of occasions I was forced to repeatedly enter my policy ID# in order to move on to the next phone tree, all with the carrot of a “patient care representative” dangling in front of me. At one step, the system insisted that I verbalize my ID#, birth date, and zip code. No matter how clearly I said any of these, I was then forced to punch them into my phone keypad. I was told at one point to represent any letters in my ID# with the star key. I was then dragged through the agonizingly slow process through which the automated system tried to figure out exactly what letter a star represented (“Press 1 for G. Press 2 for H. Press 3 for I”). At another stage in the phone tree, the automated voice refused to accept any number I pressed before it was done speaking. If I made the error of pressing a number before the sentence was finished (and the robot, for some reason, favored long, pregnant pauses), then the system would stop for about 15 seconds before telling me that it didn’t understand what I was trying to say. It would then repeat its entire spiel. When you finally reach “waiting for the next patient care representative” stage, you are invariably treated to ridiculously terribly music punctuated by a voice patiently explaining how useful the website or the automated system would be, with the implication that you’re a moronic ingrate for needing an actual operator. On one occasion, I made it through the phone tree only to be told that the call center was closed.
Perhaps my favorite roadblock was on the (otherwise useless) Humana website. Shortly after creating your account, the website insists that you read a series of statements about the confidentiality of your health care, and that you click “I agree” at the bottom of each statement. If you don’t scroll down and read the entire statement, it refuses to let you move on. Ingeniously, one of the statements didn’t show any scroll bars on the page. It simply didn’t allow you to move forward. Clicking on “I agree” only makes you more angry, with the eventual (I assume) purpose that you will hit your keyboard so hard that your computer will break, thus saving the insurance company any additional difficulty.
None of this is accidental. The point is to irritate and confuse the customer so much that he or she eventually hangs up. It works, too. We would all like to think that we have the wherewithal to fight through the system, but often we don’t. We run short of phone minutes, or we get another call, or we have to do any one of the myriad things that amount to normal, everyday life, and we end up hanging up. This is what the insurance company calls “a win.”
So, all of that was pretty frustrating. Living through the experience made the health care debate (“People in Europe have to wait! In the emergency room! For service!”) some combination of surreal and absurd. Of course, nothing about the health care bill that we actually passed does anything to solve any of this. I can say, however, that if I ever had the choice, I would absolutely leap at the prospect of a public option program; the state bureaucracies were invariably easier to deal with than the private ones. I suppose if there was real competition with a public option the private programs might get better, but I can’t say for sure.
I should also note that I appreciate how fortunate we were to actually have jobs, and for those jobs to have decent enough health care programs. I cannot imagine having done all of this without the level of security that even…. complicate coverage provides. We got the drugs we needed, were able to take the girls to the doctor when we needed to, had Elisha’s helmet (mostly) paid for, and so forth. Taking the girls to the doctor was never a difficult choice for us, as it is for some. When we were concerned about Miriam’s weezing and barfing, we were able to take her to the emergency room without worrying too much about paying for it. All of that was (and is) nice, but it doesn’t require the infuriatingly complicated system that we currently have. I don’t think that we properly factor the complication, aggravation, and genuine irritation of that program into the costs of the system that we currently have, in part because it’s so hard for Americans to properly imagine a different system.
1. Poetic justice. Shorter: states that had tight-fisted approaches to health care in general and medicaid in particular are worried about the burden imposed by the health care reform law. Longer: “But even with more federal help, the challenge for states like Alabama, Arkansas and Texas that now offer only limited Medicaid coverage will be substantial.” Opinion: Cry me a fucking river. Texas, for example, restricts Medicaid to working parents who earn 20% of the federal poverty level. With the new law allowing medicaid access to families of four at 133% of the poverty level, or slightly over a comfortable $29,000 per year, who in hell was Texas covering in the first place? I’m not going to draw the obvious connections between this generally enlightened trio. The state I spend the majority of my US time in, Oregon, has relatively solid coverage, so they’re not going to get hurt too bad.
2. Obligatory British election. The Tory lead is holding relatively steady at about 4 points. As I’m not in the office, I don’t have my vote share -> seats matrix handy, but this smells strongly of a Labour plurality in seats. If the difference in seats between the Tories and Labour is close enough, Nick Clegg will be there, ready and willing to officiate. I’d like to see a formal Lib-Dem / Labour coalition in the event of a hung parliament, but I’m not counting on it. I suspect we’ll have a minority government, from either party, that will hobble on for a year at most.
Don’t get too excited by this new MORI poll of the marginals. While the Reuters headline needlessly downplays the Conservative’s chances as a result of this poll (the swing to the Tories in these seats according to this poll still outperforms their swing nationally) the poll covered constituencies won by 10% to 18% in 2005. This represents a liberal interpretation of “marginal”.
The annual budget doesn’t seem to have caused much of a stir, save for how it’s going to hammer Universities with cuts of up to 14% in the UK (but we knew this already) leading to a large number of compulsory redundancies amongst academic staff. Fortunately, our top leaders, the Vice Chancellors, see their pay increase 10% to 20% in the last year alone, with many earning more than the Prime Minister (who I am to understand has a less demanding job). Full disclosure: the VC of my institution earns more than Gordon Brown, but we’re enterprising, so we can get away with it.
None of us should worry, really. This being the Labour government, we have been offered 20,000 additional university places for students for the next academic year in the same budget that slashed university funding by £900 million through 2013. I don’t know how they do it. It’s magic.
The other aspect of the budget that has pissed people off is the 10 pence tax rise on (hard) cider of all things. Cider’s sort of popular down here in the Southwest, and Devon, Somerset, and Dorset (real) ciders can be some of the best in the world. It’s a good thing my partner scheduled her visit to Plymouth for last week, where she consumed a fair amount of the local cider, saving ten pence a pop.
3. I have been unplanned in my absence from blogging duties for the past couple of weeks. Work has dominated, with the end of term, admin duties, several manuscript reviews to write (when it rains it pours), and the two papers I’m presenting in San Francisco at the WPSA (this upcoming Thursday no less) and Chicago towards the end of April at the MPSA dominating my time. Also, add in weekends playing single dad to my daughter, and the visit of the aforementioned occasional cider drinking love of my life for a week from Oregon, I’ve had precious little time for much else. I’m off to the US for a month on Tuesday, so I’ll have more time. Hint: if you’re an editor of a political science journal just itching to send off a manuscript for my perusal, and are not one of the three who have sent me manuscripts in the last month, now is the time to do it.
One cannot help but admire Nancy Pelosi’s skill as a legislator. But it’s also pretty worrying. Are we now in a world where there is absolutely no recourse to the tyranny of the majority?
So, to review, a party won an election, including a convincing popular vote win by the president and solid majorities in both houses of the legislature. It attempted to pass a central plank of its platform, a very moderate health care reform package. Its passage was still in doubt a few hours before the final vote, and the bill’s opponents (and wets among the bill’s eventual supporters) were able to further water down the bill and extract some repugnant compromises. And this is evidence of…the tyranny of the majority? If I understand the underlying democratic theory* correctly, no matter how many veto points you have, if a policy that Megan McArdle doesn’t like can somehow pass, there aren’t enough.
*Especially coming from a libertarian, I’m not going to take the subsequent ad hoc embrace of plebiscitary democracy seriously — does McArdle now believe that Congress is obligated to pass the very popular public option? I will note, however, that even on its own terms the argument is probably wrong. At a minimum, one has to take account of the fact that a significant portion of the narrow anti-bill plurality opposed the bill from the left. Once confronted with an up-or-down vote between the bill and the status quo, it is very likely that most of these opponents would ultimately vote yes — as happened in Congress.
And then, we have this:
We’re not a parliamentary democracy, and we don’t have the mechanisms, like votes of no confidence, that parliamentary democracies use to provide a check on their politicians. The check that we have is that politicians care what the voters think.
Unless there’s some nuance I’m missing, someone who is paid a very healthy sum to write about politics for a living has asserted that parliamentary democracies have more checks on majority rule than the Madisonian separation-of-powers system. I can only respond that McArdle may wish to investigate how often majority governments in Canada or the UK have been felled by no-confidence motions. Or if that’s too much work, perhaps she may want to consider how likely it is that any members of the Democratic majority who voted for the bill would vote to remove Barack Obama from office…
I’m not sure how Ben Stein’s understanding of Constitutional law compares with his understanding of science or the convolutions of the market, but he certainly has a flair for atom-splitting hyperbole. But Stein — who’d beaten the curve on the Obama-Hitler comparisons back in July 2008 — watched the dolchstoss on the House floor last night and wandered strangely off-message.
This is not how the U.S. government is supposed to work. This is how a South American junta does its work with a puppet legislature and a supreme Caudillo above law. This is, tragically, Barack Obama’s America. It took a mere 14 months to get us from the government of Jefferson to the government of Trujillo.
Well, now I’m completely confused. I thought Jefferson had been unpersoned. I also thought the passage of this bill meant we were all going to be sodomized by the Four Socialist Horsemen of the ACORNocalypse, or that in the very least we could look forward to a slow ride down the slope toward involuntary hypothermia studies, experimental malaria vaccinations and anesthesia-free surgery.
But Trujillo? Really? I mean, he was a corrupt, illiberal motherfucker so far as it goes, but I would assume conservatives would at least applaud El Jefe‘s pathological anti-communism and border security policies. Then again, I guess I just don’t understand conservatives anymore.
In short, I think it’s highly unlikely. The big difference between Citizens United and a potential commerce clause challenge is that the Court had a steady trend of being more aggressive in applying First Amendment libertarianism to campaign finance, while its commerce clause jurisprudence hasn’t been trending in this direction, stopping with striking down a silly, redundant gun law and a little-used remedy in fairly important legislation it otherwise left intact. It’s not, exactly, that the Court wouldn’t contradict what it said in Raich. Rather, it’s that a Court that would strike down health care reform would have continued to strike down more and more important legislation.
The Senate bill further entrenches the private health insurance system. It continues the terrible pattern of privatizing our social safety net in such a way that business skims 20% off the top.
This kind of heighten-the-contradictions argument has a certain power — if you can construct a plausible scenario under which an actual president, an actual majority of the House of Representatives, and an actual 60th most liberal member of the Senate would vote to create either a single-payer system or even a Swiss-like system of very tightly regulated non-profit private insurance. The argument not only fails but is deeply irresponsible because such a scenario is in fact wildly implausible, and while we would be playing Vladimir and Estragon a great deal of preventable suffering and death would occur. The simple fact is that high-veto-point American political institutions protect the status quo in general and powerful vested interests in particular. It’s not just that times when even significant incremental change is possible are rare — the American welfare state was basically constructed in two 2- or 3-year periods following historically unusual landslides in all three branches. It’s that even in those periods, reform involved compromises as bad or worse than what’s being contemplated in the current legislation.
Let’s take the New Deal. The parts of the New Deal that didn’t involve the creation of corporate cartels — the enduring parts — were not only incremental reforms but were all deeply compromised with interests much more morally odious than insurance companies: Southern segregationists. Social security and unemployment benefits both, through discriminatory labor definitions and by allowing for discretion in local enforcement, gave many more benefits to whites even though they would have gotten proportionately less in a fairly constructed and administered system. The New Deal not only further entrenched but disproportionately benefited the apartheid power. And yet not only FDR (who, in truth, was even more tepid on civil rights than was politically necessary) but most of his African-American supporters understood that the programs were a good deal on balance: it wasn’t a choice between a discriminatory welfare state and a non-discriminatory one; it was a discriminatory one or nothing. And they were right.
The fact is, compromises with venality and/or evil are almost always necessary in the American political system; it’s virtually impossible to accomplish anything without buying off powerful interests. Getting anything like universal health coverage is going to require giving protection money to insurance interests. This is nothing to be happy about, but arguments that fail to recognize this aren’t going to be very useful.
Fred Barnes is a terribly stupid man. In asserting that “Obamacare” will create a bitterly contentious political environment for decades to come, Barnes writes:
We only have to look at Great Britain to get a glimpse of the future. The National Health Service—socialized medicine—was created in 1946 and touted as the envy of the world. It’s been a contentious issue ever since. Its cost and coverage are perennial subjects of debate. The press, especially England’s most popular newspaper, The Daily Mail, feasts on reports of long waiting periods, dirty hospitals, botched care and denied access to treatments.
A Conservative member of the European Parliament, Daniel Hannan, last year in an interview on Fox News denounced the NHS as a “60-year mistake,” declaring he “wouldn’t wish it on anybody.” As prime minister, Margaret Thatcher bravely cut NHS spending in the 1980s, but current Tory leaders regard criticism of the NHS as too risky. “The Conservative Party stands four square behind the NHS,” its leader, David Cameron, said in response to Mr. Hannan.
So, to be clear, the debate over the NHS is so bitterly contentious, and so fractious, that the leader of the Conservative Party is unwilling to come out against it? The NHS is so unpopular that the Tories are afraid to publicly oppose it? The only voice that Barnes is able to muster in opposition to the NHS is a Conservative MEP? Does Barnes understand, I wonder, that an MEP is not an MP?
To his credit, Dennis Kucinich will be voting for health care reform. This had led to some grimly predictable concern trolling from conservatives who have discovered their admiration for Kucinich’s integrity just in time to repudiate it.
The argument, at least to the extent that one thinks that politics is about accomplishing something rather than onanistic gestures, is of course wrong. When one is a legislator, principles have to be applied to the evaluation of alternatives that are almost certainly imperfect. With something like health care reform — unless one believes in a “heighten the contradictions” scenario that given the political context would be implausible in the extreme and hence grossly irresponsible — the relevant question is whether, according to one’s principles, the legislation under consideration improves the status quo or not. Believing that it does is perfectly consistent with Kucinich’s principles — and indeed, I have yet to hear anything resembling a decent argument to the contrary. And if that’s case, voting yes is perfectly principled, even if you would make much more radical changes if you had the power.