Jack Gillis thinks the Blue Dogs’ days are numbered: [Read more →]

I have learned far more about healthcare reform than I ever thought I would in recent months.  In the end, what leaps out at me is that this issue – unresolved – will become a more and more of a thorn in conservative’s side.  If people think the Tea Party phenomenon is bad, just wait until a real populist movement rises up that is fundamentally opposed to free trade, that wants more rather than less government, that demands protectionist policies and entitlements.  The one thing which I can see spurring on something like this more than any other issue is a combination of poor employment and poor (and expensive) healthcare.  Is it so hard to imagine the Tea Partier who wants government to keep its hands off his Medicare, to be turned into an advocate of protectionist policies?

The current reform bill is not nearly liberal enough to avoid such a movement, nor is it conservative enough to really put into place any real chance at a market solution.  It keeps the lousy system we have in place now, and adds to it a tremendous cost to the middle class.  Furthermore, I see no future political will to actually implement any true market solution for healthcare.  So Republicans should think about ways to make national healthcare more sustainable via market mechanisms (choice, HSA’s, etc.) while still accepting the fact that an overall national/social model will be adopted eventually.  Otherwise healthcare will likely persist as an issue and Republicans will be increasingly on the losing side of that issue.

I think the best model would probably be something like single payer plus health savings accounts.  Make people of whatever income responsible for basic healthcare costs, but protect them from really damaging bills.  Free up businesses and entrepreneurs from the chains of healthcare uncertainty.  Somehow find a way to increase the supply of healthcare; and work toward means by which we can make cheaper, alternative healthcare solutions more available.  Alternatively we could adopt something like Wyden-Bennett.  My reluctance to support this bill, pure ideological concerns aside, is that I worry it will only help persist the status quo, and the status quo is no good.

Whether there is a reasonable alternative is harder to say.  Federalism is quickly going out of style – and the next real national movement may be a unity of tea partiers and union members, social conservatives and progressives – the sort of movement Mark has predicted, but one that is bereft of libertarian and free trade principles.  What would that do to our trade policies?  To our employment rate and productivity?

Suffice to say, for anyone with a libertarian economic outlook, or for anyone with concerns over civil liberties, this should be a concern.  Perhaps fending it off with a reasonable compromise on healthcare reform would actually make a great deal of sense.

Reading this Will Wilkinson piece (which is a follow-up to pieces by Megan McArdle, Tyler Cowen, and Michael Cannon – all of whom you should also read on this subject) has gotten me thinking once again about health insurance reform, and especially about the way we think about entitlements in this country.  More specifically I’ve been thinking about the ways we can begin to move away from entitlements and start thinking about the government as a provider of safety nets instead.

For instance, one time between jobs my family was left without insurance and without any income.  The fact that we had been living paycheck to paycheck did not help matters, making COBRA impossible to afford.  We had a baby on the way and were left without any means to pay the bills.  So we applied for Medicaid, and were accepted – which was a very good thing, since my wife was also pregnant and since the delivery was fraught with complications that I’m sure would have bankrupt us had we not had any insurance.

Soon thereafter I was once again privately insured and we were no longer were covered by Medicaid.  It functioned as a safety-net just when we needed it most.  My wife and I had, prior to having children, gone quite a long time with no insurance at all.  We were “young invincibles” without a real pressing need for insurance, and we consumed very little healthcare. I’m very grateful that there was some safety net for us to fall back on, but I also realize that Medicaid itself is far from perfect or sustainable (which is to say nothing of its big brother, Medicare).

A few thoughts on Medicaid:

• It is a very tedious process to become enrolled.  It is time-consuming and there is a great deal of paperwork.  I imagine this dissuades a number of people who need it the most from signing up.
• Many low income people do not use Medicaid as a safety net, but rather as a primary means of insurance.  They renew it every year, and have little incentive to become insured via employment or via private insurers.
• Many providers do not accept Medicaid and many more are not paid (or not paid enough) if they do accept Medicaid.

While Medicaid as a safety net against catastrophic medical costs makes sense, Medicaid as an entitlement for the poor does not.  I’ve heard of people who take lower paying jobs or who choose to only have one spouse work simply because the higher paying or second job would disqualify them from receiving Medicaid benefits.  This is quite obviously a perverse incentive.  Furthermore, the care available to Medicaid enrollees is subpar, extending the class divide ever deeper and creating a class of citizens who are increasingly dependent on the state. 

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Via Andrew, Jonathan Bernstein thinks the Democrats should pass the bill regardless of the public’s distaste for the process:

Reconciliation is thirty years old, and there’s nothing at all wrong with using it to pass legislation.  What’s more, pass and patch (or pass-then-patch) involves passing health care reform through perfectly normal, regular, procedures — and then fixing the original bill through reconciliation.  Now, granted, Republicans are apt to complain about procedure, and it’s true that Americans don’t like partisan squabbles and don’t like hearing about procedure.  But once the bill is passed, it seems very likely that the national press will tire of procedural complaints about a bill passed weeks, and then months, ago.

Second, it’s a real mistake for Democrats to worry too much about how Republicans will portray things that they do.  Republicans are naturally going to bash Democrats for everything; should Democrats respond by doing nothing?  Surely not.  Democrats should do things that they believe are good for the nation.  Democrats believe that health care reform is good for the nation.  They are, like it or not, going to be attacked for health care reform. Those who get their information only from Republican news sources will believe those attacks — but people who get their information only from those sources are not swing voters.

Regardless of my own feelings about this bill – which are mixed, to say the least – I think Bernstein is correct.  The electorate has a short memory. Tangible results stick in that memory far more than abstract procedures. Six months after the bill is passed, most Americans will still not know what reconciliation is, which deals were struck, and so forth, but a healthy portion of voters will know that healthcare reform succeeded (for now).  More Americans will be glad to hear that an end to pre-existing conditions clauses has been hammered out then will become emotionally revved up over the Democrat’s handling of the process.  It’s possible that the bill will remain unpopular, but it’s hard to see how giving up entirely will look any better for the Democrats.

That being said, I don’t think the Democrats have what it takes to push this thing through reconciliation or patch it up after passing it in the House.  Unlike their opponents, the Democrats have very lackluster party discipline.  The centrists are already calling a halt, and the progressives in the House seem unwilling to pass the Senate bill because it’s too conservative for their taste.  The president hasn’t taken much of a leadership role either, and so the bill remains in legislative purgatory.  My guess is that Keith Hennessey is correct, and the bill is dead. 

Perhaps legislators can come back with more modest proposals in the future, but I imagine it will be far in the future.  While I would love to see market reforms in the health insurance market, I don’t believe that Republicans are very serious even about their own ideas.  This is largely the basis for my own support of the Democrats’ bill.  While there are certainly libertarians and conservatives with alternative proposals for healthcare reform, Republican leadership has historically been against any changes to the status quo.  I don’t think the status quo is sustainable.  If the bill dies, I’m not really sure what we can expect.  If I thought the Republicans would take up the cause of a bill like Wyden-Bennett and join ranks with Democrats to push something through as an alternative, I would be more optimistic.  As it stands, every outcome looks grim.  Healthcare costs in the public and private sector continue to rise unsustainably, and our system is too broken to do anything about it.

 

P.S. Reconciliation is not necessarily a budget-restricted procedure, however due to the Byrd rule that is now the case.  However, anyone who thinks that the budget and healthcare reform are not inextricably linked needs to talk to Paul Ryan about the matter.  Healthcare is the budget, and without addressing it we will never be able to right this fiscal ship.

Well, that’s the headline they gave my post saying about the same thing over at David Frum’s digs in any case.

While I do think that the success or failure of healthcare reform rests squarely on the shoulders of the Democrats in Congress and with the president, I still wish that Republicans would come aboard with some reasonable compromises. At this point, though, the Democrats have several options on the table and while I think there is reasonable room for compromise they could always….

….pass a healthcare reform bill via reconciliation. Yes, the Byrd rule makes this tricky. Serious holes could be shot through the bill. But it can be done. Democrats should seriously consider this approach given the continued strength of their majorities in both the House and the Senate. Whatever is cut out during the process can be added back in later. Rather than worrying so much about public opinion should they pass the bill in the wrong way, Democrats should worry about public opinion if the bill fails altogether. That’s a lot more memorable then some abstract legislative process with as benign sounding a title as “reconciliation.” But…

…if reconciliation is too daunting, Democrats could take a Republican bill and remake it into a bipartisan bill – rather than the other way around. Market and tort reforms could be coupled with subsidies (or vouchers) and some broadly popular reforms like an end to pre-existing condition clauses and some sort of optional national exchange. All the reforms I mention below could be packaged together as one bigger bill. Or…

….the Democrats could do this incrementally, with smaller moves and compromises made one at a time – in three or four separate bills over the course of a year or two or three.

First: expand Medicaid to 200% of poverty while at the same time deregulating the insurance market so that insurers could sell insurance across state lines. Shift the regulatory burden from the states to the federal government to avoid the same problems we’ve seen in the credit card industry. Finally, have the federal government pick up the tab for the Medicaid expansion.

In the next bill, introduce an excise tax on “Cadillac plans” while at the same time tackling tort reform. Toss in some vouchers (subsidies) for low-income families to purchase private health insurance. The Cadillac tax will eventually hit enough people to start a shift away from employee-based health benefits. In the future, the vouchers can be adjusted as more and more people leave the current system to purchase personal, portable insurance.

Third, lower the age of Medicare recipients to 50 while at the same time introducing significant means-testing. Change the fee-for-service model to one which relies on results rather than services rendered. In other words, have a Medicare bill that adds more healthy, younger people to the pool, while reducing benefits and/or raising premiums for wealthier elderly while at the same time changing the biggest and most fundamental flaw with how service providers are paid.

Somewhere in here pass a VAT. Put a bunch of money into community health centers, and nursing programs. Deregulate the medical cartels allowing more barefoot doctors, nurse practitioners, and midwives to provide more of our health services. Let low-cost, easy access, for-profit medical centers set up in shopping malls and other easy access places. Make sure Medicaid is accepted at these new walk-in clinics. Let Wal*Mart run them from its stores, all across the country. Let people start tax-deductible HSA’s regardless of the their health insurance.

And so on and so forth. Plenty can be done – even incrementally – to enact change in the status quo. Things can get better for people without enacting sweeping change that scares voters and kills the process in its tracks.

Ought health care legislation be stopped dead in its tracks after the Brown win? That is a clear promise he made in the campaign (though procedurally he can’t necessarily stop it himself). But many Democrats are saying that the result shouldn’t be ignored and that HCR should be halted. You supported Brown. You supported this (not just any) health care reform. Where do you stand? ~ Michael Drew, in the comments

I went back and forth a bit on the hypothetical – if I were a Massachusetts voter would I vote for Brown (and thus against HCR) or for Coakley (and thus against my better judgment).  I honestly can’t say what I would have done, because I like Scott Brown but I also want reform of our terrible no good healthcare system.  I’ve had some pushback at my other blog (where I have been writing a great deal about Brown) from Daniel Larison and Andrew Sullivan over whether my enthusiasm for Brown was ill-placed.

I may be wrong about Brown – he may not be the reformer many of us dissidents would like, but he’s such a change in tone and style it’s been a relief seeing him actually succeed, defying not only all the odds, but also the current Republican strategy.  Whether he is a mindless Bush Republican as Sullivan has labeled him, or whether he is actually going to change things for the better in the GOP is hard to say – but the stylistic shift he represents is substantial and may be in and of itself a significant step forward for conservatives.   [Read more →]

David Brooks has several good reasons why people should support the healthcare bill – and in true David Brooks fashion, he also offers some reasons why the bill is not good.  Chief among these:

The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray.

Well let’s flip this on its head, because I’m one of those healthcare bloggers who would have really liked to “fundamentally reform health care.”  You see, watching it all go down in Congress – and especially in the Senate – I realized that America was never going to fundamentally change the status quo, at least not in one fell swoop.  We weren’t going to implement the sort of free market the Cato Institute was pushing for, anymore than we were going to expand Medicare to cover every American.  We weren’t going to adopt a Singaporean or a Dutch system or even the French system that Matt Welch recently waxed poetic about.

No, we were going to pass something vastly compromised, far from perfect, but still pretty major.  It’s big enough and bold enough that conservatives are decrying it as socialism, and conservative enough that members of the further-left are calling for its demise.  But here are the things it does that I think are fundamental and important, and really overlooked by many proponents and opponents of the bill. [Read more →]

The Senate bill isn’t perfect.  It builds upon many things in our system that we’d do better simply doing away with.  It isn’t as fiscally sound as many would like, and I’m not at all sure that many of the more fiscally responsible measures in it will ever end up being enacted.  Such is the nature of our Congress.  When it comes time to make the hard choices they’re often kicked down the road.  Unlike Wyden-Bennett, it doesn’t cover 99% of Americans while paying for itself.  It neither creates the large cost-sharing pools I’d like to see, or spurs enough competition to make up for the lack of these larger pools (or pool).  And while single-payer would probably be more efficient (especially if you think of health insurance as an operating system, which in many ways it is) we’ll likely never get either to single-payer or to a real free market solution anytime soon.  We will be plagued with imperfection and compromise because that’s the nature of the beast, and the beast, dear reader, is here to stay. [Read more →]

John Cole hits the proverbial nail on its proverbial head: [Read more →]

Allahpundit jumps on the Obama-approval-ratings-are-dropping bandwagon and, like most conservatives who try to interpret the data, totally misses the point:

More than 60 percent of indies disapprove of his handling of health care and the economy. Meanwhile, the overall 44/51 split is the widest gap yet on ObamaCare and the first time it’s been statistically significant in the WaPo poll [....]

Sixty-three percent support the recently deceased Medicare buy-in. Then again, majorities also consistently say they support the public option even though most of them don’t understand it, so it’s anyone’s guess what that “support” means in practice. Remember: It’s amazing what a follow-up question about trade-offs can do to the numbers when polling on ObamaCare. Which probably explains why one wasn’t asked here.

Somehow this leads Allahpundit to imply that disapproval of Obama’s job performance among independents has led more people to lean Republican, closing the partisan gap.  That doesn’t seem very likely to me.  I think a huge portion of independents who disapprove of Obama’s performance are actually hoping for more progressive reforms and are disappointed with how conservative the healthcare bill has become.  These folks might stay home in November, but they won’t come out to vote Republican.

What we’re seeing here is more wishful thinking on the right, interpreting every sign of disappointment with Obama as an indication of the right’s success.  That is simply wrong-headed.  If 63% of independents support the Medicare buy-in and majorities support a public option, then I’d say it’s fairly unlikely that most indies will come out and vote for the GOP in 2010 or 2012.

Remember, people are naturally inclined to vote for the lesser of two evils, and the Republicans are moving more to the right, not more to the center where a good chunk of independents reside.  Even those indies who “lean right” might be scared away by the prospect of a Sarah Palin nomination.

“There are actual sick people with actual families feeling actual pain and facing actual tragedy because of this grotesque, wasteful, perverse, immoral, evil system that we labor under. Health care reform is a necessity because this is true and the fact of its truth tells us that change has to come.” ~ Freddie, on the healthcare reform

Freddie is right and he is wrong in this post.  He is right because there are some opponents of healthcare reform who really don’t care about the human cost of all of this, about the real, suffering people out there who are, as Freddie put it, being “raped” by our current system.

These calloused, uncaring people Freddie is talking about really do exist.  Many are a subspecies of the population known as politicians.  Some are another subspecies known commonly as pundits.  And of course there are many, many people who are ill-informed enough by their political leaders and news sources to think that the real threat is not a lack of affordable insurance but rather some creeping government takeover.  I personally think that this is a bit of a dramatic position to take, whether or not there is some truth to it (and there is).

I think the human cost is very real and very troublesome, and writing it off because the government may become more involved in our insurance is just silly, though we should be honest about the repurcussions of more government in anything (rationing, restriction of choice, etc.).  These are necessary parts of government involvement in anything, and that isn’t necessarily a bad thing all the time.  I have personally benefited from Medicaid and realize full well that the government can be a force for good.  It can be a piece to the societal stability puzzle.

But Freddie is also wrong in that he is conflating the reality of the debate with the caricature of the debate.  Or rather, he is taking the caricature of his opponents and leveling an accusation against that caricature rather than at real people.  Admittedly, the leadership on the right makes this very easy to do, but doing it is nonetheless wrong.  It leaves no room for honest opponents.   [Read more →]