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. 

Scott has a thoughtful follow-up to my anti-pettiness screed.  I want to point out, however, that far more than the problems with populism, I was writing about the problems with elites manipulating it for their own purposes – which, in a sense, is the problem with populism.  It is not so much that the huddled masses are wrong, or not to be trusted, or any of that.  It is that they are all busy people.  They have kids.  They work for a living.  They don’t have as much time, money, or education as the elites do.  They don’t have the connections or the wherewithal or the behind-the-scenes knowledge of the political system. They’re not as connected to government or the media.  This doesn’t make them foolish or ignorant or bad.  Quite the contrary. 

In many ways the people out there opposing the Iraq war or the tea-partiers out there opposing big government or any of these grassroots groups are good people, honorable people doing good and important work.  Scott is involved in some activist efforts up in Canada, and if people didn’t get involved at the grassroots level or with politics in general, we’d be in much worse shape than we are now.  I am not against this sort of popular politics.  Indeed, we have a Democratic Republic so that we can elect representatives to do our will, to some degree, and in order for them to really understand our will a little bit of populism is necessary and vital to the health of our democracy.

But it can be misused and abused by the very people who so often populist anger ought to be directed.  And right now I believe we’re seeing a Republican leadership that is disingenuously manipulating populist sentiment against the president and the Democrats.  (I would argue that Obama has done much the same thing by running a very populist campaign and then following it up with a very insider-oriented administration.  He’s simply more charming than his Republican rivals.)  They are stooping to petty rhetoric and exaggeration and sometimes outright lies to rile up the base against a president who they describe as “radical” and worse. 

Now, I have no problem with opposition.  I think the Republicans should oppose Obama in many ways.  They are well within their rights and indeed within their obligations to do so.  It’s the pettiness and the dishonesty of their methods which rub me the wrong way, and I believe they stoop to these methods in order to gain populist support.  And populists are vulnerable to these elite leaders because the elites have everything the populists don’t have – high podiums, connections, funding, and so forth.  It’s a dysfunctional relationship, and one played out time and again throughout history.

So when I see Newt Gingrich on the Daily Show calling Obama a radical because we read a terrorist his rights on American soil, I just cringe.  It sounds ludicrous to me, because it is ludicrous.  We’re not talking about reading some enemy combatant over in Iraq or Afghanistan their rights after we capture them.  We’re talking about a guy we caught in a plane landing in Detroit.  There is a difference.  And of course, there is precedent with the Shoe Bomber, just as there is precedent with trying terrorists in non-military courts as George W. Bush did over five hundred times during his presidency.  Gingrich and other ostensibly smart people should know better than to dress this up as some “radical” anti-American and dangerous practice. But they do it because they believe it stokes the fires of angry populist sentiment in America, and because they want to be in charge of the narrative however absurd and petty that narrative may become.

Has it always been thus?  I suppose it has, to one degree or another.  Nor are the dividing lines so easy to define.  Some elitism is just as necessary as some populism.  Indeed, we can’t really do away with any of it can we?  The point is, however, that we can do away with some of the pettiness, some of the dishonesty, and shoot for more reason and integrity.  We don’t have to be nice or amicable either.  We don’t have to ditch partisanship in favor of some mythical bipartisan Utopia.  We can be partisan and honest at the same time.  We can be partisan and still not so petty.

Every First Lady is obliged to tackle some trendy and media-inflated crisis.  For Hillary Clinton it was healthcare.  Laurah Bush focused on literacy.  Michelle Obama wants to end the dread childhood obesity “epidemic”.  Perhaps because the federal government has shown such skill in combating similar issues – such as our nation’s failing public schools – Mrs. Obama believes that it is the best institution to tackle our expanding waistlines.  That the federal government cannot tighten its own belt is beside the point.

Despite the fact that Mrs. Obama took personal responsibility for her own children’s near-miss with childhood obesity, the First Lady believes that the vast majority of Americans could use the beneficent hand of the state to drag their own children back from the brink.  To do this she proposes that the federal government does what it does best: spend lots and lots of money.  And to do that, President Obama has proposed that the government form a task force to see which spending project will sound the most appealing to voters. 

A few of the ideas floated include:

• Working with the the American Academy of Pediatrics to encourage its 60,000 members to check the severely out-dated Body Mass Index at each child’s visit, and give out “kid-friendly prescriptions” for healthy, active lifestyles.  Kids will fill this prescription by convincing their parents that “outside” is dangerous and that what the family really needs to stay healthy is a Wii.

• $400 million in tax credits drawn from the current budget surplus will go to grocery stores to form state-sponsored monopolies in “food deserts” – areas of the country where there is no easy access to grocery stores.  This is deemed much more efficient than scaling back zoning laws and allowing Wal*Mart to set up shop in said “food deserts” because Wal*Mart’s prices are simply much too low and of course because people who write these laws really don’t like shopping there.

• A new foundation will be created “made up of existing foundations and groups to monitor the campaign”.  Think of it as a super-foundation (or a super-healthy-foundation).  Perhaps we should form a second committee first, however, just in case the first committee isn’t quite up to the task.

• $10 billion over 10 years for the Child Nutrition Reauthorization Act, which would basically reward the most well-connected health food industry lobbyists around the country to provide healthy, free and reduced-priced school meals for kids.  Because again, allowing private companies to run school cafeterias would be far, far too efficient.

• Another $25 million would go to schools in the cleverest legislators’ districts to help renovate school kitchens and replace deep fryers with free range community gardens.

Now, you might be wondering how these steps will end childhood obesity in a mere twenty years as Mrs. Obama has ambitiously stated as her plan’s goal – a time frame which also conveniently sits outside her tenure as First Lady.  You might also wonder how healthier school food will trim down our children if they continue to eat bags of potato chips at home while lounging for hours in front of the television.  Perhaps the lady doth protest too much, given the shaky evidence that there is any such childhood obesity “epidemic” to begin with.

I’ve been trying to get at the heart of what bothers me so much about contemporary conservative politics & discourse these days. The closest I can come to an answer is that conservatives have fallen into the trap of modern politics – which is to say, they’ve become petty.  Extraordinarily petty. The endless lament over the liberal menace; the incessant ballyhoo over anything and everything the president does or says; the irksome victimhood – it all boils down to a propensity toward pettiness.  It becomes a cacophony of empty gestures and equally vapid posturing.  (The other side does this as well, of course, but you know what they say about two wrongs.)

The reason for all this pettiness?  I think it goes beyond merely scoring political points.  I think it has much more to do with cheap populism.  And nothing is more damaging or antithetical to conservatism than populism, even the rightwing variety.

Populism, after all, is just a nice word for “mob”.  If ever there was a thing that conservatives were meant to protect us against it is the rule of the mob.  Conservatives were never supposed to be the mob, were never meant to be its advocates. 

The first problem with the rule of the mob is the sort of leaders it produces.  Every mob needs a despot.  That’s why we have a Democratic Republic in the first place as opposed to a more free-wheeling Democracy.  Pure, unadulterated democracy is too close to mob rule, places too much political power into the hands of the majority. All too quickly such democracy leads to tyranny of one variety or another.

Populism can also turn a nation’s spiritual efforts into political efforts.  If one goal of conservatism is to preserve the spiritual buoyancy of a nation or a civilization, then conservatives should avoid the evangelist populism dominating so-called “social conservatism” at all costs.  Subverting faith or religious culture to the narrow and corrupting goals of politics can only backfire in unintended and perfidious ways.  Certainly the divisive culture-wars that this religious populist movement has used have only led to more of a spiritually muddled nation, and a population more resistant than ever to organized religion.  Political-evangelical Christianity is just as vulnerable as any other populist movement to the temptations of despotism, the need for charismatic and extremist leaders, and the shoring up of ever more power in order to achieve ever more ambitious goals.

In other words, populism is anything but limited, and political populism cannot lead to limited government.  That is the great problem with the tea party movement.  Liberty & order are precarious cousins, and populism is not the way to balance the one against the other.  Yet the modern conservative movement has abandoned the “politics of prudence” in favor of the politics of pettiness.  And it will be a while before reasonable people can right the ship.  Populism is the sword of revolution and radical change.  It is the predecessor of the guillotine and the gulags.  It is not conservative in any historical sense, whether or not it manifests itself in the right-wing.

…the Saints did play like champions.  And it was a pretty damn good game right up until the end. After that interception, though, you could tell the Colts were rattled.  Peyton Manning especially.  That was the nail in the coffin right there, except it was the Colts and they’ve pulled back from worse brinks before.

I enjoyed the game.  I don’t watch much in the way of sports, but I do love a good football game.  On that note – anyone here read any good sports-bloggers?

Oh, and I knew this ad would get some blog-traction today.

For a slightly more dystopian take, read this.  Given the state of affairs we’re in over the growing and consumption of certain illicit plants this is not so far-fetched.  And if it is far-fetched, then so is the war on drugs.  So is the light-bulb ban.

My favorite ad – probably the stuff from Doritos.  I laughed the hardest when that kid slapped the guy for taking his chip.

And I’m pretty excited about the new Ridley Scott Robin Hood movie, which I hadn’t heard anything about until last night.  I was a big fan of Gladiator and I’ve always been big on Robin Hood stories.  I remember seeing Kevin Costner’s version when I was ten, in a movie theater in Florida.  The audience cheered after Morgan Freeman’s speech.  Yes, those were simpler times.  I still have a soft-spot for that movie, warts and all.  I mean, who cares about the accent?  If anything, Costner’s performance led directly to some really good lines in Robin Hood: Men in Tights.

You can have an open-thread here if y’all would like….

P.S. – I’m with Sonny Bunch (in the comments) on this one – to some degree.  I think the ad was a parody of enviro-extremism, but I also think it didn’t take seriously the question of the security state.  In other words, while it parodied the green movement, it laughed off the very real threat of the creeping security state, which can use green policies as easily as it can use marijuana or terrorism to grow and further intrude upon our privacy.

Opponents of high speed rail make several points about its viability: rail is a “19th century” mode of transportation; rail would be under-used and therefore would need massive subsidies to function; infrastructure in the cities connected by high speed rail is not sufficient to make this form of transportation efficient or cost-effective; even if rail is eventually necessary, right now it is impractical due to the ready supply of cheap oil.  Others point to the fact that the contracts for these rail systems will largely go to foreign companies, thus raising questions about their stimulative effects here at home.

I think these are all very good arguments.  And if we had an endless supply of oil and gas, and thus an endless source of cheap fossil fuels for our car-culture, I think that they would be good enough arguments to discourage any support of federal high speed rail projects.  However at some point I believe we will be short enough on fuel that it will become cost-prohibitive to commute or travel long distances in cars.  Having a rail infrastructure in place at that point will be instrumental in shifting toward a less car-driven economy. Local efforts to remake cities along more pedestrian and mass-transit lines can be more focused since the big inter-city travel routes will be developed already.

Of course there are difficulties. Rail suffers the same disadvantage alternative energy suffers: that is, heavily subsidized fossil fuels and a modern infrastructure built entirely around the use of fossil fuels make any effort to compete nearly impossible – at least not without further subsidies.  Removing subsides for fossil fuels could help level the playing field, but I don’t see that happening ever really. No politician wants that blood on their hands.  Nor do I see a sensible carbon tax replacing the silly and probably doomed attempt at cap and trade.

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.

Jonah Goldberg has a very smart response to Jim Manzi’s reflections on “liberty-as-means” libertarians vs. “liberty-as-goal” libertarians.  I want to focus on Jonah’s post here, but you should read Manzi as well.  Jonah writes:

My own view is that the Right is intellectually healthier and more creative because its dogma remains unsettled (yes, I’ve written about this a zillion times). The Right is divided between those who are (in Irving Kristol’s formulation) anti-left and those who are anti-State. Those who believe that the government is bad because it’s working from leftist assumptions, and those who believe that the government is bad because it is the government. (Most conservatives share both outlooks to one extent or another, but usually fit more into one camp than the other. If you’re wholly in the government-is-bad camp you’re more properly a libertarian, but still on the right). There are those who believe that liberty is an end and those who believe that liberty is a means. For more than a half century now, modern conservatives have been debating and redebating the question of where to the draw the lines between freedom and order, liberty and virtue. And because that line continually needs to be redrawn given the evolution of attitudes, changes in technology, etc, conservative intellectuals (though not necessarily conservative activists, politicians and the like) are constantly revisiting first principles and philosophical assumptions or are at least capable of acknowledging the good faith of their philosophical opponents). I do not think you can say the same thing about liberals (again, as a wild generalization). What unites most, if not all, factions of the Left, from socialists to DLC moderates is a dogmatic acceptance that the government should do good when it can and where it can.  Hence the debates on the left tend to be procedural, wonkish, and technical or rankly political. The Right has such arguments as well, of course. But they do not define and dominate political discussions the way they do on the left. And that’s because our dogma is still unsettled.

I think this strikes upon a number of smart observations.  Certainly the continual re-drawing of the many lines between liberty and virtue, freedom and order, etc. is exactly the reason I enjoy reading (intellectual) conservative blogs so much more than I enjoy reading liberal blogs.  On the flip side, I think the best wonkish blogs and writers are found in the liberal corner.

Perhaps this reveals not only the strengths on both sides of the political aisle, but also the weaknesses.

I like thinking of conservatism in these terms – as an “unsettled ideology.” This gets at the bohemian conservatism I was talking about last week.  Russell Kirk was a self-described “bohemian Tory” and I think the intellectual wing of the conservative movement, with its distrust of centralized power and so forth fits that term nicely, if the red-meat activist wing does not.  The “unsettled dogma” concept seems so far removed from the conservative movement’s attempts at purity tests and activism that it’s a bit hard to reconcile the two.  And of course I’ve always been more attracted to the intellectual struggles within the ideology than with the political processes themselves, healthcare blogging notwithstanding.  But I think this can also be a trap for conservative intellectuals, or at least for bloggers with an intellectual streak (I am not really an intellectual as far as I know). More conservatives need to focus on policy and wonkishness if only to provide their ideas with a tangible foundation, but also because the effort to dismantle or reinvent the welfare state – to really limit big government – requires if anything even more policy and wonkishness than the other side.

Addendum: I’d like to point out that I in no way endorse some of the more caricatured views Goldberg expresses here vis-a-vis liberals.  Gross generalizations are not really my cup of tea, whether they can be applied to certain people within the larger group or not.  I will, however, note that so far the conservative and liberal response here has been hostile.  That means I’m doing something right.  Re: purity tests and so forth, it’s not so much that ideological groups shouldn’t set out some standards for membership, but that the standards become awfully silly and rigid in a political climate like the one we now have.

Matt Yglesias likens transparency in Congressional negotiations with transparency in family negotiations:

Think about a family negotiation over whose house you spend the holidays at, or who goes to watch Billy’s soccer game on Saturday. At the end of the day, wouldn’t everyone be worse off if the whole extended clan had the right to watch the negotiation on C-SPAN? More to the point, wouldn’t knowledge that the proceedings were going to be seen by others bias the negotiation. If your husband says “you don’t even like your cousin John” then you more or less have to protest and insist that you do too like him and any proposal predicated on the idea that you don’t like him needs to be rejected.

And that’s how it would go in negotiations. I think people think that if there were more transparency, the dread special interests would have less hold over the process. But I suspect the real result would be the reverse. What happens when you reach a compromise is both sides agree to sell some folks out in pursuit of some bigger objective they care more about. But in a transparent process, nobody would be willing to even hypothetically entertain the idea of selling anybody out.

Ezra Klein adds:

Of course, if the whole clan was watching, the husband would never mention your antipathy to your cousin John. And that’s the bigger problem: Hard issues never get discussed at all. You’d have some private talk and then some fake public negotiations where you followed a predetermined conversational route to the ending you settled on behind closed doors.

Now, this is true to an extent.  One significant difference between family negotiations and government negotiations is the set of incentives.  There are no lobbyists when a husband and wife decide where to spend Christmas (unless you count the kids or the competing relatives).  Nor is there typically a great deal of money at stake. And while family negotiations are typically quite personal, government negotiations are not.  Obviously hashing out disagreements about our family members is not something we want to do in public because, at the end of the day, we’d like to maintain some ties with even those family members who we may be complaining about.  These same deep bonds simply don’t exist in the public policy arena.  So it is not merely a difference of scope but a difference of kind which causes this analogy to fall apart.

Would lobbyists and government officials simply negotiate behind closed doors prior to negotiating in public as Ezra suggests?  Probably.  However, there are other ways to make the process more transparent.  Even if negotiations remain behind closed doors, certainly the results of these transactions could be made more visible.  Certainly there could be a better way to publicly advertise who is being lobbied by whom.

This is the information age after all.  The trick isn’t a lack of information – the trick is distributing that information and making it as easy to understand for as many people as possible. 

A simple solution would be to treat our congressmen (and women) like NASCAR drivers.  Simply stick a bunch of sponsor logos and industry stickers all over them so that we can see that when Congressman A votes for more farm subsidies, it’s because Big Agriculture is paying him to.  Or when Senator Y votes against defense cuts, it’s because [insert weapons manufacturer here] has donated to his re-election fund.  Have their staffers do the same.  Have each bill enacted in Congress prefaced with a "This bill is brought to you by…." credits section.

And so on and so forth.  There are plenty more ways (and even some not-tongue-in-cheek ways) to make the connections between our representatives and the special interests they represent more obvious and accessible.  Not all special interest influence is necessarily bad either – but it’s good to know who is at least ostensibly pulling the strings – and how hard.

“If Obama’s efforts to create a viable regulatory framework in which individuals can buy private health insurance (a) pass congress, and (b) turn out to work well and be popular, then you can imagine a version of Ryan’s plan being put into place. But in the absence of that kind of reform, I just don’t see how you can do this, which is presumably why the implementation is delayed all the way to 2021 which helps Ryan avoid needing to think about implementation details.” ~ Matt Yglesias, writing about Rep. Paul Ryan’s alternative budget

I think Yglesias actually makes a pretty strong point here.  While I’m overall fairly sympathetic to Ryan’s budget – he does, after all, balance it (at least according to the CBO report [pdf]), something virtually no other politician is willing to even propose – I think there is a fundamental flaw with implementing a healthcare voucher program without first fixing the broken, dysfunctional health insurance market.  The exchanges created in Obamacare would be one way to do this. 

What Yglesias does not point out, however, is that Ryan’s budget proposal also puts an end to the tax exemption for employee benefits.  Simply coupling this tax reform with the ability to purchase insurance across state lines creates an entirely new health insurance market.  Suddenly people on the individual market are given the same tax preference as people who receive their insurance from an employer.  Health insurance drifts away from employers and becomes personal and portable.  People wouldn’t lose coverage when they left their jobs.  Meanwhile, insurers would lose their long-held local and state monopolies and be forced to compete nationally, driving down costs both through added competitive pressures and by the better bargaining powers that these large, national firms would have, with their much larger, national cost-sharing pools.

Of course, the hard questions in healthcare will center around two inextricably linked concepts – pre-existing conditions clauses, and individual mandates.  Almost all modern democracies have some form of universal coverage, and the only way that it has been achieved with any semblance of a free market has been by doing away with pre-existing conditions clauses and implementing some sort of individual mandate.  If the former is done without the latter, nobody would buy insurance until they were sick – defeating the purpose (and the viability) of insurance to begin with.

Other alternatives exist, of course.  My personal preference is a model along the lines of Singapore’s healthcare system, which mandates health savings accounts and then picks up the tab on any costs above a certain flat percentage of income.  This puts healthcare directly in the hands of the consumer (cutting out insurance companies altogether) and provides them with catastrophic coverage if something should go wrong.  Furthermore, by placing costs and transactions directly in the consumers hands, it keeps costs from skyrocketing.  The mandated savings would be flat, but the catastrophic coverage functions progressively, covering less and less as income rises.

Either way, before any privatization of Medicare and Medicaid can occur, the private insurance market must be transformed.  Paul Ryan has shown true grit in crafting a budget that is actually balanced, but the possibility of backlash to cuts in entitlements is very real if the systemic problems in our healthcare system aren’t taken care of first.  Both Yglesias and Ezra Klein see this budget as a sort of draconian rationing of benefits for seniors and poorer Americans. If the insurance market could actually be fixed, however, then the system of vouchers which Ryan proposes would be adequate and possibly even better alternatives to the status quo.

….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.