Back to Massachusetts (An Answer to Kos)

You make good arguments, but isn't affordability going to be a *big* issue, and won't states also be able to opt-out of several parts of this plan?

Can't we be for the reform bill as it's taking shape because 30 million more will be covered and against it because it falsely pits expanding coverage against containing costs? A few dozen other countries cover everyone and spend less - through a not for profit single system - and they have better outcomes. Can't we celebrate 30 million more of us getting coverage and also fear that as well as not passing reform killing efforts for ten years, passing this reform may kill real reform for ten years: taking the profit out of financing health care and having an efficient, single system - everyone covered and spending less?

Jonathan --

I'm a small business owner and I don't consider myself "on the left." I have experience both as someone who purchases in the individual market, and as a employer struggling to help my employees obtain coverage. Additionally, I worked for many years, as a marketing professional, with every major health insurer in my region. I am someone who has been very concerned about health care reform for a very long time. It has been the major factor in my vote over many election cycles now. I am also someone who knows a little about the health insurance industry. I am not an ideologue.

Here are my concerns: I fear that policy wonks inside and outside the administration are so focused on a few right of center obstructionist votes in the Senate, that they have lost sight of the larger and more important political picture -- what the national electorate wants, and what they will find palatable. With each temper tantrum from the small handful of Senators who the media has wildly mis-characterized as "moderates", "reform" is being stripped of those things voters and consumers have consistently shown they most want, and, sans that compensation, reduced to, or loaded up with, things a great many find unpalatable.

The things to hate are out front and obvious, the things to love are mostly loveable to policy wonks and deficit hawks.

For voters, on the left, the right and in the middle, "affordability" is the most important issue. They want affordable, quality options from which they can freely choose, based on their personal financial circumstances, priorities and goals. "Cost savings" in the sense that excites policy wonks is of course a necessary goal. But if it is not, as it does not appear it will be, accompanied by significant reductions in premium cost for the consumer, it will not only not provide any political benefit, it could be a political disaster. Especially when coupled with mandates. For middle class small business owners (and their employees), independent contractors, the self-employed, etc. who will be most affected by mandates, SUBSIDIES, WHICH LIKE WELFARE AND MEDICADE ARE BASED ON INCOME, AND MUST BE QUALIFIED FOR, ARE NOT A SATISFACTORY ALTERNATIVE to genuinely affordable options; public or non-profit. The failure of the administration, and health care bloggers, to understand that fact makes the Right's point about "out of touch elites." For people whose income fluctuates, who must make major investments to generate income, for whom cash flow is always an issue, maintaining consistent eligibility is likely to be a real problem. For them, subsidies are likely to require an intrusive, resource consuming amount of time responding to government oversight and proving eligibility that may at best be very spotty. If reform is not a good deal for people for whom reform is most important, it is not reform at all. Taking a welfare approach to reform with this constituency is a gigantic political mis-step.

If progressives allow reform to pass in this form, they will come to regret it. Because they will be totally impotent to stop much worse to come. There is no guarantee that Obama will be more than a one term president. If the economy doesn't come roaring back and/or the Republicans manage to hold it together enough to nominate someone who doesn't actually look insane, he may not be re-elected. Health care reform that doesn't meet voters expectations could make a big contribution to that outcome.

Even before that possible outcome, progressives, the one group most focused on affordability for the consumer, are likely to find themselves in a much weakened position as the unpopularity of health reform, as it is being proposed, helps contribute to losses in 2010. If Democrats lose the White House, and perhaps even if they just lose some power in the house, the mandates that wonks are putting so much emphasis on, and hope in, and that the GOP's small business constituency absolutely, vehemently abhors, is gone. If not in two years, in four. Losing it won't matter to the insurance companies because a GOP president, or perhaps even just a more right leaning congress and a Senate as it is constitued now, to the applause of still clueless beltway bloggers and pundits no doubt, will work hard to push through lots of compensating giveaways.

Furthermore, the administration, with its self-serving fear-mongering, is doing a very good job job of setting the stage for gutting Medicare.

While it may be possible to improve bad policy over time, it is also possible to make it much, much worse.

I think the administration is setting the stage, politically, for that to happen with "reforms" that are politically unacceptable.

Please tell me why you think I am wrong.

Jonathan,
The real questions are:

1) Has their been an improvement in the number of people getting treatment for serious diseases and conditions that were not getting it before.

2) What has been the cost (or savings?)

3) Have we done anything to alter the allocation of health care resources to improve health.

4) Have the changes done anything which will impact the availability of health care or new treatments, drugs and devices in the future.

BTW - Foregoing care is not a bad thing if it's not for a serious condition and it costs a lot of money. (I think that was supposed to be one of the goals for health care reform.)

I'm hardly an expert on this whole business, but a few things seem pretty clear to me:

1. If this bill blows up, it will do far more political damage than if it passes -- which will still be a huge, historic victory -- and you can kiss goodbye any chance at meaningful health care reform for the foreseeable future. You need 60 votes to do anything. It's too bad that some of those votes have to come from douche bags and morons. Welcome to democracy -- or, more specifically, what I like to call Our Stupid Senate. It's a small miracle that we've gotten this far. And this is as close as we'll ever be, at least for a good long while.

2. Whatever emerges from this process will not be the best choice. Destroying our dumb health care economy as we know it would be the best choice. The best choice is not a viable option.

3. This bill will be a big deal and do many excellent things, not the least of which is greatly expanding health coverage -- and in a way that won't break the bank and will at least arguably have a decent shot at reducing costs over the long term. It will also introduce the concept of heavy regulation of the health insurance industry, which will mean that coverage will not only be expanded over the population but that it will be better and more durable and available to those who couldn't get it before not only because they couldn't afford it but because they got sick or had gotten sick in the past. Mandates plus subsidies plus exemptions is not perhaps the ideal mechanism for increasing access to health care in an affordable way. It seems better than nothing, which is what we'll get if this bill dies.

Esmense has nailed it in his comments above. I, too, am a small business owner...and a faculty member at a large State University. I hear those same comments from dozens of other CEOs and faculty in Business, Engineering, and Science that are moderate Republicans or Progressive Democrats in no-way crazy left or right. The other complaint is that Obama and the Democratic Senate have been consistently rolled by intransigent demands by essentially all Republicans or a few Democratics on a variety of issues of which health care is Exhibit #1 such that Obama in particular consistently looks like a chump or wimp. And thats the last characteristic most voters admire. So what if he talk a good talk if he folds to Lieberman, Baucus, Snowe and 4-5 others on health care --- and to Karzai in Afghanistan, Mullahs in Afghanistan, Bankers on finance reform, etc., etc.

Kos's objections to the Senate bill go well beyond whatever has happened in Massachussets.

20 answers
by kos
Wed Dec 16, 2009 at 03:51:41 PM PST
Let me say up front that my disagreement with the "support the current bill" crowd is based on policy and political considerations, but I can see how reasonable people can come to the opposite conclusion. I don't think supporters of this wreck of a bill are stupid or compromised or anything like that. I'm not like Joe Klein railing against "assorted nonsense from left-bloggers", which so reminds me of his ad hominems during the Iraq War debate. How'd that turn out, Joe?
In short, there appears to be a divide between those who think the insurance industry will play nice, even with little incentive to do so, and people like me who don't. They believe that government will enforce the new regulations, people like me have seen entire industries employ armies of lawyers and lobbyists with the sole intent of undermining and avoiding such regulations. I'm a half-empty guy, others are half-full. Regardless, this is a fantastic debate. For critics who bemoaned the lack of policy discussed on blogs, this year has certainly proven that when we do have the opportunity to impact policy (i.e. a Democratic-run government), we certainly can get into the weeds on policy.
Ezra Klein takes me to task for my opposition to the mandate, pointing out that Switzerland, among other systems, have mandates that require citizens to purchase health insurance from private insurers. It's true. They do. Those countries also have strict regulatory regimes that heavily regulate those insurance companies. In Switzerland, for example, insurance companies cannot profit from the essential benefits plan everyone must purchase. That's kind of an important detail missing from the Senate's monstrosity of a bill. In addition, Switzerland also strictly regulates the price of medicines and medical devices -- something this Senate has explicitly refused to allow.
Give me those kinds of restrictions to the Senate bill, and I'll rethink my opposition.
Then there's Nate Silver and his 20 questions For Bill Killers, which I'll happily answer:
1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?
The assumption here is that this bill is the only option on the table. The House still has a say in the matter. And really, the point of reform isn't to shovel taxpayer dollars to the insurance companies, it's to expand care and lower costs. I'm not willing to surrender on costs.
2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?
This betrays a simplistic view of liberals, as if our answer is to merely shovel money at a problem. What we're looking for is good policy, which in this case, would also be good politics. So no, throwing money at the insurance companies doesn't change a thing. The insurance industry would simply absorb the new subsidies just like universities have raised tuition to shovel up any increases in financial aid.
3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?
Where is the evidence that insurance companies would rig the system to extract record profits? I don't know. Perhaps the last decade or two might provide the answer.
4. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?
Because it is a measure that would disproportionately affect blue collar workers in high-risk jobs, or workers that have given concessions on wages to preserve good benefits packages. Limit that provision to people making over X amount (say, $100K/year), and I wouldn't have a problem with it.
5. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?
Because without premium caps or a public-run competitive option, there is no incentive for them to lower their premiums. They have a monopoly, and monopolies aren't in the business of unilaterally reducing their prices. There are two ways to force them to do so -- government regulation or market competition. The former is out, and the latter is inadequate.
6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: "forcing you to buy government-run insurance?"
If you start worrying about Republican talking points, you've lost the game. They're accusing Democrats of trying to kill grandma. They're not going to back off because a talking point isn't 100 percent accurate. 2010 will be the year of the "commie socialist Democrats", no matter what health care reform bill is passed.
In any case, Republicans have tried to destroy socialist programs such as Medicare and Social Security for years. If people like a program, there's nothing the GOP can do about it.
7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?
Is this argument that the mandate doesn't matter because too few people will be subject to it? If so, then strip it out. It shouldn't matter.
8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?
I'm not sure how the future composition of Congress has anything to do with a battle in our current congress. This battle isn't over. But if anything, this argues for pushing for the most progressive bill possible.
In any case, most of the endangered Democrats next year are of the Blue Dog variety, while most of our (relatively meager) pickup opportunities are in Democratic-leaning districts. In other words, while our majorities will likely be smaller, it will be a more intellectually cohesive caucus. That's why all of the outright House retirements thus far have been Blue Dogs -- they're not interested in having to defend themselves in a caucus that is trending leftward.
9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?
No, the idea is to get the best possible legislation today. We may not be able to get something with reconciliation before Obama's State of the Union Address, but I don't think something this important should be beholden to something as trivial as a speech, even one as important as the SOTU.
10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?
Given that the current bill only has 32 percent support, I don't think this turd of a bill in the Senate has much support of anyone, much less party activists. And the voter intensity numbers are clear -- base Democratic voters are planning to sit out 2010. And I doubt 18-29 year olds -- a key part of the Democratic base -- are going to be thrilled with a mandate. In fact, it may be the single least popular item in the bill.
11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?
Nope, if Democrats gave it a serious shot, and then built campaigns around the obstructionists. Caving in to Lieberman, Republicans, and corporate interests, on the other hand, sends the message that the Democratic super majorities are irrelevant, and all the hard work from the last four years in electing them was a wasted effort.
12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?
Likelier. Seems self-evident. And really, Medicare and the VA health system shows that the government is quite capable of handling health care.
13. What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?
Fallout with the DC press corps? They didn't mind when Republicans used it to pass their tax cuts under Bush, but that's a different time. I'm sure they'll hyperventilate about it now. The voters? I've seen no data that suggests they care about process. Just results. Democrats would cheer, Republicans would bitch, but those guys will bitch anyway.
14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?
It'd be nice to find out.
15. Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?
Expand medicaid, add a national exchange instead of the state one, get rid of mandate, etc.
I'm curious ... how many concessions has the other side made? Maybe it's time for a "compromise" that actually includes a compromise.
16. What are the chances that improvements can be made around the margins of the plan -- possibly including a public option -- between 2011 and the bill's implementation in 2014?
I'm actually a little more optimistic about this. But here's the thing -- everyone surrenders now, the impetus for such tinkering will be gone. If people are angry and campaign on these key issues, then political pressure will be maintained for further action. The "surrender now" crowd actually makes further tinkering less likely, not more.
17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a 'mandate' for a public option that could be inserted via reconciliation?
The public option remains popular, despite the year-long demonization process by insurance interests, Republicans, teabaggers, and even some Democrats. Popular enough to base a "referendum" around it? Beats me, I'd have to see more data. But if 2010 is a referendum on that current Senate bill, we're in deep trouble.
And in any case, I don't think we have much of a choice in the matter. 2010 will be all about Democratic "socialists", and HCR will be Exhibit A in the wingnut playbook.3
18. Was the public option ever an attainable near-term political goal?
Yes. But even if it wasn't, perhaps we would've been better off starting with a Medicare For All approach, or at least an expansion (back when Lieberman was for it). I'm sure someone will write a book about all the tactical mistakes made during this battle. There's no doubt the Democrats blew it big time, but that's not the same as saying a desired policy outcome was not attainable.
19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?
Depends on the details of that public option.
20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?
Max Baucus caused more damage to this process than Lieberman, by slowing things to a crawl pretending that Enzi (from Wyoming!) was ever a good-faith negotiator, giving Republicans and teabaggers a chance to ramp up the hysteria and slowing whatever initial momentum the administration and congressional Democrats ever had on the issue.
I don't give a shit about Lieberman's opposition. He's just confirming everything we ever said about him. In fact, it's kind of nice seeing the Beltway and congressional Democrats start to finally understand who the real Lieberman is. But I never expected anything less from him, so pretending that this is some weird grudge match minimizes what are serious policy disagreements. Lieberman may be petty about this, but I'm not. I settle those grudges on the electoral battlefield, not the policy one.

I agree with esmense that affordability is a big issue. I guess if I had to choose affordability over helping people threatened with medical care induced poverty, I would take the latter. But if I had to choose helping the poor accompanied with a giveaway to the health care industry, I would reject it, just like I think the public would have rejected a financial bailout that permits large compensation to the employees of the beneficiaries of the bailout. There is no question in my mind that whatever Congress does, it will cost more than anticipated, which is okay only if it benefits those who need it.

Esmense: your argument about affordability makes a certain amount of sense politically, but ultimately falls flat.

First, you can't have affordable, choice unless you either first rein in health care costs dramatically, or subsidize someone: the system is absorbing 17% of GDP with the current incomplete coverage, it can't get cheaper than that by adding additional, currently underserved population, unless you have cost control.

Second, affordable presumably means affordable to everyone, whether they're earning $200,000/yr, or $20,000. Since the per family cost of quality choice-based health insurance would easily hit or exceed 50% of the lower figure, either you subsidize them, or you set flat-rate (relative to means) community-underwritten plans at a rate they can afford but which does not cover the costs, and then subsidize the payors, which in effect subsidizes the high earners.

The way around this, of course, is to put the entire population into a single pool, and make it actuarilly sound, but affordable, by funding it from a pre-existing means-tested plan that adds no overhead - such as the income tax. But this is the dreaded single-payor, that I'm guessing based on your use of the word choice, you would also oppose.

At the end of the day, you can't simultaneously have freedom from subsidies, high quality, universality, and choice all in the system at the same time. Something's got to give.

Affordability/trusting known thieves versus political disaster now if the bill explodes (political disaster later if it does?)...

Does anyone know if social security had so many rabbit holes you could fall in even as it was being signed?

I know this is an extravagantly complicated, singular event in our history - but historical references help me think.

(terrific posts by all).

sdemuth:

You are correct that single payer is the solution that provides affordability without the problems inherent with subsidies. But you are wrong to think I object to single payer. I'm a pragmatist, not an ideologue. Single payer is the pragmatic answer to the problems in our system. The ideological objections to single payer don't make practical sense. The aim of those who make those objections isn't to find effective solutions to the problems of our current system. Their aim is to effectively beat back opposition to the status quo, maintain the system as it is, and support those who profit from it. And they have been quite successful at that.

So successful that the most pragmatic, practical way to achieve universal health care is banned from discussions about how to achieve universality -- while those who do bring it up being labeled as unpragmatic and ideological. For reasons anyone who calls themselves a pragmatist, a moderate or a proponent of common sense should be ashamed of, single payer is off the table.

So, when I talked about choice I was thinking about the Swiss approach. Where affordability is achieved and maintained by heavy regulation of the insurance industry and with limits on profits.

As for subsidies, I personally object to using a welfare model, which I think subsidies are, to help people achieve affordability -- because I believe reform should help free people from the indignities of our welfare system, not throw more people into it. I also object to it because as a business owner I know the practical problems subsidies can create for small business owners, the self-employed, etc. And, I object to them because I do not believe they will prove to be politically smart.

Esmense: apologies for the wrong guess.

I too like the Swiss model, but for it to work here - and achieve anything like the universal coverage I think we need - we'd first need to solve the problem of massive income inequality in the US. Otherwise you've got a well-regulated, equitable health care system to which 25% or more of the population won't have access anyway.

Wandrey, I couldn't find a quick, convenient link on this, but I've heard that the Social Security Act, when it first passed, did not cover a lot of categories of workers and that the benefits were small when compared with later expansions. The Act was debated and revised all throughout its history.

I guess I'm a little frustrated by the repeated complaint here that the White House and Democrats are somehow allowing a few recalcitrant Senators dictate a watered-down bill. Yes, a few recalcitrant Senators have a lot of power in this process. How do you imagine you're supposed to get around that?

Single payer was never going to happen. I think we knew some time ago that a public option probably wouldn't happen either. It's irritating that the best policy is impossible to achieve, but it is, unless Obama has magical powers he's been keeping under wraps. Like I said before, it seems like a miracle that this is actually going to happen. What was the last piece of really landmark domestic liberal legislation that was signed into law? I don't remember.

If it's this hard to get something this imperfect passed with 60 votes in your caucus, how are you supposed to get something better done with 59 or 50, or, God forbid, less? The trigger has to be pulled now -- no way around it. I suggest that those of us dissatisfied right now take the glory of the moment and then focus on making it better.