Why Reform Is Hard

by publius

I'm glad Ezra Klein wrote this, because it helps provide context for increasingly disillusioned liberals who think Obama and the Dem leadership are blowing health care.  The upshot is that it's hard to say things like "if the bill isn't sufficiently progressive, we'll oppose it" when that's exactly what the other side wants.  Here's Ezra:

The problem, I think, is that there is a tendency to understand heath-care reform as an equal negotiation in which all sides want a deal, and you can game out various bargaining stratagems. But health-care reform is not a negotiation. It's a campaign.

"Walking away" is a great strategy only when the other side needs you at the table.  Think about the iPhone deal between Apple and AT&T.  If AT&T asks for too much, then Apple will walk.  But because AT&T really wants the iPhone on its network, it will modify its position.  Same deal in reverse.  If Apple asks for too much, then AT&T will walk.  But because Apple wants a deal (and subsidies, etc.), it will eventually modify its position.

That's not at all how health coverage reform negotiations are structured.  If the progressives threaten to walk, Republicans and Blue Dogs will say, "fantastic, don't let the door hit you."  Accordingly, the prospect of not passing reform provides virtually no leverage with these people -- particularly as the bill gets picked apart day after day by slanders, complacent media, and delays.  Thanks Max!

Another point that Ezra raises is that progressives really really want reform to pass.  Virtually anything that can get 60 Dems + Snowe/Collins would exponentially improve the status quo.  And so progressives would be foolish to walk away.

I don't really know what this analysis implies in terms of actual tactics and strategy.  It's just one of the many reasons why health care reform is really hard to do, and really needs to be fought for -- whether you're the President, or whether you're correcting lies on Facebook or talking to friends at the Little League game.

Political idealism isn't about self-validation and catharsis.  It's about elbow grease, and volunteering, and sweat.  It's the difference between JFK idealism and Ted Kennedy idealism.  Ted's accomplishes things.  JFK's makes you feel good about yourself.  Obama's election made us all feel good about ourselves.  But if we're going to get something done, we'll need more Ted.  More fight.  It's hard because it's important.

Comments

[jon (aka Vandy J)]

Well put sir.

Politics is the art of the possible. If you want to dream, major in theater.

[brent]

Accordingly, the prospect of not passing reform provides virtually no leverage with these people

Sure, but the question of course is: What will provide leverage? The upshot of all you write is that, for progressives, there really is no leverage to be had and if that is the case, there really is no negotiation. Its basically theater for the purpose of moving public opinion in favor of one position or another.

I agree and that being the case, taking the posture that the progressives are taking in this, that they are prepared to walk away, is just as legitimate an approach as any other. As you say, its a campaign, and I am not sure how their political position would be helped by sending out the signal that they are prepared to accept whatever watered down deal they are handed. They are banking on the notion that the public really does want reform and would not be any happier with failure caused by the fact that progressives are being shut out than any other obstacle.

The negotiations may be pretend but no one gains any ground by pretending to be too conciliatory from the outset.

[Gary Farber]

"It's the difference between JFK idealism and Ted Kennedy idealism. Ted's accomplishes things. JFK's makes you feel good about yourself."

Gosh, but this is an incredibly arguable analogy.

JFK made me feel awfully good by getting the Soviets to withdraw their missiles from Cuba, without starting a nuclear war. Ditto by defusing the confrontation of Soviet and U.S. tanks in Berlin.

Ditto by creating the Peace Corps.

Ditto by making the decisions that enabled us to have a real space program, and land on the moon.

Ditto by getting the minimum wage raised for everyone despite Congress.

Ditto by enacting Executive Order 10925.

Ditto by sending federal marshalls to accompany the Freedom Riders.

Ditto by getting the Interstate Commerce Commission to make discrimination in bus stations, train stations, and airports, illegal.

Integrating Ole Miss with James Meredith.

It's easy to poormouth JFK for having a recalcitrant Congress, but to reduce him to somehow less effective than Ted Kennedy seems like a completely false and unnecessary dichotomy. It pushes us towards making silly comparisons such as: which was more useful?: JFK's presidential campaign of 1960, or Ted Kennedy's of 1980? Which was more about accomplishing something, and which was more about making people feel good about themselves?

It's really not a useful argument to try to stimulate, I think.

Deconstructing the Camelot myth was necessary, but it's not necessary or useful to throw out the John F. Kennedy baby of good accomplishments with the Camelot bath water. It's not as if he was an airhead, who accomplished nothing but good speeches until he got shot.

Like all presidents, JFK had his flaws, failures, errors, and unfufilled dreams, but as a summary, I think "JFK's makes you feel good about yourself" is reductionist, cartoonish, and highly unenlightening. Worse, it's cheap and lazy.

It's also a complete distraction from your point.

[jrudkis]

If JFK had survived, Teddy would be remembered as an earlier Billy Carter.

[Ben Alpers]

I just think that Ezra is wrong about this.

He's right, of course, that opponents of reform want to just kill it. But from the start, this time round, opponents have understood that the public feels that some kind of reform is necessary. That's why relatively clever conservative strategists, like Frank Luntz, have urged that opponents of reform not oppose reform outright. And, indeed, a lot of strong opponents of reform, like my Congressman Tom Cole, have been singing from this hymnal. Cole told a townhall meeting last week that he thinks some kind of reform is necessary. I'm not at all sure he believes this, but he clearly feels he has should say so....even in deepest red Oklahoma.

Klein writes that, "With every week, and every month, that drags by, health-care reform becomes a bit less popular. At this point, disapproval of the president's plan -- if not of his plan's ideas -- outpolls approval. " Note that even he admits that the ideas have not grown unpopular, just the plan itself. In fact, I haven't seen much evidence that reform per se has grown less popular. The larger dynamic remains unchanged: opponents have to pass something, however phony, labelled "reform" in order to please the public. Simply killing it this time through is not an option, unless you can blame someone else for the failure. Republican opponents of reform are in a fairly good position to do so. Democratic opponents, not so much.

And this is particularly true for Senate Democrats, who have the most to lose if reform entirely fails. And that includes Senate Democratic opponents of reform. How do you "go into a back room and torture" Conrad or Baucus? You threaten the Democrats' Senate numbers by dangling the possibility of no reform at all. Even if their seats are safe, the fewer seats held by their party, the less power they have.

It's interesting watching how uncomfortable liberal intransigence makes Klein. He's argued against it every which way: the public option isn't important, intransigence won't work, reconciliation in the Senate won't work (or if it will work, it will entirely blow up that body).

I fear that this is something like the germinal stage of Broderism. Ezra Klein's argument about healthcare can apply equally well to any progressive reform effort. And its message--liberals should compromise first because doing otherwise is both unnecessary and utterly futile--is just a slightly more sophisticated variation of the run-of-the-mill, inside-the-beltway notion that centrism is always the answer.

[Barry Deutsch]

If the progressives threaten to walk, Republicans and Blue Dogs will say, "fantastic, don't let the door hit you." Accordingly, the prospect of not passing reform provides virtually no leverage with these people...

I'm sure this is true for the Republicans, but like Ben, I'm not sure it's true for the blue dogs. If the Democratic party's popularity does a crash-and-burn, that will hurt the blue dogs, too -- probably more than it hurts liberals from safely blue areas.

Blue dogs need the democrats to succeed. We don't need all the blue dogs in the senate to vote for the reform; we just need a handful of them to not filibuster the bill, even if they vote "no" on it. I think that's a lower threshold than you and Ezra seem to believe.

[Brett Bellmore]

"The larger dynamic remains unchanged: opponents have to pass something, however phony, labelled "reform" in order to please the public. Simply killing it this time through is not an option, unless you can blame someone else for the failure."

Feh, you could just substitute "proponents" for "opponents", and it would be at least as true, probably more so. Which is why you were so keen to have a vote before anybody had time to look at the legislation: You didn't much care what was in it.

[Joe]

Fine. Progressives should show Blue Dogs that if they are disrespected and screwed too much, it will hurt them.

Or, they can show Obama. Likewise, they need to show that backtracking and giving Republican opponents credibility is dangerous. Item:

Bowing to Republican pressure and an uneasy public, President Barack Obama's administration signaled Sunday it is ready to abandon the idea of giving Americans the option of government-run insurance as part of a new health care system.

http://www.talkingpointsmemo.com/news/2009/08/white_house_appears_ready_to_drop_public_option.php?ref=fpa

Bowing to Republican pressure?!!

Virtually anything that can get 60 Dems + Snowe/Collins would exponentially improve the status quo.

Oh please. We have a major opportunity here, the public wants and was promised real reform (and elected people to help pass it), the opposition repeatedly look sorta crazy (at best), and "virtually anything" is the test of success.

"Sir, can I have more gruel?"

[scott]

I agree with brent and ben. We pay too much money in this country for health care that isn't universal and that really doesn't result in good health outcomes relative to other countries. As liberals who supposedly care about the effects this gouging has on all of us, particularly the disadvantaged, we should care about health-care reform that really does reduce costs, makes coverage universal through generous subsidies if necessary, and that reduces the unhealthy stranglehold that the for-profit model in health care has over us. If what Baucus and Co. are pushing, with weak and unequivocal signals of sorta-kinda support from the WH, doesn't do that, why am I obligated to salute based on the premise that someday it will all be fixed? As brent and ben note, Ezra's arguments lately seem to be striving to convince us that capitulation to crap legislation will serve the greater good and that we can't ask for anything better. I'm not convinced.

[AIMAI]

Can we have a little less of this convenient aphasia? Of course the bargaining positions are asymetrical but that doesn't mean that staking out a far left progressive position is meaningless grandstanding. The fact that the right doesn't want *any* reform and the blue dogs want to be kingmakers is *part* of the picture, but not the whole part. Each party to the negotiations has to do the best it can to get what it wants. Getting half a bill isn't, to my mind, worth much. That's because I doubt very much that any strong reform that is partial will end up meaning much. There's a lot of blather about how "insurance companies won't be able to deny you coverage or use recission" if that isn't the most easily gamed part of the system I dont know what is. Without the public option, or medicare for all, we are screwed. And that is the position that *obama* should have taken, firmly, to force the centrists to his side. In attempting to be the balance point at the center, with each "side" being seen as tilting "too far" he has fundamentally screwed the process to the point where the only leverage the progressives have is to piss in the pot.

Its true the republicans will never "sweeten the deal" but since we actually have majorities the right thing to do was simply to peel off our own blue dogs--which we could and should have done with threats of primaries and loss of white house support and loss of dccc and dscc support. We never needed to do this dog and pony show with the republicans or, if we did, we should have played it a bit smarter.

Its not because progressives and people who need health care reform want "theater" or "drama" or to "act out" that they want to see some serious action on the public option. Its becuase they believe, on balance, that half measures that force everyone to pay a mandated fee to the insurance companies are a bad bet politically, morally, and in terms of health care policy. I live in MA and it would, in the end, have been far better to *tax everyone* more or less invisibly to pay for state wide health care than to create the massive paperwork and cost hassels to force everyone not only to buy insurance but to prove they've bought it.

If I'd been Reid and Pelosi I would have put an "opt out" clause into all the bills saying that Senators and Congressmen who refused to sign on to a massive, robust, public option would, in effect, cut their populations out of the pie of tax monies raised to fund their uninsured or underinsured populations. Go district by district and explain to each district that your congressman refused to allow health care reform *in your district* and see how fast the debate would shift.

aimai

[cleek]

But from the start, this time round, opponents have understood that the public feels that some kind of reform is necessary. That's why relatively clever conservative strategists, like Frank Luntz, have urged that opponents of reform not oppose reform outright.

on this point... the GOP does have a few health care reform proposals out there already (for example). so they can kill the Dems' bill and still be able to say they are for reform.

but, they want reform to happen under a GOP president, so first they have to get rid of the Democratic President.

[Scott P]

They only problem I see with the argument is that the "Walk Away" threat is not aimed at Republicans. It's aimed primarily at the White House, and to a lesser extent at the Blue Dogs. As they should have been almost from the outset, the GOP is finally being bypassed. And the White House does want reform to pass, so the threat has leverage. The bigger question is how many of the Blue Dogs feel the same.

I hope that in the end, regardless of how they feel or want to appear to their constituents, they realize they have a D next to their name, and a failure to pass any reform is what will hurt them the most.

[Marty]

"That's because I doubt very much that any strong reform that is partial will end up meaning much"

I think any bill that provides basic coverage, by any means, for the currently uninsured means a lot. Maybe I am missing something but we seem to have gotten away frorm that basic goal.

[publius]

Various good points here. Real quick -- I do agree that Blue Dogs should be made to understand in no uncertain terms that this crap will have consequences.

That's why I'm not really worried about the House. The Senate, as always, is the problem.

[Joe]

PS ... this at times feels like a "lower expectations" skit ala Mad TV.

The audacity of "let's settle."

[Uncle Kvetch]

But from the start, this time round, opponents have understood that the public feels that some kind of reform is necessary. That's why relatively clever conservative strategists, like Frank Luntz, have urged that opponents of reform not oppose reform outright. And, indeed, a lot of strong opponents of reform, like my Congressman Tom Cole, have been singing from this hymnal.

I'm not sure I agree. Is the climate today really that different from 1993? My sense is that the Repubs could very easily get away with "yes to reform, but not this reform," talk about the need to proceed more slowly and carefully, and then once the bill is dead, proceed to do nothing. Not only were they not punished for this in the 90s--they retook both houses of Congress the following year. And they kept reform off the table for another 15 years.

I'm just not seeing how it's all that different this time around. They don't have to convince people that the current system is good, only that the reforms will make it even worse. And of course, as we've seen, they'll lie through their teeth to accomplish that goal, if necessary.

[Sebastian]

The problem is that Democrats interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system. Also they have (for almost a decade) aligned themselves with the idea that health care reform should involve pretty much an enormous takeover by the government. Further, they have pretty much said that while *this* may not be the complete government takeover, that it ought to lead to--at a minimum--single payer in the long run.

The political problems with this are large:

1. Nobody believes you when you suggest that you don't want the government to take over.

2. Lots of people are actually satisfied for the most part with their current health care. (An enormous majority of people are covered by either private plans or Medicare).

3. People are afraid of changing things even that they are kind of dissatisfied with.

The key problem is 1. If Democrats had focused their efforts on making sure that the uninsured were protected, and seriously made that their primary goal, the case would have been much stronger. But they didn't, and arguably the reason they didn't is because they really would prefer that the government (at a *minimum*) would turn into the single payor of insurance.

People are insecure about their jobs. They realize they could lose insurance. This would be a great time to focus very firmly on the problems of linking insurance to workplace and the problems of going without insurance.

Democrats have decided not to focus largely on that issue, but instead propose all sorts of other things that detract from that central moral issue of the uninsured and largely unprotected.

I believe that health reform which is mostly focused on insuring the uninsured can pass (and should pass). I think the chances of a useful overhaul getting through are low. Even worse, trying to force an overhaul may make it so that reform focusing on the uninsured can't pass.

And that would be stupid.

[Ben Alpers]

My sense is that the Repubs could very easily get away with "yes to reform, but not this reform," talk about the need to proceed more slowly and carefully, and then once the bill is dead, proceed to do nothing.

I agree that the Republicans could get away with this. But that's cold comfort for Democrats who stand in the way of reform.

Ezra Klein's piece is an argument about how there's no way to twist the arms of Democrats like Baucus and Conrad. And that's what I was disagreeing with. Because when Republicans win, even those Democrats lose. And that's the leverage progressives need to get at least real-ish reform. We don't need a single Republican vote.

And today we get the excellent news is that the White House has begun to signal that it's willing to drop its ridiculous insistence on bipartisanship for bipartisanship's sake.

[cleek]

The problem is that Democrats interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system.

got a cite for that?

i'd love to see the polling...

[Sebastian]

Which part do you want a cite for/disagree with?

The idea that people in the US are vaguely dissatisfied with health care in the nation, but not very dissatisfied with their own?

The idea that single payer isn't very popular?

The idea that anything more than single payer is definitely not popular?

The idea that Democrats have had to walk back plans again and again?

I'm not sure which part you have trouble with.

[russell]

The part where Democrats want to do "pretty much anything" to the health care system.

[cleek]

Which part do you want a cite for/disagree with?

the part i quoted, obviously.

i want to see the polling data that backs up your claim (again, the one i quoted).

[bjrubble]

while *this* may not be the complete government takeover, that it ought to lead to--at a minimum--single payer in the long run.

It really pisses me off how badly this point has been sold, to the extent that I wonder if I was fooled by the campaign into believing that Obama is an effective communicator.

Case in point: the incident where Obama supposedly backed off the public option. This was in response to a question from a guy who named his (public) university in his question. I suppose the question could have been teed up a little more perfectly if the questioner had been a student at a private school, but Obama really whiffed on an opportunity to demolish the notion that public and private entities can't coexist.

It's not too late, IMO, to present the USPS as the rough model for the public option. Right now we live in a world where every package is a $5 delivery with scheduled pickup/dropoff and a tracking number, and even this option isn't universally available. It's great for some packages, but wouldn't it be nice to be able to send small, everyday things for something less, like 44 cents? Not that this would stop the wingnuts who hate the USPS, but here's one of the least controversial government services, which plainly exists alongside private options and hasn't put them out of business.

This also ties into another point that's, bizarrely, only really surfaced recently -- the public option means less regulation. Which would be more onerous to UPS and FedEx: the USPS offering delivery service, or a regulation requiring them to implement the equivalent of first class mail?

[Sebastian]

"the part i quoted, obviously.

i want to see the polling data that backs up your claim (again, the one i quoted)."

Ummm, the part you quoted is an interpretation, right? The polling is on dissatisfaction with health care and is pretty well known. Are you disputing that? The interpretation is mine (obviously) and is based on the history of Congressional Democratic action on health care (which to simplify is a history of broad rhetoric about the need to totally overhaul the system combined with constant walkbacks when it comes time to change the system).

So again, you are going to have to be clearer about what you think I should provide a cite for. Are you disagreeing with my interpretation of the citeable polls?

By analogy, if someone wrote that Republican Senators interpret the population's general fondness for lower taxes as an excuse to the bankrupt the country by never lowering spending but cutting taxes--it would be obviously correct but asking for a cite would be silly. It is an interpretation of Republican actions and motivations.

Same here. Unless you want a cite for the well documented polling on Americans being dissatisfied with health care in general but much less dissatisfied with their own health care, I don't understand what you are asking for.

Do you want to disagree with my interpretation? Great, I guess. But just do it. Don't be a cite-please troll.

[Carleton Wu]

Klein writes that, "With every week, and every month, that drags by, health-care reform becomes a bit less popular. At this point, disapproval of the president's plan -- if not of his plan's ideas -- outpolls approval. "

That should not be taken (as many have, including Klein) that his proposals are too liberal or that people are unhappy with reform. Many liberals are unhappy with the watering-down of the plan- counting "those who disapprove of the President's plan" as "those opposing health-care reform" is poor thinking.

Towards the original point of the post, I have underestimated Obama in the past & am inclined to give him the benefit of the doubt on tactics and long-term thinking. First, he may well want to have a vocal group on his left shouting for more reform, as this reduces his ability to compromise without reducing his perceived desire to do so. Likewise, his coddling of the group of 6 may well be the handing over of enough rope to string them up- every time he offers compromise, Grassley et al are forced further to the right (eg Grassley now says he may not vote for his own bill- he seems to be running out of concessions he can reasonably ask for, and this reveals his desire for compromise to be a sham).
In the end, it all comes down to
1)what concessions will get the conservative Dems in the Senate to not join a filibuster- if this satisfies the House & the WH, then that's the bill (assuming the two ill Dem Senators can make it to the floor)
2)if it doesn't, then we get a reconciliation bill.

But either way, Obama will make sure to demonstrate his willingness to bend over backwards to make something happen, and to demonstrate that the 'moderates' in the GOP are not negotiating in good faith.

[Carleton Wu]

The problem is that Democrats interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system.

But I read the polls on American dissatisfaction with health care, and conclude that Republicans like it when poor people get sick and die. Just another interpretation, guess we can't argue about that either.

[AIMAI]

Go carelton wu. This is correct.

I would like to take issue with something that was said way upthread while I was off doing something else. The "main goal" of health care reform is not to cover the 50 million uninsured by any means necessary. The main goal must and should always have been to make sure that every child has cradle to grave coverage and never *falls into* the category of uninsurable or underinsured. Those 50 million people aren't just too poor to pay premiums. They are also people who are uninsurable or underinsured or recently unemployed or working two or three partial jobs for employers who can't, or won't pay the employer share of health care costs.

The currently uninsured are an epiphenomenon of a broken system which the government already supports and subsidizes by paying--through SCHIP and Medicare and Medicaid--while allowing the insurance companies to sell high priced, essentially unregulated, fake "insurance" to relatively wealthy and healthy people in the middle. As soon as those people are old enough to have chronic health care issues they are dropped and move over to medicare. As soon as those people have serious and chronic health care issues but they are employed their premiums shoot up, don't cover much treatment, or they are found guilty of "fraud" and recission lets the insurance companies boot them out to die or to try to get on medicaid.

Ditto for people with sick children.

The real issue is not the mere 50 million who are uninsured. It is the fact that the rest of us are caught in a high priced, for profit, system under which we are only temporarily and contingently insured. Health care may or may not be a right (I think it is) but it is a necessity. It is a constant factor in everyone's life, if they live long enough. Allowing the young and healthy to go without coverage--and without paying into the system--while ensuring that the elderly, the poor, and the unhealthy are covered by the taxpayer is a recipe for disaster.

Single payer, properly explained, would convince even Sebastian that if you are going to pay X dollars a year to your insurance company to refuse to cover your major illnesses you would actually prefer to pay X dollars a year to the government in the form of taxes to have the certainity that you will never be thrown off the plan when you need it. This is not rocket science. There was never any need to kow tow to some fantasy of libertarian/never dying/galtian/free market nonsense. We don't have a free market now. And we'd be better off with a single payer system like Canadas or some variation of France or Germany's. There's simply no question of that and absent the hysterical "death panelist" lunatics--who are lunatics full stop and need not be considered as real actors in this drama--we'd be well on our way to having a logical, profitable, reasonable discussion of health care reform. But the democrats caved in principle to the loony right on this by pushing single payer off the table instead of starting with it and being bargained down fromit.

aimai

[Marty]

" would like to take issue with something that was said way upthread while I was off doing something else. The "main goal" of health care reform is not to cover the 50 million uninsured by any means necessary. The main goal must and should always have been to make sure that every child has cradle to grave coverage and never *falls into* the category of uninsurable or underinsured. Those 50 million people aren't just too poor to pay premiums. They are also people who are uninsurable or underinsured or recently unemployed or working two or three partial jobs for employers who can't, or won't pay the employer share of health care costs."

This is a great definition of the make up ( constantly changing) of the 47M or so uninsured. So insuring them should meet the test of providing all Amercans with coverage, as it will address the breadth of all of those reasons.

But it should be the main goal.

Then we should address the delivery system.

[cleek]

Ummm, the part you quoted is an interpretation, right?

it is? 'cause it sounds like a statement of fact. i don't see any "IMO" or "as i see it" or "seems to me". what you wrote is a highly-inaccurate blanket statement.

you don't actually know the opinions of Democrats (all Democrats? some? those you know? those you've mind-read?).

i'm a Democrat, and i don't "interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system"; nor have i ever said that "while *this* may not be the complete government takeover, that it ought to lead to--at a minimum--single payer in the long run".

in other words: you're attacking a strawman.

[russell]

Do you want to disagree with my interpretation?

Don't know if I want to or not, but I do.

What most folks, of whatever political persuasion, want is for a decent and useful level of health care to be accessible to everyone regardless of their position in life, whether "position" is measured in terms of wealth, income, disability, prior medical condition, etc etc etc.

Folks who don't sign for that, I'm just not really interested in talking to. For the record, I don't include anyone on this thread in that group.

The question, or set of questions, on the table is how best to make that happen.

Democrats aren't looking to "do whatever they want" with the health system. The number of Democrats who are interested in making anything like a significant change to the status quo is not particularly large. The number of Democrats who are interested in having government "take over" the health care industry is, depending on what you mean by "take over", somewhere between pretty small and nonexistent.

So, net/net, I think this particular statement of yours is something of an overreach.

[Shygetz]

Ezra's wrong, and you're wrong by proxy. The liberals aren't negotiating with the Blue Dogs, they are negotiating with the moderate Dems. As many others point out, many Blue Dog Dems need some kind of health care reform to pass, and many more won't filibuster reform even if they won't vote for it. But, if the liberal wing makes no concessions, then there is no reason for the moderates to not give the Blue Dogs every single thing they want, watering down the bill to the point of uselessness. But, if the Blue Dogs and moderates know that the liberals will walk, sinking them all, then we are much more likely to get a moderate bill. This is increased if the White House tells the Blue Dog Dems that Obama will not campaign for any of them, and will shoot down their pet issues from behind the scenes if they don't play ball.

[Sebastian]

"But I read the polls on American dissatisfaction with health care, and conclude that Republicans like it when poor people get sick and die. Just another interpretation, guess we can't argue about that either."

What part of my comment provoked that?

I didn't say you couldn't disagree. I didn't say you couldn't argue about it. I said that "cite please" wasn't doing so.

Thanks.

[Sebastian]

"in other words: you're attacking a strawman."

It is a rather well developed strawman then, that has at various points in their political careers included such non-entities as Ted Kennedy and John Conyers (along with his 90 cosponsors in the House last year). It seems to include such familiar faces here as eric martin.

Remember the quote you are complaining about is "while *this* may not be the complete government takeover, that it ought to lead to--at a minimum--single payer in the long run"

Both eric and publius have strongly suggested that the bill is merely a first step. Eric has flat our said that it ought to lead to single payer.

Even if I'm not disagreeing with you (which is unclear to me) I'm definitely not making up a strawman.

[GoodOleBoy]

'But I read the polls on American dissatisfaction with health care, and conclude that Republicans like it when poor people get sick and die. Just another interpretation, guess we can't argue about that either.'

And who here is likely to contest this which, if my memory serves me well, gets expressed in one form or another frequently here and largely without cites.

Thanks for that on cites, Sebastian. Here's what I think about cites. I don't do many because the political principles I have the strongest sentiments about are mostly related to processes not results. Although cites can be useful for both, they are very apt when describing conditions and outcomes of processes. Since many here value outcomes more than processes, IMHO, citing sources has become a disorder for some. Every time someone refers to a republican elected official or d'd'd'dave as a liar should reduce requests for cites by one.

[Turbulence]

I don't do many because the political principles I have the strongest sentiments about are mostly related to processes not results.

I don't understand why this distinction matters. There are all sorts of things one might believe about a given process, but it is very hard to convince someone who doesn't share your beliefs about a process without producing some evidence. I mean, people can easily have unsupportable beliefs about processes, right?

Since many here value outcomes more than processes, IMHO, citing sources has become a disorder for some.

Who are you talking about? What makes you think that many here value outcomes more than processes? And who exactly has this disorder?

Every time someone refers to a republican elected official or d'd'd'dave as a liar should reduce requests for cites by one.

d'd'dave is a liar. This is a fact. He wrote multiple comments claiming to be someone that he was not. He lied about his identity. Now, people can disagree as to how compartmentalized dave's lying is. It might be that he is scrupulously honest when writing about health care but lies when writing about war. Or not. But dave is a liar.

[russell]

The problem is that Democrats interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system. Also they have (for almost a decade) aligned themselves with the idea that health care reform should involve pretty much an enormous takeover by the government.

Not to beat this into the ground, but a couple of observations here.

The Republican and/or conservative suggestions for addressing health care issues generally consist of some combination of transfer the tax break for businesses to employees and let them buy their own insurance, let people buy insurance across state lines where they cannot do so currently, eliminate requirements for standard coverage levels so young, healthy people can just buy catastrophic coverage, etc.

All of these suggestions are a *significant* departure from the status quo, and *all* of them are motivated by an ideological preference for free market solutions.

*All* of them also present important and unanswered questions. Like, what if employers don't take the money they're not spending on health insurance and hand it over to employees? What if they just put it on the bottom line?

Ya think that could happen, maybe?

Even your suggestion, Seb, which I actually quite like -- expand Medicare to anyone who isn't insured and provide a tax credit so poor folks can buy in -- represents a significant change, and a huge expansion of federal responsibility.

There is no way to get from where we are to anything like a better place without changing something in some significant way.

And everybody's idea about what to change, and in what way, and to what degree, is going to reflect their personal bias in one direction or another.

There is nothing that has been proposed by Democrats that can be meaningfully described as "doing whatever they want". The most radical proposal on the table is single-payer health insurance, which we already provide to everyone over 65 who wants it. Single-payer is no more or less wacky, partisan, undesirable or unpopular than anything else that's been put on the table.

Some folks think it's fine, some think it sucks. Most that think it sucks have that opinion because they have an ideological aversion to it.

And single-payer represents the radical fringe. I'm not aware of anyone, anywhere who is looking for government ownership or control of health care providers.

We should focus on what's going to work, and what's not going to work. Anything we do that is going to have a snowball's chance in hell of making anything better is going to require doing something other than what we do now. So we all need to just get over it.

[Gary Farber]

Some quick summaries of agreements and disagreements from me:

publius: "I do agree that Blue Dogs should be made to understand in no uncertain terms that this crap will have consequences."

Yes, that would be nice.

Uncle Kvetch, re the Republicans: "I'm just not seeing how it's all that different this time around. They don't have to convince people that the current system is good, only that the reforms will make it even worse. And of course, as we've seen, they'll lie through their teeth to accomplish that goal, if necessary."

Yes. Republicans won't be harmed with their base, certainly, by walking away from health care reform; the base will be heartily thrilled, whereas any reform is apt to earn hardcore ire from the Republican base. And only a few elected Republicans seem to care much about wooing independents.

Sebastian: "The problem is that Democrats interpret dissatisfaction with health care in the US as if it were an authorization to do pretty much anything to the health care system. "

As previouslly discussed, this seems like a vast exaggeration to me. It's not as if Democrats are even seriously proposing a single-payer, let alone an NHS. So I think your assertion is demonstrably false.

Ben Alpers: "Ezra Klein's piece is an argument about how there's no way to twist the arms of Democrats like Baucus and Conrad. And that's what I was disagreeing with. Because when Republicans win, even those Democrats lose."

How much do the Blue Dogs lose? How far can we get them to move? I don't know the answers to those questions, and I don't know if you do, either. But if you're disagreeing with Ezra, which is fine, because I'd rather believe you, if you can make a convincing case, that it would be useful if you can be more specific as to how we can make them suffer, and how that would be enough, and how far you think we can get them to move, in some specifics, not just vague generalities that don't, with all the greatest respect, really tell us anything useful.

"Further, they have pretty much said that while *this* may not be the complete government takeover, that it ought to lead to--at a minimum--single payer in the long run."

If you changed that to "at a maximum," you'd have an arguable case. But there still wouldn't be such a possibility of a change to a single-payer system any time beyond the horizon of another decade or so, I'm reasonably sure, given the time frame for the public to get used to any theoretically improved new system before such a change would possibly be on the table.

Fighting against single-payer now is fighting against a bridge not in visible sight, but rather only a dream (alas, from my POV).

bjrubble at August 19, 2009 at 12:40 PM is correct. There's no contradiction between single-payer with add-on private insurance as desired -- that's basically what Canada has -- and that's what I wish we were selling.

AIMAI at 01:58 PM: I agree.

Russell at 02:52 PM, as almost always: I agree.

Shygetz at 02:58 PM: I'm either confused by some of what you're saying, or wish you'd provide support for the other bits beyond assertion.

Sebastian: "It is a rather well developed strawman then, that has at various points in their political careers included such non-entities as Ted Kennedy and John Conyers (along with his 90 cosponsors in the House last year). It seems to include such familiar faces here as eric martin."

We're talking about what's being negotiated now, I thought, not every last passing comment or wish expressed by any or every Democrat in the past. Neither does Eric Martin, or me, or you, get any say in these negotiations.

[Sebastian]

"Even your suggestion, Seb, which I actually quite like -- expand Medicare to anyone who isn't insured and provide a tax credit so poor folks can buy in -- represents a significant change, and a huge expansion of federal responsibility."

I am of course partial to my own suggestion. But it is only a medium expansion of federal responsibility and even less an expansion of general 'government' responsibility insofar as we already don't let people die in the streets for the most part and treat them in the emergency room. From that perspective, we are just moving to a more rational way of subsidizing care (not ONLY doing it in the ER).

"The most radical proposal on the table is single-payer health insurance, which we already provide to everyone over 65 who wants it. Single-payer is no more or less wacky, partisan, undesirable or unpopular than anything else that's been put on the table."

Ok, but look how much more radical that is than my plan. My plan extends to about an additional 20 million people at any given moment (the 40 million number is pretty much a scare number based on the number of people who are without insurance for any period of time during the year). A single payer plan extends to 210 million more people, with all of them changing their current coverage.

That is quite literally an order of magnitude difference.

I said this at the beginning of the thread, I think it is a huge tactical mistake to use the moral case of the uninsured to try to change all of the rest of the system at once. And that is the mistake that lots of Democrats sound like they are willing to fight over. Save the uninsured. Go for it. But don't let saving the uninsured get away just because you have a grander vision that the American people are sounding more and more like they might reject.

[Gary Farber]

I don't do many because the political principles I have the strongest sentiments about are mostly related to processes not results."

That's fine, theoretically, and in terms of how you consider things. However, if you wish to make arguments to other people that go beyond "this is what I'd like, but I can't support why beyond that it's my personal prejudice," you have to make arguments that are obectively supportable.

To make arguments that are objectively supportable, you pretty much have to go to outcomes. Preferences as regards process are, in contrast, are simply matters of personal opinion, and aren't arguable.

So it comes down to whether you're here to engage in useful debate, or simply to pronounce your inarguable, unsupportable, opinions.

If you prefer to stick to the latter, that's your privilege, but you shouldn't be surprised if people try to turn the discussion to something that's actually useful to debate, rather than points that are inarguable opinion based on completely vague general principles.

"Since many here value outcomes more than processes, IMHO, citing sources has become a disorder for some."

It's actually a process developed decades ago on ARPAnet, passed on to Usenet and thence to some blogs and elsewhere, that serves to filter conversations down to that which is useful discussion, while attempting to keep pointlessly inarguable, and unprovable, statements of opinion, to a minimum, and discourage them.

Opinions are nice, but there's no visible useful point to simply mutually uttering unsupportable opinions.

If one prefers to simply announce unsupportable opinions, rather than discuss facts and supportable claims, you're not apt to get very far in convincing anyone of anything. Why should anyone care what anyone's unsupported opinion is?

Why would you care what my personal preferences are about anything, rather than whether I can demonstrate with facts whether a particular point is objectively correct or incorrect?

Russell: "And single-payer represents the radical fringe. I'm not aware of anyone, anywhere who is looking for government ownership or control of health care providers."

This is a statement unusually confusing from you, Russell, as it's apt to lead to confusion between single-payer, in which the government merely acts as your insurance company, paying currently existing private health care providers for their services, and the entirely different idea of a government-run, owned, or controlled, health care system, such as Britain's NHS. They are two entirely different things.

(And even in Britain, there are still private providers you can pay for if you want to pay out of pocket for additional, or quicker, or more preferable for whatever reason, services/doctors.)

[Sebastian]

"We're talking about what's being negotiated now, I thought, not every last passing comment or wish expressed by any or every Democrat in the past. Neither does Eric Martin, or me, or you, get any say in these negotiations."

We're talking about why reform is hard in health care. Part of why it is hard in this particular case, regarding what is being negotiated now, is that:

1) Democrats have spent decades suggesting they want single payer;

and

2) there are still lots of Democrats running around suggesting they want single payer (I can apparently add you to the list of strawmen that I invented on that topic);

and

3) a focus going well beyond the actual moral problem (the uninsured) into tampering with everyone else's insurance;

and

4) plan? what plan? we still don't really know what plan we are talking about.

Politically, part of the problem is that Democrats as a brand are closely linked to single payer or more. So they are having a difficult time convincing people that they aren't really for single payer. This is reinforced when they use the moral club of the plight of the uninsured to try to flog for a plan that goes well beyond relieving the plight of the uninsured (and strangely focuses so much on doing other things that apparently it won't even make sure that all of the uninsured get insured).

[russell]

This is a statement unusually confusing from you, Russell, as it's apt to lead to confusion between single-payer, in which the government merely acts as your insurance company, paying currently existing private health care providers for their services, and the entirely different idea of a government-run, owned, or controlled, health care system, such as Britain's NHS. They are two entirely different things.

Quite so, and in fact that's the point I was trying to make, albeit somewhat obscurely. Thanks for making the distinction clear.

[John Spragge]

Sebastian, your argument seems to rest on two assumptions: first, that American health care does not need to change, and that you can set parameters for the changes based on political, rather than economic considerations. I disagree with both.

You claim that most Americans feel satisfied with their own health care but dissatisfied with the system overall; does it occur to you this makes perfect sense as the response of patriotic citizens who understand that the system that takes acceptable care of their needs could very well bankrupt their country in the coming years. Making this a matter of personal satisfaction misses the point: nobody disputes that many, if not most, Americans get acceptable if not great care out of your system. But all the economic numbers indicate that they don't get it at a socially sustainable cost.

This gets us to another point: economics also dictate the shape of your changes. Maybe you can come up with a solution that simply covers the Americans who now go without insurance, but it will take more than good intentions.

You now have the problems you do not because the people who run American insurance companies have a vicious streak worthy of Saddam Hussein. The problems with your system come about because of basically decent people making decisions that work for them, but which lead to serious problems on a national scale. If your solution creates too many perverse incentives, it may not, in fact probably will not work. I consider it important to understand that at least some of the people who propose a single-payer system do so not because they want to replace the starts on your flag with maple leaves, but because they honestly do not see any other real change that could produce a sustainable system.

[JanieM]

Russell: "And single-payer represents the radical fringe. I'm not aware of anyone, anywhere who is looking for government ownership or control of health care providers."

This is a statement unusually confusing from you, Russell, as it's apt to lead to confusion....

What I thought Russell meant was that in the context of the current debate, people talking about single payer are the "radical fringe," and a system like Britain's NHS is so far outside the debate that not even the radical fringe would bother to argue for it.

Was that a misunderstanding?

[Jinchi]

If the progressives threaten to walk, Republicans and Blue Dogs will say, "fantastic, don't let the door hit you." Accordingly, the prospect of not passing reform provides virtually no leverage with these people

This is a pretty toxic mindset for progressives but apparently a pretty common one. It's just flat out wrong to think that Blue Dogs won't suffer if health care reform tanks. They'll be the first out the door in the next election and that's a pretty powerful motivator.

You're also ignoring the fact that businesses and individuals are increasingly suffering because of health care related costs including bankruptcies. This isn't an issue that came out of Obama's hope chest, it's a real one and there is real public pressure to accomplish something worthwhile.

As for Republicans, they don't have any power that the Democrats don't give them. They don't have the numbers to filibuster and their ideas for health care are even less popular than the Democrats. Grassley and Enzi want to be at the negotiating table because Barack Obama has assured them that their ideas will be included even if they don't vote for the bill.

This is an idiotic strategy and the desperation ploy which you appear to be embracing is the one most likely to lead to complete failure.

[Sebastian]

"Sebastian, your argument seems to rest on two assumptions: first, that American health care does not need to change, and that you can set parameters for the changes based on political, rather than economic considerations. I disagree with both."

I do believe that health care should change.

I'm not sure what you mean about the parameters for the changes being based on political rather than economic considerations. Both are important.

"You claim that most Americans feel satisfied with their own health care but dissatisfied with the system overall; does it occur to you this makes perfect sense as the response of patriotic citizens who understand that the system that takes acceptable care of their needs could very well bankrupt their country in the coming years."

Sure. I'll go further. They could be happy with their own health care and see that other people (for example the uninsured) still need help with theirs. In fact, that is exactly what I feel.

"You now have the problems you do not because the people who run American insurance companies have a vicious streak worthy of Saddam Hussein. The problems with your system come about because of basically decent people making decisions that work for them, but which lead to serious problems on a national scale. If your solution creates too many perverse incentives, it may not, in fact probably will not work. I consider it important to understand that at least some of the people who propose a single-payer system do so not because they want to replace the starts on your flag with maple leaves, but because they honestly do not see any other real change that could produce a sustainable system."

Sure. But I'm not trying to demonize people who want single-payer (even though I believe they are wrong). It might be good for the debate if people who want single-payer realize that at least some of the people who oppose it do so because they honest do not believe that it is a change that could produce a sustainable system without seriously compromising medical advancements and/or hurting the quality of care for those that already have it.

[Gary Farber]

"It's just flat out wrong to think that Blue Dogs won't suffer if health care reform tanks. They'll be the first out the door in the next election and that's a pretty powerful motivator."

Cite, please? Maybe you're right, but you need to provide some argument as to why you're right. Why are you right?

"Grassley and Enzi want to be at the negotiating table because Barack Obama has assured them that their ideas will be included even if they don't vote for the bill."

Cite?

[Gary Farber]

I've suddenly lost the ability to post or preview from Firefox again, by the way. Once again, the boxes are greyed out, and I can only post from IE.

This is as annoying as ever.

[John Spragge]

I'm not sure what you mean about the parameters for the changes being based on political rather than economic considerations. Both are important.

Whatever reform proposals you come up with have to work economically, in the sense of keeping perverse incentives in check and also delivering the goods. Allowing political preferences to override these considerations simply does not strike me as wise.

...at least some of the people who oppose [single-payer] do so because they honest do not believe that it is a change that could produce a sustainable system without seriously compromising medical advancements and/or hurting the quality of care for those that already have it.

I don't dispute anyone's honesty, but I wonder how well your beliefs accord with experience. Let's take the quality of care for those who have it: based strictly on outcomes, Canada's single-payer system does as well, in the aggregate, as the American system. On the critical indicators, such as life expectancy and infant mortality, Canada actually leads the United States. And while some American conservatives call Canadian health care a disaster, referring to our waiting lists, they often misstate the issue of wait times. The numbers you see tossed around (3 weeks for an MRI, etc) represent the (intended) maximum time the system asks anyone to wait. In any case, the idea that insured Americans have the health care they need, exactly when they need it, does not fit with my experience; once in the US, with one of the best health care plans in the US and in considerable pain, I simply could not get an appointment with the relevant specialist. In Toronto, I got an MRI within two days.

As for the issue of research, first let me point that Canada has a distinguished record of medical research. Your diabetic cousin annoys you? Blame Canada. Your uncle came out of hypothermic heart surgery as irritating as when he went in? Blame Canada. The mobile medical facilities that saved so many lives in World War II, Korea, Vietnam and the Gulf? Invented by a Canadian communist. Senator Paul Tsongas's post-cancer career? We have to own up to that one, too. That said, money does make a difference, and the American system provides (proportionately) about four times as much of it as ours does. But in perspective, that amounts to about a tenth of the difference in what our prospective health care systems cost. Canada ought to spend four times as much on research as we do, no question.

All that said, I don't recommend you simply adopt our system; single payer works better than what you have, but I have no illusions: our system does not work as well as any system could.

[Hartmut]

Before someone else comes up with it, the German system is in serious longterm trouble but mainly due to a native birthrate of just 1.4 children per woman. It is kept stable mainly by immigration (which is almost as much of an obsession with the German right as with the US). It does not look like the US suffers similar problems or will in the forseeable future. And to my knowledge the more illegal an US immigrant is the more he puts into the system in relation to what he takes out of it, making the 'illegal aliens' a net asset. [only half-ironic]

[russell]

What I thought Russell meant was that in the context of the current debate, people talking about single payer are the "radical fringe," and a system like Britain's NHS is so far outside the debate that not even the radical fringe would bother to argue for it.

Exactly right.

Or, almost exactly right: not only do I not think the existing "radical fringe" would argue for something like the NHS, I doubt they'd even want or recommend it.

As far as I am aware, government-sponsored single payer insurance, with private providers and a private market for value-added insurance products, is the most "socialized" proposal on the table. At least among folks who have any reasonable likelihood of affecting policy.

There are actual Greens, socialists, etc in the US but in terms of actual policy making they are, FBOW, noise.

Thanks Janie!

And while some American conservatives call Canadian health care a disaster, referring to our waiting lists, they often misstate the issue of wait times.

Any claims of American superiority based on wait times is, IMVHO and experience, insane. Which is to say, not congruent with reality.

If I call my GP with something serious and potentially time-critical -- shortness of breath, step on a rusty nail, weird vision problems -- I will get an appointment to see a nurse practicioner within 24 hours.

That's great, and I'm grateful for it.

Anything else -- physicals, referrals to specialists, tests other than walk-in stuff like a basic blood draw -- and the wait time is normally weeks to months.

I have very good insurance, and based on conversations with other folks I know I believe my experience to be completely typical.

[bedtimeforbonzo]

I agree with all of your points, AIMAI. I am sick of the Blue Dogs holding the Democratic Party hostage.

And thanks for making me reach for my dictionary -- "aphasia" was a new word for me.

[Gary Farber]

"And thanks for making me reach for my dictionary -- 'aphasia' was a new word for me."

And it's virtue is that it can be again! And yet again!

[Gary Farber]

Argh. S/b: And its virtue is that it can be again! And yet again!