Obama at his best

by von

I have to agree with Andrew Sullivan.  This is Obama at his best:

What I reject is when some folks say we should go back to the past policies when it was those very same policies that got us into this mess in the first place.  (Applause.)

Another way of putting it is when, you know, I'm busy and Nancy busy with our mop cleaning up somebody else's mess --- we don't want somebody sitting back saying, you're not holding the mop the right way.  (Applause.)  Why don't you grab a mop, why don't you help clean up.  (Applause.)  You're not mopping fast enough.  (Laughter.)  That's a socialist mop.  (Laughter and applause.)  Grab a mop -- let's get to work.

My first thought was:  Thank God this Obama didn't show up six months ago.  We'd probably have the House Democrats' version of health care reform, which is the worst set of reforms currently on the table.  Although the Senate bills are far from perfect -- and, when I say "perfect," I mean as perfect as any health care reform can be (ahem, Wyden-Bennett) -- they are improvements.  Costly improvements that don't actually do what needs to be done; but, still, improvements.  (I realize that a lot of readers will disagree with me on some or all of these points.)

My second thought was:  Is there a good comeback?  After all, I'm one of the folks accusing Obama of mishandling his Che Guevara-branded mop.  A superficial response goes something like:  "But, dude, you aren't holding a mop.  You're holding a flyswatter."  (I'm pretty sure that can be made pithier.)   But it doesn't address the real challenge for Republicans, which is that they don't have a good alternative.  They're holding flyswatters too. 

I don't have another team to root for.  That strikes me as a pretty big problem for Republicans.  It's also a problem for folks who, someday, might consider voting Republican again.  For instance, me.*

UPDATE:  As Mark Thompson points out in comments, he has a post over at The League of Ordinary Gentlemen on a related topic.  Here's part of Mark's take:

Reading Jamelle’ s post, though, the answer finally became clear: the conservative wonks simply aren’t doing their jobs.  What they are doing is picking apart liberal proposals, picking apart conservative proposals, attacking the low-hanging fruit of conservative extremism, and occasionally making suggestions to liberals on ways of either improving liberal proposals or making those proposals more palatable to conservatives.  What they are not doing, and largely are not even trying to do, is to drive the GOP agenda.  They are, in effect, content to leave the GOP agenda as little more than “vote no on everything” and tear down whatever the liberals do.

Read the whole thing, as they say (and not just because of the kind shout-out to yours truly).

*That's not entirely fair of me:  Every ticket I've ever voted has been split to some degree.  But the last two elections I voted for the Democrat for President. 

Comments

[Point]

Have you heard though -- the Wyden free choice amendment amendment looks like it's going to be in the merged Senate bill.

[rick]

I think the appropriate response from the left would be that Obama isn't using a mop to clean anything up. He's just throwing more dirt on the floor, albeit a little less fetid.

[Marty]

I agree that it is Obama at his best. Still talking about what others did, blaming previous policies, and taking little responsibility but as much credit as possible. The fact that policy alternatives are part of things offered in the past don't make them bad.

The statement, repeated often and yet untrue,

"But it doesn't address the real challenge for Republicans, which is that they don't have a good alternative"

is a mantra to protect bad policy and lack of action.

The Republicans have offered hundreds of amendments to various bills reflecting a different way to address healthcare, few have been passed and none of the most fundamental changes will. Thats the way Congress works, the majority creates a bill, it gets amended and debated and then voted on.

No Republican bill would have made it TO committee, much less out.

[von]

We'll see what comes out of those negotiations, Point. The only think that makes me hopeful is the fact that Wyden is a little bit crazy on this issue.

[von]

Marty, my complaint isn't about the legislative process, but rather the politics. There is no visible Republican plan that Republicans routinely talk up. Consequently, there's nothing for me to talk up (assuming I liked what the Republicans were offering).

Contrast this to 1993, when Republicans were also out of power: The Contract with America was critical to Republican recovery.

[Point]

"The only think that makes me hopeful is the fact that Wyden is a little bit crazy on this issue."

But that's no small think. ;)

[cleek]

shockingly, a generation of politicians who were raised on the teachings of Atwater and Rove don't seem much interested in governing - they prefer base-rallying demonization and demagoguery to the hard work of policy-making.

the GOP offers jackoffs shouting "You Lie!", conspiracy theorists, idiots who don't even know the meanings of all "-isms" they constantly scream about, gun-toting dittoheads, devotees of an ignorant serial liar from Alaska, and, of course, the usual cast of privately-perverted public moralizers.

that is not a party of serious policy-makers. it's a party of clowns.

[Michael Cain]

The Republicans have offered hundreds of amendments to various bills reflecting a different way to address healthcare...
==========
There is no visible Republican plan that Republicans routinely talk up... The Contract with America was critical to Republican recovery.

I'm with von on this. Hundreds of individual amendments do not make a plan that can be evaluated. I'd go a step beyond von, and say that talking points (ie, as in the Contract with America) do not make a plan. This is an area where the devil is in the details, and unless the Republicans have something that approximates a real bill in the level of detail, they have nothing.

I could live with Wyden-Bennett. To be honest, I would probably be happier with that as a foundation from which things could be modified in the future than I am with what's likely to come out of the Senate.

[hairshirthedonist]

Still talking about what others did, blaming previous policies, and taking little responsibility but as much credit as possible.

Why still? Obama's been president for less than a year, after 8 full years of Bush/Cheney.

The fact that policy alternatives are part of things offered in the past don't make them bad.

No. But the fact that they're bad makes them bad, and that they were offered in the past means that they were offered in the past. Both make them both.

Are past policies not subject to criticism or to being avoided, given their past failures?

[Marty]

"Are past policies not subject to criticism or to being avoided, given their past failures?"

Past policies include everything.

This is just subtext for Republican or conservative policies all of which have not always failed. It is just a way to not have to discuss the merits of individual policy positions by lumping them together as part of all of those "past policies that failed".

And the punch line of the joke is then, "if the Reps have any good ideas we will listen to them."

[tyronen]

If the Republicans were a reasonable party, they would be pushing a private-sector-based reform plan, such as the current bills or Wyden-Bennett, while the Democrats would push for single-payer.

Instead, Democrats push for what logically should be a Republican bill, while Republicans push for the status quo, and nobody pushes for single-payer.

[mattH]

But it doesn't address the real challenge for Republicans, which is that they don't have a good alternative. They're holding flyswatters too.

More like holding a banana peel and a low mounted chain to trip anyone who tries to get past em.

[Ben Alpers]

I don't have another team to root for.

Not much else I agree with in this post (other than admiration for Obama's rhetoric), but, if it's any comfort, I feel the same way, von. I want single payer. And neither of the (major league) "teams" is remotely interested in supporting it.

Or, to put it more simply, what tyronen said.

I'm sick and tired of voting for Rockefeller Republicans with D's after their name because the alternative is Teabaggers and Birthers.

[Mike Schilling]

The Republicans are not even holding flyswatters. The only thing they're holding, the posting rules won't let me name.

[Mark Thompson]

Von:

I hate to leave one of those "look what I wrote" comments, but my post today coincidentally seems to be directly relevant to your point here.

Conservatives who want the Republican Party to be more than just the "Party of No" and capable of governing if and when they return to the majority need to stop just taking potshots from the sidelines at what the Dems are doing and start talking to their own base about what they would be doing instead.

[jonnybutter]

This is just subtext for Republican or conservative policies all of which have not always failed.

Sophistry, Marty. Is the correct metric how *many* policies have failed, or is it how big or important certain key failures are? The previous administration set a new standard for Executive Awfulness. War, the Economy, domestic security, civil liberties - just remarkably awful - and Bush in fact mostly continued what had been modern GOP policy for many years. I think the phrase of the moment is, 'epic fail'. Sorry if that hurts your feelings.

If you want to sort out what is worth saving from what looks to me like an exhausted ideology, go for it. Someone ought to. But whining about 'subtexts' is just silly.

[Marty]

"I think the phrase of the moment is, 'epic fail'. Sorry if that hurts your feelings."

Doesn't hurt my feelings, it is just wrong. Very few of the policies contributed to your"epic fail". Many of those were in place through the Clinton years and some were Democratic policies on financial reform (Fannie and Freddie).

It isn't sophistry, it is reality. Policies and execution get intertwined also.

The Obama policy line has failed (welfare) and succeeded (Medicare) alternatively in the past but we don't refuse to discuss these ideas pros and cons.

It's just an easy out.

[von]

Mark, thanks for pointing your post out to me. It's well worth reading, and I've added an update and link.

[...now I try to be amused]

If the Republicans were a reasonable party, they would be pushing a private-sector-based reform plan, such as the current bills or Wyden-Bennett, while the Democrats would push for single-payer.

Instead, Democrats push for what logically should be a Republican bill, while Republicans push for the status quo, and nobody pushes for single-payer.

This is an example of Republicans getting most of what they want even when they're out of power. Later, when the great mushy middle decides it's "time for a change" again, they'll get back into power and get all of what they want. Extremism is still working for them.

[Jay Jerome]

Von: There is no visible Republican plan that Republicans routinely talk up. Consequently, there's nothing for me to talk up (assuming I liked what the Republicans were offering).

David Brooks column in today's NYT may be relevant to your concerns...

[hairshirthedonist]

Doesn't hurt my feelings, it is just wrong. Very few of the policies contributed to your"epic fail". Many of those were in place through the Clinton years and some were Democratic policies on financial reform (Fannie and Freddie).

Marty, Bush was a terrible president. God awful. The recent Republican-controlled congress was terrible, too. The above just doesn't get around that. And that's what Obama's subtext is, as johnnybutter pointed out. No one is claiming the Democrats and all their policies are perfect, but the relative records recently aren't even close.

[jdog]

Isnt' the Republican plan: let the "free market" decide? No need for government actions at all. In fact, the high cost of health care is due to programs like Medicare and Medicaid. If we would just get the government out of health care, everything would be fine.

Pass the Koolaid.

[SimonK]

Jay - David Brooks is a generally sane person who I happen to usually disagree with. He's said very sensible things about health care reform (most memorably "I wish their were death panels in the bill. I'm pro-death panel"). Most house republican however are not behaving like sane people - they're ranting about spending while militantly defending medicare, which makes absolutely no sense.

There is a sane conservative position on health care reform - approximately speaking its that you need to tax benefits, and encourage health savings accounts, and then watch the health "insurance" industry die from its sheer inefficiency. I see no Republicans in power actually advocating for this position, though.

[Mark Thompson]

Thanks for the link-love, von!

[Marty]

"The recent Republican-controlled congress was terrible, too."

Yes, the Congress that was controlled by Republicans fro 2002-2006, four of Bushes 8 years. One of the more irritating memory lapses in revisionist history. The Democrats controlled the Congress the other four years, including the last two.

So, foreign policy, particularly the view of America in the world, is a criticism I don't spend a lot of time defending because for better or worse the Republican administration owns it.

Domestic affairs, particularly spending is really a shared responsibility. The Democrats passed the last three budgets. None of that even addresses that Bush never had the kind of majority that approached 60 votes in the Senate, even when the Republicans had control.

So, the next time you want to generalize about the last eight years of Republican control, remember 4 of those years and the last two Democrats own the responsibility for.

[jonnybutter]

Very few of the policies contributed to your"epic fail". Many of those were in place through the Clinton years and some were Democratic policies on financial reform (Fannie and Freddie).

You're making my point for me. Your original comment was: "This is just subtext for Republican or conservative policies all of which have not always failed." That Democrats have sometimes embraced neo-liberal (conservative) economic policies does not make them other than what they are. And you are in denial about the current problem if you think Fannie and Freddie were the chief cause. I am not a fan of most aspects of either a mild neo-liberalism (Clinton) or a harsh one (Reagan, Bush), but they are both 'conservative ideas' and both giant failures.

Of course we're also leaving out a few other things, like Iraq, utter hostility to oversight in financial markets and everything else (a 'conservative' idea), indifference to climate change and the environment generally, Katrina, the tainting of the Justice Dept, torture policies which objectively weaken the country (and sully its name),.....I could go on, but I'm really sick of it at this point.

[Hogan]

None of that even addresses that Bush never had the kind of majority that approached 60 votes in the Senate, even when the Republicans had control.

And yet in eight years he issued only twelve vetoes, which I believe is a record for a two-term president. He couldn't have had much of a problem with what was coming to him from any of those congresses.

4 of those years and the last two Democrats own the responsibility for.

Some responsibility. Some.

[Marty]

"4 of those years and the last two Democrats own the responsibility for.

Some responsibility. Some."

I appreciate the acceptance of some, and will just agree.

[Troy]

the high cost of health care is due to programs like Medicare and Medicaid. If we would just get the government out of health care, everything would be fine.

Land-use rights and health services. Two critical sectors -- the MOST critical sectors -- of the economy that free market fundamentalism inevitably flails and fails.

Land is a good in fixed producer supply and unbounded consumer demand (in most areas). Elementary economics informs us that the price of land will thereby be bid up to the point of unaffordability. Land is the source and sink of all wealth. Show me a decade of history of the US back to the 1750s and I can probably point to a land speculation cycle that devasted the economy of the time.

Health Services. If you want a juicy income, provide wealth to your customers, and what provides more well-being ( the actual definition of "wealth") than health preservation and restoration?

Free market fundamentalism in this sector would teach us that independent providers will bid their margins down as supply strives to meet demand, but one look at the net margins of Big Pharma can dispose of this fairytale.

[SimonK]

Troy - you're making the mistake of treating the status quo as if it were in fact a free market in health care. It isn't - its about a as far from one as you can get without the government running the whole thing. Possibly further. Many free-market proponents are also making this mistake and reflexively arguing for the current system when they should be opposing many aspects of it.

Various branches of government already regulate what insurance can cover, how much it can cost and who can get it, as well as who hospitals and doctors have to treat and for what, how much that should cost, and what treatments they should provide. A sane opposition would advocate for dismantling this mess in the hope of actually engaging people's self-interesting in the provision of their health care. Most people right now don't know what their insurance costs, let alone what it covers, or how much their treatments costs. This is hardly a free market in any reasonable sense of the word.

[Catsy]

Yes, the Congress that was controlled by Republicans fro 2002-2006, four of Bushes 8 years. One of the more irritating memory lapses in revisionist history. The Democrats controlled the Congress the other four years, including the last two.

What is revisionist is pretending that Democratic control of Congress during those four years was in much more than name only, given their numbers and the way Republicans exploited filibuster rules to block anything of substance.

The idea that a narrowly Democratic Congress could have advanced health care legislation past a lockstep Republican filibuster--let alone managed the numbers needed to override Bush's veto--is pure fantasy. And the idea that Congressional Republicans would have done any differently is delusional. The only reason we're seeing as much give from them as we are now is because public sentiment has turned and they see the writing on the wall.

So when Obama says this:

What I reject is when some folks say we should go back to the past policies when it was those very same policies that got us into this mess in the first place.

He's dead on. The Republican health care policy--such as it is--has for generations been the reflexive free market fetishism that they think is a panacea for every problem, total denial that our health care system is anything other than the best in the world, unthinking opposition to any government involvement in the industry, and the ignorant notion that anyone without insurance can just go to the ER.

What's more, up until this year they were proud of it. And now that it's clear Americans overwhelmingly support reform, and that they're paying a lethal political price for sticking their fingers in their ears and blathering about our best-in-the-world health care system, suddenly they're changing their stripes.

Nobody's buying it. Their numbers are in free-fall. And there's a very good reason: they have no alternative plan. Republican hands-off, free market fetishism is at the heart of why our system is so broken--conservatism cannot provide a solution to this because there is no conservative solution, only variations on the same kind of policies that got us here.

Congressional Republicans, lacking any better idea, have wedded themselves to the strategy of screaming "socialism!" and saying no to anything the Democrats suggest. And it's patently obvious. No amount of petty sniping at Obama's rhetoric or finger-pointing at Blue Dog Democrats can change that.

[Troy]

you're making the mistake of treating the status quo as if it were in fact a free market in health care.

True. Earlier this decade I was confused about Medicare Part D sailing through the Republican Congress until I finally figured out that it was just a price-support mechanism for the major drug companies.

Still, given the barriers to entry, asymmetrical information, and the undeniable human need to preserve/regain one's health, it doesn't take a Nobel Prize in Economics to see that health care will always have market failure written all over it.

n the hope of actually engaging people's self-interest in the provision of their health care

People have a very difficult time planning for the unexpected, accurately discounting the future. This prompted mandatory retirement insurance schemes starting with Bismarck in the 1880s.

The funny thing is I see a strong interrelation between health care costs and housing costs -- the money we save not adequately insuring ourselves for the massive future health care expenses we and our family will quite likely incur AFAICT goes directly into inflated rents and home values. Mandated health insurance has to come out of some budget item and rent/OER is IMO first on the list. I don't know if it's dollar for dollar, but in the rough approximation I do think that "all taxes come out of rents" so the more government can "interfere" in the private market the better off we'll all be.

Low-tax minarchists simply fail to factor in the real estate market into their utopianism. Cut taxes 50% and I guarantee you home prices will go up 50%. It's a freeking treadmill.

[SimonK]

I agree people have a very hard time discounting the future correctly, and there are aspects of future health that are unknown unknowns, and therefore can't even be discounted correctly even if people were able to do it. For this reason, I'm strongly in favor of forced saving for healthcare costs, and pre-commitment to sharing of costs between individuals. I don't think insurance is a terribly good model for most of this, because by and large we're insuring against known predictable expenses, but it seems we're stuck with it.

[cleek]

The Obama policy line has failed

if you can conclusively decide that a presidency has failed 10 months into a presidency, WTF were the All Holy Founders thinking in giving him a four year term ?

and, sure, i know the GOP would like to use impeachment as a mid-term election tool but that's not the intent of the All Holy Constitution, either.

so until "conservatives" are kneeling in the street, apologizing for the past 8 years, why should serious people give a shit about what they think about presidential policy?

[russell]

People have a very difficult time planning for the unexpected, accurately discounting the future.

As SimonK alludes to upthread, the reason people have such a hard time accurately planning for their future medical expenses is because those can range from $0.00 to more money than the average person makes in ten years, and where in that spectrum you are likely to fall will largely be due to things that you can neither predict nor discover.

Not that they're *hard* to predict, they *cannot* be predicted for you or your personal family.

You can eat a pure vegan diet, go to five yoga classes a week, run a marathon once a month, and get hit by a bus. Or fall off of your bicycle and hit your head. Or succumb to an odd congenital or environmentally induced cancer.

It's *not knowable*.

The reason the insurance model is attractive is because things like this can, in fact, be usefully estimated over large populations, over time.

Forced savings at an individual level does nothing to address the basic problem. How much should you be forced to save? Are you saving for a head cold, a broken leg, a heart and lung transplant, or 20 years of 24/7 care while you decline into Parkinsonism and dementia?

If you're talking about "forced individual savings + shared costs between individuals" what's the difference between that and insurance?

[Troy]

For this reason, I'm strongly in favor of forced saving for healthcare costs

It'd be nice if the gov't would just let us stash aside any amount of pre-tax money for {education/health/retirement savings}.

But then again it would suck that your child can't go to the expensive college they want because complcations from the gall bladder surgery your wife had 10 years prior wiped out the account.

We can dance around it, and no doubt will, but a national single-payer insurance system with mandated (forced) entry a la Social Security is the way to go. Me, I hope to GTFO this crazy-ass country again next decade, by 2012 if I'm lucky.

[bobbyp]

"We'd probably have the House Democrats' version of health care reform, which is the worst set of reforms currently on the table."

UNAMBIGUOUSLY FALSE.

But conservatives such as von believe the magic genie of the free market can cure all ills, despite the following:

1. Economic theory shows free markets break down wrt health care (Kenneth Arrow).
2. Current trends are simply unsustainable, but what--me worry? We have the best health care in the world!
3. Fee for service paradigm-the real danger to cost containment.
4. Lack of real competition and restraint of trade (cf Dean Baker).
5. What do for profit insurance companies bring to the table wrt health care? Absolutely nothing.

So what is the conservative answer? Tort reform. Yep. You heard me, meaningless balony.

And they wonder why they are thought irrelevant.

[ChrisJ]

". . . the reason people have such a hard time accurately planning for their future medical expenses is because those can range from $0.00 to more money than the average person makes in ten years, and where in that spectrum you are likely to fall will largely be due to things that you can neither predict nor discover."
Russell, I think that's exactly right. In my mind the only way to deal with this problem is to have the largest risk pool possible -- the entire population (i.e., single payer). Yes, lifestyle (personal choices) matter. But most sickness is random and arguably has more to do with what you inherit from your parents than it does with how you live your life. Since the insurance industry is for-profit, the obvious way for them to make money is to cherry-pick the risk pool. Some risk is predictable, but much isn't. Hence their need to jettison those who develop expensive illness.

"Fee for service paradigm-the real danger to cost containment"
I wholeheartedly agree with this. I've been salaried my entire 30-year career, but I see around me every day the behavior of docs who aren't. When you get paid more for doing more, the temptation is too great to do more.

[Doran]

A good comeback?

"Yeah, but your mop bucket has holes in it."

[hairshirthedonist]

When you get paid more for doing more, the temptation is too great to do more.

My wife used to be an office manager in a dental office. There were two dentists, one older who started the practice and one younger who joined later. The younger dentist eventually took over the practice.

The older dentist was a laid-back guy who liked being a dentist and making sure people had healthy teeth. He made plenty of money without thinking much about making money. He probably could have made more, but he didn't care.

When the younger dentist took over, he started hiring consultants to advise him on how to run the office, mostly in a business/accounting fashion. He was a dollars-and-cents kind of guy.

The end result of this was that the staff was instructed to push certain types of services based on the time it took to provide them and how much revenue they generated. It had nothing to do with the proper practice of dentistry, or the proper allocation of resources. (Sort of like doing CAT scans on a far-too-great proportion of headache or dizziness sufferers, only for revenue rather than defensive purposes.)

(He also had time clocks installed for the staff to clock in and clock out and implemented other such morale-deflating policies. Patients began to notice the change in the mood of the office and the decline in the once pleasant, warm and personal atmosphere. It all struck me as being very self-defeating.)

/anecdote

[Hartmut]

Now imagine the next alternative dentist would have his practice a hundred miles away, so there would be no choice...
I know that this type of dentist (or medical doctor in general) exists and has become too common.
(That's), fortunately, so unlike some dentists I know that send patients to colleagues for certain procedures not because they could not do them themselves but think that the colleague does it better.
My dentist (who belongs to the latter group) loves to complain about the illogical reimbursement rules*, which repels some patients, but she does good work and is very clear beforehand about the options and the connected costs.

*low and even decreasing for prophylactic measures (like scale removal) that would save lots of money later while the treatment of preventable tooth damages is (still) paid for.

[hairshirthedonist]

I know that this type of dentist (or medical doctor in general) exists and has become too common.

I agree, but I feel the need to add that the younger dentist is an excellent dentist and that I think he does ultimately want what's best for his patients. It's just that, AFAICT, his focus is too easily moved toward the business end of things. I don't think he realizes it's even happening. (I'm not a mind reader, so I can't be sure.) I want to be clear that I don't think he's cackling and twisting his non-existent mustache while counting his money, indifferent to cavities forming in the mouths of young children.

But, really, that makes the point even stronger. Even people with good intentions can be swayed by the revenue structure in which they practice. It's not just some number of bad guys who are subject to this.

[ChrisJ]

"But, really, that makes the point even stronger. Even people with good intentions can be swayed by the revenue structure in which they practice. It's not just some number of bad guys who are subject to this."
That's exactly what I meant. Once in a blue moon I've run across a physician who truly is a money-grubbing fiend (which is not necessarily related to competence). But most of the time folks find a way to convince themselves, for example, that the patient really needs this endoscopy (for a gastroenterologist) or cardiac cath (for a cardiologist).

The other thing to remember is that procedural folks like to do procedures -- it's their bias and what they were trained for. It's even kind of fun. So even if there were no money involved, there need to be additional brakes on unnecessary ones. We must have expected pathways for evidence-based medicine. Right now it's sort of like this: "Let's cath this guy tomorrow -- I'm curious what's there, and there's an open time slot in the cath lab schedule." The system we've got conspires against good care.

[ThatLeftTurnInABQ]

"Fee for service paradigm-the real danger to cost containment"

I wholeheartedly agree with this. I've been salaried my entire 30-year career, but I see around me every day the behavior of docs who aren't. When you get paid more for doing more, the temptation is too great to do more.

I think there is another skewed incentive system at work here as well - our development of new medical techniques since the discovery of antibiotics and the development of modern surgical techniques has turned into a techo-fetishist's dream, and that has helped to drive up the cost of health care. Cutting edge medicine today is like cutting edge physics - it usually involves big dollars, and then when some new technique is proven out to be successful and goes mainstream it drags the cost curve up.

We could be more vigorously pursuing other cheaper approaches (e.g. nutrition and lifestyle oriented preventive medicine) to helping people stay healthy in addition to high-tech medicine, but the former is much harder to capture in the form of a profitable private business model than is the latter. Thus our current system of privatized medicine steers us towards the type of medicine where the most money is to be made, and this will remain the case regardless of how the insurance system is administered and paid for.

That is why in the long run I favor a truly nationalized health care system more like the British NHS. A good deal of what we are doing now with health insurance reform is reshuffling the deck chairs, at least so far as cost containment is concerned. I fully expect that within another decade the US will be spending 20% of GDP or more on healthcare if we don't deal with some of these deeper issues.

[Bic]

Did anyone else catch CNN's editing of Obama's speech in SF last night?

Click on my blog link to see what I'm talking about.

[Turbulence]

I think there is another skewed incentive system at work here as well - our development of new medical techniques since the discovery of antibiotics and the development of modern surgical techniques has turned into a techo-fetishist's dream, and that has helped to drive up the cost of health care.

Your description reminds me of the military industrial complex. In both cases, we spend fantastic amounts of money buy amazing technowizardry that isn't as useful as either the cash spent on it or the wow-wow awesomeness might suggest.

There's a local hospital group near where I live that was seriously considering requiring their physicians to have RFID tags implanted into their bodies in order to ease tracking the spread of multidrug resistant infectious outbreaks. Now, those outbreaks are a big problem and RFID is an awesome technology, but it seems like we could do a lot more in terms of building a culture where everyone uses Purell every five minutes before we start demanding that medical staff have special tracking devices surgically implanted into their bodies. But part of the reason that adoption of alcohol based hand sanitizers was so much slower in the US than in Europe is that Purell is dirt cheap and not techno cool. Kind of like how native Pashto speakers are dirt cheap (compared to F-22s) and not at all techno cool.

We could be more vigorously pursuing other cheaper approaches (e.g. nutrition and lifestyle oriented preventive medicine) to helping people stay healthy in addition to high-tech medicine

I just finished reading Good Calories, Bad Calories so I'm a bit skeptical of nutritional approaches since so many of our commonly held nutritional beliefs seem to be witch doctory and quakery. I have a vague suspicion that changes in the built environment might be more effective than most lifestyle oriented medicine. My dad spent about 15 years commuting to NYC to work in the World Trade Center, but after 93, his company relocated to a suburban office park. It seemed to lead to a big drop in his quality of life. He used to read a lot while taking the train into the city but that doesn't work so well when you're driving for an hour plus each way. His blood pressure improved dramatically once he discovered books on tape. Of course, when you're working on Manhaten, you spend your lunch hour walking around because you're in one of the most amazing places on earth...suburban office parks do not really have the same effect, so there's a lot less walking.

More to the point, I have trouble seeing how nutritional and lifestyle treatments will offset more expensive interventions. After all, you can do both at the same time, right? You can speak with the nutritionist and get your stents put in. And if each of those is good, shouldn't you do both? The real problem here seems to be that normal people believe that "more care = is more health" and I'm not sure how we can fix the system without addressing that head on.

[ChrisJ]

Lifestyle things play a big role in reducing the risks of bad things happening, but it's much less clear that they do much in raising the chances of good things happening. Most disease and injury is still random, with risks of particular big categories (such as cancer and heart disease) having a strong genetic component.

[Turbulence]

Lifestyle things play a big role in reducing the risks of bad things happening

I can buy that, but do physician efforts to change their patients' lifestyles actually benefit them? I mean, the guy who eats a really nutritious diet and runs three miles a day is less likely to get heart disease, but is there any evidence showing that having a doctor urge healthy man's really unhealthy brother to improve his diet and exercise more will actually reduce unhealthy man's chance of developing cardiac disease?

[ChrisJ]

Turbulence:

I don't know offhand about diet and exercise, but there's a huge literature about physicians' abilities to affect patients' smoking. Google Nancy Rigotti if you're interested (she's an old friend of mine).

[Turbulence]

ChrisJ, smoking seems to be a special case. As I understand it, the research suggests that physicians are remarkably ineffective at getting their patients to achieve sustainable weight loss for health reasons through lifestyle and nutritional changes.

[elaine]

Diet and exercise may in fact not be best managed through doctors and nutritionists at work, but at home, since it appears social networks drive (un)healthy behaviors more than medical care if the results of the Framingham study hold up. (This was the longitudinal study data that was analyzing, showing (un)healthy behaviors tend to propagate through social networks.)

[John in Nashville]

A superficial response goes something like: "But, dude, you aren't holding a mop. You're holding a flyswatter." (I'm pretty sure that can be made pithier.)

When the Republican leadership told the Republican members to make their criticisms pithy, perhaps folks like Joe Wilson thought that they were thpeaking with a lithp.

[Anthony Damiani]

"It's *not knowable*."

This understates the problem!
Assume I have a 1% chance of getting hit by a bus in such a way that will cost me a hundred thousand dollars worth of medical expenses. My exposure might be $1,000; but that won't do me a whit of good if the bus actually hits me. Neither would $50,000-- even being protected for an amount far in excess of my theoretical exposure would still be no barrier between me and bankruptcy in this scenario.

The function of insurance is fundamentally not to be pre-paid medical care; a forced-savings approach is utterly inadequate to addressing health-care needs.

[Amos Newcombe]

conservatives such as von believe ...

How wrong is this? Let me count the ways.

1. I can't speak for von, but as a long-time lurker here I really don't think this is an accurate portrayal of his views.

2. Which are the views being discussed here, not the views of conservatives like him, whoever they may be.

3. And if they do believe what you say they do, then how are they like von?

4. von is a conservative? Who knew?

5. This argument really steams me when "liberals" appears in it instead of "conservatives". If we're mannering up around here, can we also avoid this kind of cheap shot, on both sides? Please?

[Model 62]

Contrast this to 1993, when Republicans were also out of power: The Contract with America was critical to Republican recover.

The Contract with America was rolled out ~six weeks in front of the 1994 midterm elections. Prior to that, the GOP was tearing down Speaker Foley and monkey-wrenching Clinton initiatives.

It's a well worn strategy.

[Marty]

Interesting, faced with increased pressure to move on Afghanistan, this weeks line from the White House is...it's still Bushes fault. Despite at least two Obama administration strategy changes. CNN headlines were:

Emanuel: Bush never asked key questions on Afghanistan

here

Clinton criticizes Bush handling of Afghan conflict

here

[Warren Terra]

Marty, what is your point? Do you assert that the Obama Administration's criticism of the Bush Administration's handling of Afghanistan is inaccurate? That the criticism is inappropriate?

I submit to you that the Obama Administration's criticisms of the Bush Administration's record are well founded. And on the second point I proposed you may be making, as to whether the criticism is appropriate - well, I'd say that if it was their first response or their constant refrain when asked about Afghanistan, if they were using it to avoid acknowledging any responsibility for the hard choices they face, then you'd have a fair claim against them. But it seems to me that it's not a crazy description of the current situation, and they're not using it as an excuse to throw up their hands in disgust; so what is your complaint?

And have you actually read the transcript of the Emanuel interview? The transcript isn't obviously linked from the news story you linked to, and even searching CNN's site for "John King Rahm Emanuel" the transcript not the first or second search result. Take a look, and you'll see that the interview starts with an Afghanistan question, and aspects of that conflict are discussed for a total of five questions, all the way to the commercial break, well over a thousand words in the transcript. A couple of times in those thousand words, Emanuel does mention that the Obama administration feels that there's little or no progress in Afghanistan to build on. But that's far from the only thing Emanuel says - it's just the only thing featured in the story you linked. Part of this is that, in order to drive traffic, CNN is playing a game here and has posted a piece created by cherrypicking the part of the interview most likely to hit your buttons. Worked, too.

[Marty]

"if it was their first response or their constant refrain when asked about Afghanistan, if they were using it to avoid acknowledging any responsibility for the hard choices they face, then you'd have a fair claim against them"

My point is that every time they get asked a tough question that is their fallback answer, Axelrod did it on This Week on Sunday morning.

But on Afghanistan it doesn't ring true, more likely Bush did ask all those questions and came to the same conclusion that Obama is coming to, more troops and more investment is not appropriate.

After months of saying the war languished for 8 years they seem to be concluding that there isn't a justification for escalating it. That would be almost a sweep in duplicating the Bush foreign policy "actions" rather than words.

CNN is playing a game here and has posted a piece created by cherrypicking the part of the interview most likely to hit your buttons.

They are focusing on the WH message they are handed. When Emmanuel, Clinton and Axelrod all say it the same weekend it isn't an accident.

[Warren Terra]

So, Marty, your position is that Obama and Bush have both implicitly and probably carefully and deliberately decided that the right thing to do is to maintain current levels of involvement in Afghanistan? Even though essentially nobody thinks that under the current course things will ever get any better and enable us to leave, as they say, "with honor"? When the other options are either to write it off or to escalate?

Isn't that basically the definition of perpetuating a quagmire, at huge cost in the lives and wellbeing of American troops, of Afghan bystanders, and of course money? How is that position morally defensible?

I think we should probably leave Afghanistan, because I'm not convinced escalation stands any reasonable chance of success. But if it's decided that we cannot depart, I'd prefer further involvement with a plan, even if it means escalation, to further drift. Because if we're just there with no plan, to no purpose except to avoid acknowledging defeat, what are we?

And it seems to me that you're acknowledging that, whatever that is, that's what Bush was - with the exception that perhaps he'd have liked escalation and a plan in Afghanistan, but our army was just too busy in Iraq, leaving aside the still-mysterious question of why we're in Iraq. And whatever that thing is, you're saying Obama is it, too. I hope not.

[Marty]

Warren,

I think they both think that having a base and a presence in Afghanistan is a good thing, for many of the regional political reasons discussed here in the past. the fewest troops to accomplish that mission is what we need (and have needed for 8 years).

[russell]

But on Afghanistan it doesn't ring true, more likely Bush did ask all those questions and came to the same conclusion that Obama is coming to, more troops and more investment is not appropriate.

With respect, I think this reply excludes the great big elephant in the middle of the room.

The reason more troops and more investment was deemed "not appropriate" during Bush II was because those troops and that investment was re-allocated to invading Iraq.

Deciding whether it's wise at this point to escalate our involvement in Afghanistan, whether to do that through military or other means, or whether to just call it a bad job and pack up and go home is far, far above my pay grade.

But there are about 1,000 ways for a decision to not escalate that war to *not* be equivalent to a simple continuation of Bush policy. All that is required, frankly, is to not treat it as if you had bigger fish to fry.

[marty]

Russell,

Those are great words for deciding the same thing, there are more important and productive things to do. That is exactly the same policy.

[russell]

I think the difference here is between saying "screw Afghanistan, this is our shot to invade Iraq" and saying "what is the strategy that will yield the best result *in Afghanistan*".

Decidedly not the same thought process or policy.

Also, what might be good policy now is likely not what would have been good policy in 2001. Context is actually pretty important, taking the same actions now and then (if that's what happens) does not equate to a continuation of, or a validation of, the attitude or policies of almost a decade ago.

Shorter me: no, it ain't the same.

[hairshirthedonist]

Context is actually pretty important, taking the same actions now and then (if that's what happens) does not equate to a continuation of, or a validation of, the attitude or policies of almost a decade ago.

My over-simplified analogy: If I'm driving from Pittsburgh to Cleveland and I take a wrong turn, ending up in Erie, it doesn't mean that the best thing to do now is to drive back to Pittsburgh and start over. I should "continue" the drive from Erie and go to Cleveland.

Or we could discuss squirrels making it 3/4 of the way across the street, then deciding that they shouldn't be in the street and that they should turn around, only to be needlessly squashed on the way back.

(Isn't this fun?)

[Marty]

"Also, what might be good policy now is likely not what would have been good policy in 2001"

But if, as they said over the weekend, that the situation hasn't really changed much in 8 years, which it hasn't, then they look a lot like the same diecision.

[Nate]

I dunno, I would think that if we haven't managed to change the situation in 8 years, that would make it quite a different decision than at the beginning. For one, it would point to what we have been doing as not working, so something needs to change.

[Marty]

"For one, it would point to what we have been doing as not working, so something needs to change."

Not sure how this disagrees with me, if we keep doing the same thing then it points to the fact that the goals we have been meeting all along are the right goals.

[Nate]

Marty: "Not sure how this disagrees with me, if we keep doing the same thing then it points to the fact that the goals we have been meeting all along are the right goals."

If the situation hasn't changed, that means there hasn't been any improvement in the situation, or worsening. Which means our current methods may be good enough to keep things from getting worse, but it's definitely not improving things. It's not working, if our goal is to fix things in any reasonable time frame. I'm not sure how that translates to "the goals we have been meeting all along are the right ones."

And I will happily admit I don't know what the right thing is to do now in Afghanistan. I can tell you some things that were definitely wrong, and were done years ago, such as taking troops out of Afghanistan to invade Iraq for no reason. If those same troops will make a difference six to eight years later, I don't know. It'd probably help if we'd stop bombing weddings and stuff, too.