The Case for Cowardice
With regard to some recent exchanges on universal health care, I think Greg Anrig's correct to say that only political cowardice can explain Democratic reluctance to get behind a big push on this score. But to amplify what I think Mark Schmitt is saying here, cowardice may be the better part of wisdom here. Or, as Plato puts it in Laches, it's not cowardice if it's wise -- it's caution. Voters who are primarily concerned with health care are already strongly inclined to back Democrats who pursue an incrementalist approach to health care, suggesting to me that the political upside to a bolder approach may be smaller than a straightforward read of the polls suggests. It doesn't really matter how many people agree with you, what matters is how many people who really care agree with you.
If you try for a "big bang" overhaul of the health care system, one group of people who's going to care a lot will be the folks who run the businesses that will be aversely impacted. A single payer system would more-or-less put the insurance industry out of business (among other things) and you can't expect to try that without meeting some fierce opposition. Understanding this, the inclination is to try and devise big bang proposals that somehow co-opt the vested interests by retaining a primary role for private insurance in the context of a regulate-and-subsidize scheme that would get you universal coverage.
As we saw in 1993-94, however, interest group opposition to something like that can remain pretty fierce and you lose a lot of the simplicity that makes universal coverage politically appealing. There are also, I think, pretty serious substantive problems with all the ideas along these lines I've seen.
What I take from this is that even though a massive overhaul of health care would be desirable, it's not really feasible to get it done in a desirable way.
At the same time, incrementalism has a lot of promise. We have a lot of government-run health care in this country -- Medicare, Medicaid, S-CHIP, the Veterans' Administration, etc. -- and we've seen over the past ten years that it's possible to expand the ambit of these programs. The Kerry campaign had a good plan to expand state-sector involvement in a modest-but-important way by essentially shouldering super-catastrophic costs. I think that was a good idea. Expanding Medicare to cover prescription drugs was a good idea, albeit one that under Bush's watch turned into an albatross. Re-doing that reform is important. Gradually expanding Medicaid eligibility to take in more of the working poor and a bigger-and-bigger proportion of children is a good idea. "Medicare for all," is a nice slogan but not really doable and it's not clear what it would mean. But "Medicare for 60 year-olds" seems more plausible.
If you keep working at it over time, I think this kind of approach can get you -- eventually -- to a much better health care system. Going for the whole enchilada is just going to get you mowed down by an unprecedented advertising barrage. Taking a chance on a big bang reform that doesn't actually achieve what liberals want (basically what Clinton did) seems unwise. It's oft-forecast that "one day" large employers will get behind universal health care and maybe the insurance industry will see the writing on the wall and welcome a compromise. I'd welcome such a compromise, too, but I think the compromise proposal needs to come from that side and, in practice, this doesn't seem to be happening.
To make a long story short, there's a difference between bravery and taking foolish risks. There's a lot at stake in small bore issues. Even when the differences between the parties are less-than-gigantic the differences that exist are still matters of life and death for non-trivial numbers of people.
Then, again, as one of my bosses used to say, "You don't ask, you don't get."
I don't really see what is to be gained at this point by an incremental strategy since the only way we are likely to actually get incremental changes is to ask for the whole enchilada.
Compromises are probably inevitable but I don't see why scaring the SOB's in the insurance industry into some of those compromises is a bad strategy.
--Emma
March 4, 2006 10:15 AM | Reply | Permalink
The two major goals of the US healthcare 'system' are to:
(1) produce millions in political contributions for politicians, there are up to 5 or more full-time drug/health insurance lobbyists for each senator/congressman in DC.
(2) produce profits for insurance companies and for-profit healthcare corporations.
This is the heart of the 'system', it primarily relates to dollars not health. It is why the USA spends twice as much on healthcare as any other nation on earth, while lagging well behind many countries on measures of healthcare effectiveness like infant mortality, pre-natal care, longevity, number of doctor visits pre person, vaccination rates, etc.
If the Democrats pushed for a lower overhead, more effcient, cheaper, single payer plan, it would risk billions of dollars of profit and political payola. It would take an electorate far, far more informed than the American public to appreciate such an agenda.
March 4, 2006 10:35 AM | Reply | Permalink
I agree very much with Matt.
During the big debate on the drug benefit bill, it became clear early on that the bill was going to be, at the detailed level, a truly awful piece of legislation. (In fact, it came out even worse than I could imagine).
Nonetheless, I felt at the time, that ANY bill providing a drug benefit was a good thing, as it would be almost impossible to take away something like that in the future. And, in the end, new reforms would almost have to make it better, if only to save money. After all, the overall goals of a drug benefit plan are pretty simple -- subsidize medical drugs to some segment of the population.
So, I think we should keep this in mind, and always climb on board incremental approaches to providing benefits in things such as health care.
March 4, 2006 12:04 PM | Reply | Permalink
I'll buy the idea that incrementalism is preferable in theory. But in practice, what does this do to costs? I could be totally off base here, but it seems to me that universal health care is only more efficient than the current system when everyone buys in.
Expanding existing government programs like Medicare and the VA is well and good, but it will only increase overall spending. It's only when you get the healthy, wealthy, young, and voluntarily uninsured people to buy in to a publicly financed system that you really see the efficiency, right?
Otherwise you're just bringing more and more of the high-risk patients into the public system, which increases the overall costs and makes public health care seem less appealing to those who might otherwise support it.
Am I wrong?
-- Bruno and The Professor: Dynamic Talk Radio
March 4, 2006 5:45 PM | Reply | Permalink
I don't disagree with your point, but I will note that if there really are 40 million Americans with no form of health insurance/coverage, and those people are brought into a semi-universal system, overall costs to society could well go down even though there is probably a larger percentage of high-risk people in that group. That is, if those people received regular care and access to preventative treatment/medication, their overall cost of treatment could fall.
Direct cost to goverment, however, would go up- which is what the Radicals will scream about.
sPh
March 4, 2006 6:17 PM | Reply | Permalink
I think that people are talking past each other. Visions are what you have to guide you, incremental changes are what you do to get closer to your goal. For an example, look at how the wingnuts have pursued their goal of getting rid of Roe v. Wade: sure, they talk a big game to get the base fired up, but what they've actually been doing has been mostly incremental. They've imposed extra burdens here, intimidated clinic workers there, cut funding for women's health some other place, and so on until it all adds up to the thing they want.
The goal is universal healthcare. Not a better patchwork system or some complicated wonkery about who expands what where, those are only steps on the way to the goal. And the first job is to win on the goal.
March 5, 2006 12:13 PM | Reply | Permalink
I've posted a comment/question at Ezra Klein's personal blog here that has not been answered from the legal point of view yet.
I am fully for universal health care (UNC) in the US. I am supportive of single-payer UHC, but I think there is probably a major legal and Constitutional obstacle, which I'm hoping to hear someone rebut in the legal, not political sense.
The question is: If the Congress passed and the President signed (without a contradictory 'signing statement') a law saying that health care would be paid by the US governent (like Medicare), thus effectively ending the domestic health care insurance industry, would not this be illegal as a taking without just compensation (under the 5th amendment of the US Constitution - "nor shall private property be taken for public use, without just compensationnor shall private property be taken for public use, without just compensation"?
Is the existing business of the private health insurance companies 'private property'? I think the courts would say yes, this is a private business currently, just as they would for an auto repair business.
Would the Congress provide funds to purchase the fair market value of these health insurance businesses? The cost of this buyout/compensation would likely run into the hundreds of billions of dollars, if not trillions.
Would the SCOTUS (with today's conservative composition) agree that these health insurance businesses can be taken by the US Government even WITH compensation? At least some of the court, perhaps even a majority, would say that nowhere in the Constitution is there authority for running an insurance business - this actually could impact Medicare as well, since the government is not providing the service, but is only paying the bills.
I'd support a single-payer UHC program if there were hope of getting a law passed to enable it that could also pass the legal barriers of the Constitution on takings with or without compensation.
Can anyone cite a legal argument that makes sense that would allow single-payer WITHOUT compensation to the private health insurance companies for the loss of their businesses?
It doesn't make sense to me that we should advocate single-payer if we are immediately going to meet the argument that without paying compensation to the health insurers the plan is illegal or unconstitutional.
March 5, 2006 1:40 PM | Reply | Permalink
Jim Portlander - somewhere along the line you have been conned by a wingnut point.
1) On takings clauses in general - the "takings clause" refers to taking someones property. It does not refer to regulations that lower the value of that property, nor to the state making private services unneccesary. For example there are private schools who would certainly make a killing if all that unfair competition from free public schools would go away. They are not entitled to compensation under the takings clause. Dangerous products get outlawed all the time; no compensation is given from the takings clause.
2) On thes specifics of government health insurance. The government would not "outlaw" private insurance. It would provide manatory health insurance to everyone. As a doctor if you wanted to accept it, you would have to accept that compensation as payment in full. A doctor would have two choices in terms of private insurance ; a doctor could accept private insurance only for things the public insurance did not cover - which would be fine. Or the doctor could accept private insurance for stuff the public policy did not cover - in which case he would be a pure free enterprise doctor, not qualified for private insurance. Of course with our new ultra-Republican supreme court who knows what rulings may come. But to the extent the courts stay within existing precedent there is zero problem under the takings clause. None.
March 5, 2006 3:04 PM | Reply | Permalink
Typo Boy
Umm typo. Should say that in case the doctor accepts private insurance for stuff public policies cover she would not be eligible for public insurance. In other words if you want to go private on stuff for which there is standard private coverage, then you have to go private for everything.
March 5, 2006 3:05 PM | Reply | Permalink
To add to what Typo Boy said, any act of Congress that comes from the Commerce Clause is subject to the "rational basis test" (RBT). Legislation to extend Medicare to all Americans (and by extension Medicaid recipients) would be subject to the RBT. Under the RBT, an act of Congress to guarantee payment to medical professionals only has to have "some rational relation to a legitimate government interest."
Guaranteeing payment for medical services involves neither the taking of real property nor intellectual property. If we were to extend the takings clause to any act of Congress that adversely impacts some business or economic interest, very few laws could be passed by Congress at all -- because almost every law passed by Congress under the Commerce Clause has, by definition, some impact on the overall economy.
So, rest easy, that constitutional challenge will unlikely be successful if some sort of National Health Care plan were to be passed.
Find the Truth. Do Justice.
March 5, 2006 3:56 PM | Reply | Permalink
I like Matt's rational discussion of the issues, and even though I disagree have to give him props for it. Lately posters are really bumper sticker minded, talking about moral imperatives and such more than practical reality. Generally that's a bad sign.
Having said that, I think UHC is feasible now because things have changed considerably since 93-94. Business is struggling under the weight of medical costs and our economy isn't booming like it was then. So efficiency is a lot more appealing/motivating now.
GM regularly complains Japanese have the advantage due to health care. Part of that is just excuse making, but they do need help. There's an example of the zero sum game between Big Insurance and other US business under the present system, a game we can no longer afford. Dems can promise some favorable legislation to business to support UHC.
March 6, 2006 4:36 AM | Reply | Permalink
While I'm generally an incrementalist, it doesn't apply here. Med-D for example was unblockable, but it won't be signifigantly improved either. It's fundamentally flawed in bargaining and designed from the ground up to be a cash cow for private companies and Big Pharma. How will that be fixed without a complete overhaul?
Simply broadening the existing Medicare model would have been fantastic. I don't see how we'll ever get the middle men out of Med-D now.
March 6, 2006 4:46 AM | Reply | Permalink
Very doubtful that the uninsured population has a higher percentage of high-risk people. They tend to be poor, but they also tend to be young. Obviously the highest risk group, namely the over-65s, are not among the uninsured at all, since they have Medicare.
March 6, 2006 8:08 AM | Reply | Permalink
Corvid
This really puts it in a nutshell. I would only add that the notion of incrementalism (basically doing nothing, a fine, time-proven political strategy, I suppose) may be wise in terms of getting votes but doesn't make any sense at all if you're trying to actually improve people's lives or remove the yoke of excessive health care costs from our economy--a problem, by the way, that is absolutely screaming for immediate and decisive resolution. How do you think an ordinary voter would react if he/she knew that this was how Democrats formulate policy? On the one hand, they see Republicans (however goggle-eyed) out on the stump saying with conviction that they truly, truly believe that the market is the god-given answer to every conceivable human problem and if the voters would only consent to more deregulation and tax cuts we'd reach nirvana. On the other hand they see Democrats hemming and hawing and finally coming up with policies that manifestly lack any trace of conviction and are formulated only with an eye toward looking slight less alarming than the Republicans. If health care isn't an issue where Dems can, for once, ignore the lobbyists and seize the banner, then what good are they? With that in mind, I believe that, regardless of what the polls tell us and barring all-out, undeniable civil war in Iraq, the Republicans will expand their majorities in Congress in November. The hard-core 35 pct who love Bush will turn out to vote, while folks with any light in the belfry will stay home in droves.
March 8, 2006 10:22 AM | Reply | Permalink