Friday, 22 January 2010

Sibling Rivalry?

I've been having a very interesting Facebook discussion with my brother (say hi Tim), that I thought might be worth airing for my wider blogging public. (Both of you...)

Tim wrote:
My opinion is that the electorate is more sophisticated and independent than professional politicians give them credit for.

Lets be honest I have not even heard the Vice-Chair of Democrats abroad say that the voters made the wrong choice in MA.

I have heard much about how inconvenient the results are.

Here is a crazy idea... spend less time in defending the "Status Quo" and more time recruiting candidates that can lead and inspire the country. And damn it... why are the lawyers taking over politics and business there must be other options.
And I responded:
Tim, you haven't heard me defend Martha Coakley as a candidate because I can't. She ran a terrible campaign, she said things on the campaign trail that offended me and annoyed me. I think I understand why MA voters chose the way they did, and I don't blame them for it. iBut for the record, yes. I think the voters of Massachusetts made the wrong choice. I think they made a choice that is going to directly lead to a lot more people dying in America, cause the government's budget to explode (remember that health care reform is deficit REDUCING), and continue the unacceptable insecurity for American families. If you lose your job you should still be able to get health care. If you have a pre-existing condition, you should be able to get health care. You should be able to afford health care even if you don't have a lot of money.

The status quo in America is the opposite of that, and I hate it with a fiery passion that only groes every day. The status quo is that America is a country that pays more PUBLIC health insurance alone than most other countries, but doesn't cover more than 46 Million people, and has higher infant mortality and lower life expectancy than most countries in Europe. The status quo is that everyone lives with this as if it were somehow normal, whereas to me it's a national emergency or 9/11 scale happening a few times a year. I'm not defending the status quo, I was hoping and working, and trying very hard to change it. That may not be possible now, and I will never accept that as anything other than a terrible, terrible outcome.
Tim responds:
Amen Sister!

If the legislation under consideration was going to do all those things America would vote for it. I can guarantee it. If you can assure me that the compromise health care bill that was being jammed through the legislature was going to do those things I would fight for it.

The one concrete benefit of the bill is (was?), the elimination of selective underwriting. There is very little else I can point to as a concrete benefit. The cost benefit was not a strong case as the best anyone could hope for was to minimize the increasing costs of coverage. I am not sure even the strongest supporters of the bill want to hang their hat on those projections.

Apparently the citizens of MA do not believe that we must spend Trillions and create a huge government program to accomplish those goals.

If you want to get a proper Universal Health Care system in the United State then it should be a system that is good enough to get implemented without the level of compromise and strong handed tactics that we have seen in this process. "Super Majority or bust" is a tough way to illustrate the value of any legislation.

What is difficult to understand, or at least difficult to remember, is that those with coverage in the US are content with it. Coverage for those that have it (voters) is state of the art and it is paid by the employer (generally). That contented group is your starting point for any discussion of National Health Care. What Clinton missed and Obama has tried to circumvent is that Americans that vote... are OK with their health care coverage.

The people who do not like health coverage are business owners, the uninsured/uninsureable and to a large extent the health care system itself.

We must prove legislation can fix the major issues with health care before we trust a legislatively mandated paradigm shift. (1) Stop premium from growing at an unsustainable rate and (2) provide coverage to every American that wants to buy it. If you can show some positive results on those concerns, that would put a more comprehensive Health Care overhaul within reach. I can even offer pragmatic solutions to affect this change.

It took other countries years to get a system they are comfortable with. Why should it be any different here?


Just thinking out loud.
And finally, here's me again:
Thanks Tim - really useful and interesting thoughts.

I think you and I are largely on the same page on all the key points. The bottom line lesson for me here is that the country's problems will ALWAYS be un-solvable if we need a 60 vote Senate majority to pass anything. It's time we all (not just Democrats) start getting serious about insisting that a majority is a majority - and if that means that in a few years time a small Republican majority can push through legislation that I don't like, then you know what? Fair enough. Democracy only works if voters can see whether the policies that their politicians advocate actually work or not. THe current situation where voters can express a clear preference for one set of policies and those policies can never be delivered just leads to stagnation and a total lack of accoutnability. In any other national parliament in the world, this process would already have resulted in a law. And frankly, a better law than the one we have.

Now, to the current health care bill. This bill (even the watered down Senate version) would have covered, by CBO estimates, over 30 million uninsured Americans. It would have put strict regulations on insurance companies that means no one can be denied insurance for a pre-existing condition (that the simple answer, by the way, to "what does this bill do for me" - the day after it passed you would instantly be protected against the common sceniaro of getting sick and then having to desperately hope that you don't lose your job or insurance lest you face bankrupcy), it would create a national health care exchange that would for the first time create real competition in the industry - right now there's 90% consolidation within each state. And finally, by adding an individual mandate and carefully offsetting that with tiered subsidies based on income, it established for teh first time the principle that every American must be covered. The Senate bill isn't perfect, but I was genuinely excited about it. It would have been a major and irreversible step forward. I still hope we might take that step. We've come so far, falling at this hurdle... well, it would be pathetic.
One further thought - to Tim's question about "no more all or nothing" health care plans...

The reality is that this plan WOULD be an incremental plan - it definitely wouldn't solve every aspect of the crisis in one go, it would just establish a framework for future tweaks and innovation. The New Yorker had a really good article recently about how health care in this sense may be like agriculture in that it will always need hands on management and constant adjustment to keep it working.
But, to begin solving this problem there is no way to avoid bold action, because the types of small improvments that would be superficially easy to make can cause the whole of the existing system to collapse. Most crucially, simply making it law that insurers can't deny people for pre-existing conditions - which would be the simple and fair thing to do - would massively increase costs for everyone because the incentive then would be to not buy health insurance at all until you get sick. The system only works if healthy people are paying into the system too so that it will be there for them when they get sick. That's why the individual mandate is important.
It's confusing and complicated and difficult. But it's vital, and I'm not prepared to give up. Ever.


KathyF said...

Karin, I think Paul Krugman (as well as many, many posts by Ezra Klein) has a good explanation of the "three-legged stool" concept that you're hinting at in the last paragraph.

Most Americans don't understand it, nor do most commentators, but it really isn't possible to do health care incrementally, as your brother (and countless others) have suggested. Simply preventing insurers from discriminating against pre-existing conditions, etc., would create a "death spiral" where premiums would go up, more healthy people would leave the system, premiums would then go up again, and so on. So there has to be a mandate, and if people are forced (really too strong a word for the wimpy enforcement in the bills) to buy it then it has to be subsidized for those at the bottom of the income ladder.

Also, it costs nowhere near "trillions" of dollars. It costs an average of $90 a year. That's nothing. Taxes would not go up for middle income workers, only the rich (in one version) or the very well insured--likely no one your brother, or most Americans, know. (People who have executive level, "Cadillac" plans)

This bill, as you suggest, was pretty tame. It didn't get Republican support, despite the fact many Rs contributed ideas to the respective bills, for partisan reasons. That's the only reason.

That's the real crime. That's who we should be lambasting right now.

Obama London said...

Thanks Kathy - have expanded upon this in my next post.

Tim said...

The New Yorker article is very interesting but indicative of the schizophrenic debate over health care reform in the United States. When discussing the “value proposition” of health Care, we become distracted by specific policies and delivery methodologies. Those are powerful and important discussions but they also take away from the mandate of “health care reform”.
I agree that there was much in the senate bill that was good but it left many of my personal hopes, fears and... well... prejudices unaddressed.
My hope; is that all Americans that want coverage can have coverage. I also hope to control the amount of money I pay for insurance and keep it a reasonable number.
My fear is that the answer to health reform is more and bigger government. We know from history and tradition if we give government more money they will spend it on whatever the priority of the hour is and not on what it was pledged for. Social Security plugging our budget gaps may be the most public realization of those concerns. Instead of collecting Social Security taxes and putting it aside to pay benefits, those dollars are spent and benefits are paid by current tax revenue (Senator Ponzi must have sponsored that legislation).
My prejudice; is to simple elegant solutions to complex problems. I believe government works best when it creates a level playing field and acts as a referee. I believe it works poorly when it writes the rules plays both sides of the ball and acts as its own referee.
This largely means implementing much of what was proposed in the Senate bill but implementing with an ideological mandate that is more in line with American culture. More accountability and minimal government is where I see this ending up regardless of how this gets implemented.

Obama London said...

Hi Tim,

I do get your fear of "more and bigger government", but I think as it relates to health care this fear is somewhat irrational. The reality is that in America today already 60% of all health in this country is paid for out of the public purse. If you look only at the amount of PUBLIC money (your and my tax dollars, in other words) Americans spend more per capita than any other country in the world EVEN though we in theory have a private sector system and leave more than 15% of the population uncovered. That's just spectacularly inefficient. The SEnate bill as written doesn't actually create a new government program (remember, there is no public option - which I consider a mistake) but it does allocate money in a far more efficient way. That's leaving aside the question of fairness. In short, we are wasting FORTUNES on a very inefficient way of spending government money because it is politically difficult to create a system in which our tax dollars get more for the money.

After all, taxation is just one way that way pay for health care costs, and in every other way (insurance premiums, deductables and direct purchase) costs have skyrocketed in recent years. If paying a little more taxes means paying much less out of pocket, that's good value for money.

Obama London said...

PS: Thought you might be interested in this thoughtful article from the Libertarian Johnathan Rauch with his take on reform: