The 60 vote majority in the Senate, the collapse of the nationally prominent Republicans, and the approach of critical health care, environmental and consumer protection reforms has created a perfect moment for the Democrats.
Here's a to-do list:
Use it. Be smart. Think of what the Republicans would do in this situation, strip out the evil, and go from there.
The silly debate about whether to have a public health insurance option or not is an indicator of how far the progressive side has to go before it can influence major policy debates. The private health insurance market is a colossal failure; it is an easy target. But as I have noted before, the debate seems to be just as much about helping private insurers as it has been about expanding coverage and reducing costs. I wonder if the Democrats really want to do health care reform; they sure seem to go about it as if it were a burdensome, joyless chore.
The very idea of a public option among many private ones is, thanks to the right wing, highly controversial, although it is the only option that nearly every other western nation has. Those who have pushed for a single payer public plan feel as if they have been ignored, allowing the debate to be framed further to the right. Pushing for a single payer option, and scaring the opposition into having to deal with it would probably make a public option alongside private ones seem like a good compromise.
But instead, we have the only public option bandied about and pilloried for weeks, and dispensing it is now underway by murmuring that the Dems don't have the votes, and this non-profit cooperative thing sure looks promising. See? Public option makes a non-profit cooperative look more plausible. This is political framing 101.
In a few months, we'll hear that the non-profit cooperative is under fire, and that 'better regulation of private insurers' is more acceptable, and the NPCs will be dropped quietly from the bill of one house or the other, or sacrificed during conference. Remember that single payer wasn't even allowed to be discussed because it "didn't have the votes," which is completely the backwards way to do it.
If the Democrats really want to have viable sustainable health care reform, they need to reboot their talking points, expand their options and reframe this thing before it's too late. Here is one way to do it: How about multiple public options? At the least, it will make it difficult to kill them all, and they would be based on successful ideas from here and abroad:
A nonprofit public health insurance, such as Medicare.
A VA-type plan that provides medical services as well as pays for them.
A service provider like the military's medical system - no insurance needed.
Subsidizing cost-cutting private sector initiatives, like urgent care facilities and Walmart and Target clinics for mundane illnesses, run by nurse practitioners.
Catastrophic coverage. This could allow private insurance to focus on insuring less costly procedures, strengthening their bottom lines. It would allow the government to fight the profiteering that goes on with end of life care and to fight life-threatening diseases.
What about only using the threat of a public option to keep the private insurers in line? That's not a public option, that's a threat to threaten a public option. The only trigger that should exist is one that institutes a single payer system automatically if outcomes don't improve and costs don't come down with this round of health care 'reform.'
In addition to worrying that the private insurance company and doctors are not too inconvenienced by health care reform, the President apparently has opted for bipartisanship over health care reform, if the two are somewhat incompatible:
“I said, ‘Yeah, it’s a problem,’ ” Mr. Grassley said of the public plan, “and he said something along the lines of, ‘If I get 85 percent of what I want with a bipartisan vote, or 100 percent with 51 votes, all Democrat, I’d rather have it be bipartisan.’ ”
Which means that if the public plan is the concession that will bring Grassley and may be some other Republicans aboard, then the President is willing to do so. And the GOP knows it.
What exactly will the President do with a bipartisan vote? Does anyone remember if the votes on Social Security, Medicare, civil rights or other major issues were bipartisan or not? (They weren't.) What does bipartisan mean? That one person from the opposition voted with the majority? That a majority of the minority did?
By making such a move, the President has undermined both his negotiating position and the substance of health care reform. He has signaled to the Republicans that the public plan is as good as dead, and they can push him further for more concessions. This is what happened during the budget negotiations when those three bipartisan GOP senators took the Democrats for a ride in cutting their own programs, etc. just because the President had telegraphed that he'd do anything for their votes. The GOP can now add insurance regulation to the existing concession and keeping upping their price.
Substantively, the public plan is absolutely critical to making health care reform work. Public plans in the shape of single payer systems are the only ones that have worked elsewhere outside the US. Junking this whole avenue now is a big indicator that health care reform may ultimately be a photo op and rather toothless, too complicated and subsidized, and its costs underestimated to ever work.
I can already see this administration's lead advisors chuckling sheepishly on talk shows in 2017 at how they just never thought how badly it would turn out, how the costs would explode beyond their expectations, how the insurance companies and providers would profit rather than be reigned in, how the ranks of the barely insured would explode and deaths and bankruptcies would pile up.
But hey, after they effectively lose their insurance coverage during a medical crisis, maybe ailing people can feel better knowing that their health and wealth was sacrificed for a bipartisan vote that tried to bind up the nation's bipartisan wounds. Is laughter the best medicine when it is bitter?
I've made this point before, but probably nowhere as well as E.J. Dionne did in the WaPo. Money quote:
For all the talk of a media love affair with Obama, there is a deep and largely unconscious conservative bias in the media's discussion of policy. The range of acceptable opinion runs from the moderate left to the far right and cuts off more vigorous progressive perspectives.
Lately, regressives have fallen back to their last line of cogent argument: government action costs too much money. Call it the phantom budget menace: regressives would love to support some critical program, but it just costs too much and raising taxes would cause more harm than any program could do good. Unless regressives like a particular spending program. I will begin tackling actual budget problems that don't receive the same attention that regressives pour into programs that actually help people and are money well spent (health care, education, etc.).
Today's subtle but corrosive entitlement crisis: the criminal justice system. The U.S. has the highest incarceration rate (1 in 100 Americans is behind bars) and the largest number of prisoners (over 2 million in 2007). According to a Pew Center report: corrections chew up a larger part of state and local budgets. From 1987-2007, state prison costs quadrupled, and that is after adjusting for inflation. In FY 2006, corrections spending grew faster than education and Medicaid spending. In some states, as much or more is spent on incarceration rather than higher education.
All of this becomes completely non-sensical when viewed in light of the fact that violent crime, even property crime, has dropped for decades. The violent crime rate is lower than it has been since 1976 and the property crime rate is lower than it has been since 1968. (And property crime ought to be punished with financial restitution, rather than hitting up taxpayers for prison stays.)
The regressive response would be that crime rates dropped because we have spent so much on prisons: with more criminals locked up, fewer crimes are committed. This simplistic thinking falls apart when compared to other western countries that have lower crime rates and lower rates of incarceration. In fact, you could make the equally silly claim that higher incarceration rates leads to higher crime rates. Or maybe the US just has more criminals for some reason? What would that reason be?
One could argue that a large part of the American infrastructure investment has gone into constructing and maintaining prisons rather than projects that have a payoff, such as roads, bridges, schools, an electrical grid or nation-wide broadband. Rather than hiring legions of prison guards, border guards and straining state and local budgets, we could be improving our universities, reducing dropout rates and training a generation of high skilled labor in rural areas.
Building and maintaining such a huge prison infrastructure creates other perverse incentives. There is implicit pressure to keep those prisons full, because the local economy depends upon prisons for jobs. This creates a perverse incentive for the criminal justice system to lower the bar on what constitutes an imprisonable offense.
As health care reform moves closer to reality, it seems to be less about health care and less about reform. The focus on improving health care access and health care outcomes has taken a back seat to expanding ownership of private health insurance and pretending to lower cost growth.
The dispiriting debate over having a public health insurance plan is a symptom. With single payer talk and talkers seemingly kicked away from the table, the public plan is the last vestige of dealing directly with the failed private health insurance industry. Congress seems to be finding common ground on allowing a public health plan if maybe it were regional, or run by states or only down the road as a threat to private health insurance industry if they don't lower costs. At some point the debate has shifted its sympathy to private insurers and left the uninsured and the lightly insured behind.
There's a dozen reasons why this is wrong headed, but that is really not the point, because the debate has become so sidetracked about how to finance reform. Democrats are coasting on public urgency to fix health care. They are letting the GOP and the blue dog Democrats control the message. How can I prove it? Here's what we are hearing about today:
1. How can we pay for this? (whatever 'this' is) 2. Should we kill the public plan to try to make this bipartisan, even though we know it won't be? 3. How do we protect the medical-industrial complex, specifically the insurers and providers? 4. How do we buttress the tragicomedic employer-sponsored health insurance system?
The questions we should be pondering are: How do we prevent families from going bankrupt and falling apart over medical bills? How do we deliver better health outcomes for the same amount of money? How do we eliminate profiteering that is costing lives? Has any other system proven that it can produce better health outcomes than a single payer system?
The private health insurers came out voluntarily and said that they could cut about $2 trillion in health care costs over 10 years. That's $200 billion a year, roughly. There are a couple of points to draw from this:
The health care industry is scared silly that health care reform will be worse without them at the table than if they are.
Apparently, their bottom lines are so good that they just promised to give away a huge amount of profits over the next decade (20% of expected cost growth is 20% of their expected future earnings). How do they justify that to their shareholders?
Apparently, their bottom lines are so good that they must still have some profits left over in this calculation. They have just announced that they could stand to cut another trillion if really pushed.
The ways they laid out to cut those costs (for us) or income (for them) didn't include key cost increasers and inefficiencies.
This last point is indicative. The costs that were mentioned essentially parroted the Administration's talking points: electronic records, linking payment to outcomes, etc. But nothing about attacking the mafiaso-like markups for end of life care, or markups for critical drugs like cancer medications. Nothing about reducing the 20% overhead that everyone sees at their doctor's office, with incompetent front office staff losing records, messing up billing, etc. Nothing about covering preventative medicine or not denying needed care because of inability to pay. Nothing about stopping their fight against paying only for properly vetted treatments. Nothing about dropping their fight against generic drugs or a public plan option.
I have to echo Ezra Klein's skepticism that the medical industry giants are playing a game here:
What we have, in other words, are promises of future cost containment that exist alongside concrete and continued opposition to the cost containment ideas that are actually on the table.
Even if the medical-industrial complex is playing a subtle game of killing reform from the inside, their change in tactics belies some fear that they could be staring at a UK-ish National Health Service if they didn't change. If they didn't think they needed to be at the table, they would stand back and throw bags of hazardous medical waste at the players, like in 1994.
Plus, it's easy to talk yourself into how you let the other guy grab your balls, just to get him close for a fatal blow. But it doesn't change the scrotum possession situation, it just draws attention to your own weakness.
And it's nearly time for the President to squeeze. Squeeze in this case means using a single payer system as the hammer to scare these well-dressed pirates. Scare them so badly that they accept a public plan option, coverage expansion, brakes on cost growth and good old fashioned efficiencies on the back house operations.
Just like David Brooks' bizarre political rantings, I have withdrawn all energy and effort into worrying, watching or thinking about the Republicans, AKA Teabaggers R Us.
They have gone so far off the deep end that I can't take them serious. At best they are having a severe mental health issue, at worst they have become a fringe movement, the Lyndon LaRouche of the right.
I'm not the only one. The 'moderate' Democrats in the Senate have picked up the GOP's fallen opposition banner, the one they left in the mud when they dropped it to mutter into their aluminum tea bag/tax cuts hats. I don't think the Dems need to do so, and they clearly are lip-synching the budget hawk talking points without much feeling, but they would do anything to keep a debate going long after it's over.
On to actual policy discussions that may benefit the serious, competent adults who are calling the shots today.
Lincoln was calm, steady, and willing to make, admit, and fix mistakes. President Obama has modeled himself after Lincoln and one gets the sense he constantly measures himself against his presidential mentor. This is in some sense a 'reboot' of the Lincoln franchise, but with a different cast (Seward = Clinton, obviously) and different problems (secession = economic collapse). But the script seems eerily familiar, unfortunately.
By the by, Lincoln chose a less than stellar Treasury Secretary, Salmon Chase. Corrupt, full of himself, despised by his own party, he was the Sarah Palin of the 1860s. He did do some good banking work and funded the Civil War, but on his 4th resignation ploy, Lincoln accepted it. But that's not where I'm going with this, although Chase plays a role. The financial sector now plays the Chase role.
No, the point I want to make here is that for all of his great traits, Lincoln was a lousy Civil War manager. He went through generals like Sherman through Georgia. Even his best commanding general, Grant, won in the slowest, bloodiest, most destructive way possible. Sherman, Hancock and Sheridan were very good, but no one was as good as Lee. Lincoln had the good sense to offer it to Lee, but Lee made other plans. Managing the Civil War was Lincoln's number one priority, the focus of his attention.
The economic crisis is Obama's Civil War. And I fear that history repeats itself. Lincoln's first general, Irvin McDowell, who had never commanded troops in combat before but was promoted by his mentor, Treasury Secretary Chase, and was pressured into rushing into Bull Run with unready troops and an overly complex battle plan. He lost. And nearly lost the war in a single day.
Part of the problem with Lincoln's generals, from McDowell to Meade, was that, unlike Lee, they failed to change fast enough to meet the needs of the times. Grant, like Lee, had a better grasp of how the then-new military tactics worked.
Secretary Geithner and the toxic asset/bank bailout plan look similar: rushed, deemed to fail, yet stubbornly sticking to his plan despite circumstances dictating other actions. As Paul Krugman points out, the Treasury keeps floating the same old proposal with new bells and whistles, and no one but the bailees have given it a thumbs up. Geithner blames the dealers but not the casino, when everyone outside Wall Street understands that the casino is responsible for the dealers.
And Larry Summers' guiding hand resembles that of Gen. Winfield Scott: a hero of previous wars, brilliant and experienced bar none, but tarnished by scandal and standing behind a plan that was completely out of touch with the current situation (blockading the Confederacy to win the war 'bloodlessly').
It seems to be growing more apparent that Obama's current economic team is at the McDowell stage of not getting it. They were put in by their mentor, the financial sector, as was former Treas. Sec. Paulson, and the mentor clearly does not get it. Maybe Obama, like Lincoln, will give the supposed experts a chance to try and fail, allowing the President to plod along until he finds his Grant and Edwin Stanton (Secretary of War, who put the logistics behind the war in order) who get the job done, no matter how messy.
