Middletown Politico

B-b-b-but the st-t-tim-u-u-lus...

2010-02-20T03:31:00.002-05:00

"If I could help create one job in the private sector, it would be one more job than Congress has created in the last six months."

- Evan Bayh (D-IN)

Finally

2010-01-30T11:48:00.000-05:00

A clip of President Obama responding to Republican questions at yesterday's House GOP caucus meeting:

I have to say that, with regard to the stimulus package, Democrats really need to hammer home the notion that so much of it was tax cuts and that a huge chunk of it was aid to state and local government and unemployed insurance/COBRA help. Democrats need to really challenge the Republicans to defend "not doing the stimulus" and the situation - in small towns and cities across the country - that it would have led to.

This forum, by the way, was great. It was great for our politics in that it is great for citizens to see members of the different parties talking and disagreeing in a civlized fashion. It was also great for the President, because he finally was able to take head-on so much of the garbage that Republicans have been throwing around. It was not great for the House Republicans, but they do deserve a bunch of credit for allowing cameras in the room for the whole thing (which, some are now saying, they came to immediately regret).

Why the Republican "alternative" is just not very good

2010-01-30T11:32:00.000-05:00

Timothy Jost, over at TNR's health care blog, "The Treatment," explains why the Republican plan to reform the health insurance system is, in general, a really bad plan:

Association health plans are plans offered by groups--such as business or professional associations and chambers of commerce--to their members or to the employees of their members. Association plans are already common in the United States, but the regulation of them varies from state to state. The Republican bill would subject them to federal regulation, largely preempting the existing state regulations. Consumer protection under the federal law, however, would be quite minimal, focusing primarily on financial solvency.

Congress has rejected Republican association health plan proposals in the past. The main reason has been concerns that association plans could pick off the best health risks, making it more difficult for higher risk individuals and groups to find coverage. Another concern has been the lack of consumer protection and fraud prevention in association health plan proposals. (See here and here.)

The Republican bill would also permit an insurer licensed in one state to sell insurance across state lines, largely free from regulation in the states in which the insurance was sold. The idea is to increase competition among insurers and to free insurers from burdensome state regulations. Both the House and Senate health reform bills also permit interstate insurance sales. But those bills would give the states substantially greater power to protect its consumers--because there is a very real concern that the sale of insurance across state lines could lead to a race to the bottom in insurance regulation, with a significant increase in risk segmentation in insurance markets and in fraud.

High risk pools, another idea endorsed by the Republican bill, already exist in 34 states and provide needed help to many Americans excluded from insurance markets because of their health status. (See here.) Too often, though, they offer insurance with high deductibles and out-of-pocket costs. The Republican bill would allow them to charge premiums of up to 150 percent of a standard premium. This coverage would simply be unaffordable to many of the uninsured.

It is hard to argue against malpractice reform. Our current system leaves most victims of medical negligence uncompensated while it infuriates doctors and primarily benefits malpractice insurers and plaintiff and defense attorneys. There is ample evidence, however, that simply capping recovery of non-economic damages and attorneys fees at low levels, as the Republican bill would do, has the primary effect of making it difficult for victims of malpractice to get legal representation and nearly impossible for those who suffer no-neconomic loss (such as loss of reproductive capacity, disfigurement, the death of a child, or loss of functional capacity by a person who is not employed) to get any compensation.

Although it is commonly believed that defensive medicine is a major contributor to medical costs, there is little empirical evidence the support this belief. The CBO estimates that reductions in the utilization of medical care due to the Republican tort reforms would reduce national health care expenditures by only three tenths of one percent. The CBO also acknowledged that the Republican reforms might result in worse patient outcomes. We need malpractice reform, but it must do more than simply turn victims away from the courthouse door.

Click on the link above to read the full post. He goes into CBO comparisons of the two parties' proposals, which is worthwhile.

I'll just add that it is important to remember that these proposals have been brought up before, including several times when the Republicans controlled Congress from 2003-2006, and for some strange reason, they never even made it out of committee. Why would that be? My guess is that the Republican Party is just flat-out not serious about reforming the health insurance system.

'B' 2012 Watch: January 2010

2010-01-28T14:55:00.001-05:00

Back in November, I briefly posted thoughts on the 2012 race. This is a quick update of that.

I decided to limit myself to candidates that are at least semi-likely to run. Thus, I will only be considering candidates with at least 3% on intrade. With that said:

Qualifying candidates:

Mitt Romney (24.9)
Sarah Palin (18.0)
Tim Pawlenty (10.0)
John Thune (9.5)
Mike Huckabee (7.8)
Rick Perry (4.0)
Ron Paul (3.6)
Jeb Bush (3.0)

Top 5 Preferred Candidates for GOP Nomination

Again, these are just out of the qualifying candidates. I have also divided support for the top 5 from a pie of one to further explain my preferences.

John Thune (.40)
Mitt Romney (.30)
Tim Pawlenty (.25)
Jeb Bush (.04)
Rick Perry (.01)

I am ditching the "Dist...Vote" thing I did last time. It had no mathematical basis. Instead here is a "Power Rankings" type thing of (B's preference * intrade strength). Max. is 100 if a candidate is virtually guaranteed the nomination and also receives 100% of my support:

Romney (7.47)
Thune (3.8)
Pawlenty (2.5)
Bush (.12)
Perry (.04)

Likelihood of Final Vote

GOP (.82) (+.02)
Dem (.18) (-.02)

Approval of President Obama (1-10/Binary): 3/Nay (no change)

Sane talk on the health care reform bill

2010-01-25T09:35:00.000-05:00

From National Journal's Jonathan Rauch, who says that the Senate bill passes the "Thune test":

"Doing nothing would be better than doing what they are proposing to do," Sen. John Thune, R-S.D., told CNN in December. Regardless of what you think of Thune's answer, he raises the right question about the Democrats' health care reform. Is it better than nothing?

Republicans think that doing nothing this year might yield a GOP House majority in 2011 and a better bill in 2012. Maybe. But after the last attempt crashed in 1994, it was 15 years before Congress was willing to try again. If the current effort fails, the next chance for comprehensive reform might not arrive for years.

In the meantime, piecemeal changes might make matters worse instead of better. Absent broader reforms, legislative scrambles to cut Medicare would mostly shift costs to private payers, and requirements to cover all comers could price private insurance nearly outof existence. A few more years of ad-hockery and Band-Aids might leave the public in the mood for exactly the kind of single-payer socialized medical system that Republicans dread. Doing nothing, in other words, is not a risk-free proposition, even for the John Thunes of the world.

The Democrats' shocking loss this week of the late Edward Kennedy's Senate seat in Massachusetts certainly increases the odds that Republicans will block the bill. Still, even without a filibuster-proof majority, House Democrats could finish the job by swallowing their pride and simply passing the Senate bill. Should they?

I think the answer is yes. The Senate health bill, though flawed, passes the Thune test.

True, it could have been so much better. If, for example, it were bipartisan (but Republicans chose to boycott it). If its "pay-fors" were more solid (but this is the U.S. Congress we are talking about). If it were serious about malpractice reform (but these are Democrats we are talking about).

The expansion of health care coverage to many, though not all, of the uninsured may prove to have found the exact sour spot: enough new beneficiaries to increase demand for health services and so raise system costs, but not enough to deliver the risk-spreading and efficiency-capturing benefits of true universality. Despite mandates, many people will manage to free-ride, and some who don't free-ride will pay more in premiums. There is plenty to worry about here.
So what's to like?

First, the expansion of insurance coverage to tens of millions more Americans and the abolition of the "pre-existing conditions" insurance exclusion are changes for the better. A friend of mine made a full recovery from prostate cancer, only to find that he could not get health insurance at any price. Stories like his are common -- too common to be politically sustainable, let alone morally acceptable.

On paper, Congress might have found better ways of making insurance available to high-risk individuals than by requiring insurers to cover them and by creating government-regulated markets ("exchanges") where these individuals can buy insurance; the alternatives, however, are complicated, lack political support, and in the end might make government even bigger. (Indeed, one striking feature of the reform bill, given its all-Democratic provenance, is the extent to which it leaves the existing infrastructure of private health insurance intact. In a few years, the public might be less willing to do that.)

Second, the bill is probably as close to paying for itself as the political system is likely to manage. It would be great if Congress made up-front reductions in other programs, rather than counting on, for example, Medicare savings that may or may not materialize. But, given the political unacceptability of horror stories like my friend's, the real-world alternative to plausible-maybe-almost-sort-of fiscal neutrality is something more like the Republicans' 2003 Medicare prescription drug bill, which made no attempt at all to pay for itself.

Although long-term budget projections are squishy, the Congressional Budget Office's are the best we have to go on. Notably, CBO scored the Senate bill as deficit-neutral (actually, it would slightly reduce the deficit) over the reform's second decade after enactment, which is well beyond the window of cost-shifting and timing gimmicks. We could do worse, and possibly will do worse next time around.

And what about bending the cost curve? Health care inflation devours wages, burdens employers, and could eventually bankrupt the government. A reform that fails to grapple with the cost problem, the critics say, is not worth having. I agree.

So how does the reform score on cost control? The original House bill does poorly. However, the Senate-passed bill is better on cost control than many people realize. Although far from optimal, it contains a potential pathway to a restructured health payment system that gets incentives right instead of wrong.

I'll return to that weasel word "potential," but first the major elements. Most economists believe that two pervasive market distortions fuel health cost inflation. The first is Medicare's fee-for-service payment system, which pays providers based on the number of procedures they perform, rewarding inefficiency. The second is the tax deductibility of employer-provided health insurance, which subsidizes high-cost policies, hides the costs of those policies from employees, and denies employees the opportunity to shop around.

Both distortions inhibit market discipline, and both originate with bad government policy. If socialized medicine is state payment for most health care, then the country is there already: When the value of the employer tax subsidy is included, the government (federal and state) pays for almost 60 percent of all U.S. health care, according to Paul Van de Water, an analyst with the Center on Budget and Policy Priorities. Dealing with Medicare and the employer tax deduction is therefore crucial to cost control.

Medicare is a tough problem, both because of the politics and because no one really knows how to fix it on a national scale. The reform bill includes programs designed to identify better payment methods, and it establishes a special commission that could, theoretically, help push through worthwhile Medicare reforms. There is no guarantee, obviously, that those schemes would work. But they might well improve the situation, and they are unlikely to do any harm.

As for the employer tax break, the Senate bill docks it. Not a ton. Only high-premium policies covering a minority of workers would be taxed. But even the limited tax is very important, for several reasons.

Crucially, the threshold for taxation would not rise as fast as health inflation. Translation: Gradually more and more employer-provided policies would be taxed. The change would be incremental, even glacial -- but slow seems to be the only pace with which Americans are comfortable.

Moreover, after reform is enacted, the taboo on taxing employer-provided health benefits will be shattered once and for all. From then on the question will be how much to tax, not whether. A door that had been welded shut will have been pried open. The country will be able to have a new kind of discussion, one in which the tying of health insurance to employment -- which is insane, when you think about it -- is no longer sacrosanct.

Meanwhile, the reform also includes a provision quietly inserted by Sen. Ron Wyden, D-Ore., that allows a narrow band of workers to cash out their employer's health insurance tax break and use it to buy a policy of their own choosing. In other words, instead of being captured by the employer, the tax subsidy would flow to the employee.

Again, the provision applies only to a few workers -- at first. However, as rising costs push up premiums, more workers would qualify. No less important, the provision puts in place both a precedent and a mechanism for rewiring the system so that consumers, not employers, can make the choices.
Taken together, these measures could set in motion a virtuous cycle. As health costs rise, more employer-provided health plans become taxable, giving employers an incentive to find cheaper plans. As employer-provided plans grow less generous, more employees have an incentive to take a tax credit and shop around, and, as premiums rise, more qualify to do so. Little by little, insurance coverage shifts toward an individual-based, consumer-driven market. And the faster health insurance costs rise, the faster the transition happens. The disease triggers its own antibodies.

Again, no guarantees. The transition would be very gradual, and political blowback could easily disrupt it. But the point is that the reform contains a pathway to sanity. No one can say that about the status quo.

Is Evan Bayh a spineless, weak, empty shell of a people's representative?

2010-01-21T14:17:00.002-05:00

I'm just asking:

“The only we are able to govern successfully in this country is by liberals and progressives making common cause with independents and moderates,” Bayh said. “Whenever you have just the furthest left elements of the Dem party attempting to impose their will on the rest of the country -- that’s not going to work too well.”

This is pure garbage, and Bayh knows it. In what universe are the furthest left elements of the Dem party imposing their will on anybody? In the real world, liberals and progressives have been making common cause with independents and moderates on health care, which is why "the furthest left elements of the Dem party" are very disappointed in the quite tepid health care bill, the stimulus bill that had to be stripped down by $100-200 billion for no stated reason, the lack of activity on gay rights, the troop buildup in Afghanistan, and the failure to carry through any meaningful reform of the financial industry.

There are whispers of Mike Pence running against Bayh. Obviously, I don't like Mike Pence and, yes, he would appear to make a more terrible senator than Bayh. But after all this, I'm actually not sure just how much more terrible Pence would be than Bayh has been as of late. And at least with Pence, we know what we'll be getting, but with Bayh, who knows?

Voting for Pence is like buying a gallon of rotten milk that is already past its "best by" date: you know it's going to taste awful and be bad for you; voting for Bayh is like buying a gallon of milk with a mis-printed "best by" date: you think it's going to be delicious and nutritious, but it tastes of feet and old cheese, and on the bottom of the jug a printed label tells you that you really shouldn't have wanted non-spoiled milk in the first place because, well, that's just over-reaching.

Caption: Evan Bayh (D-IN), seen here at a town hall forum on how to use ridiculous claims about the fringe elements of one's own political party in order to avoid the responsibility that comes with being a leader, feigns trying to hear the concerns of an uninsured constituent. Bayh used the same gesture when two other constitutents spoke: one was a woman who had been denied coverage because of a pre-existing condition, and the other had been repeatedly denied coverage that was included in his original insurance policy. Bayh did not seem to have any trouble hearing anything that representatives of the health insurance industry had to say, especially those from WellPoint.

Supreme Court fights boldly to keep the voices of corporations and unions from being drowned out by the voices of actual people

2010-01-21T13:18:00.001-05:00

From the NYT:

The Supreme Court threw out a 63-year-old law designed to restrain the influence of big business and unions on elections Thursday, ruling that corporations may spend as freely as they like to support or oppose candidates for president and Congress. The decision could drastically alter who gives and gets hundreds of millions of dollars in this year's crucial midterm elections.

By a 5-4 vote, the court overturned two of its own decisions as well as the decades-old law that said companies and labor unions can be prohibited from using money from their general treasuries to produce and run their own campaign ads. The decision threatens similar limits imposed by 24 states.

It leaves in place a prohibition on direct contributions to candidates from corporations and unions.
Critics of the stricter limits have argued that they amount to an unconstitutional restraint of free speech, and the court majority agreed.

The key change:

The decision's most immediate effect is to permit corporate and union-sponsored political ads to run right up to the moment of an election, and to allow them to call for the election or defeat of a candidate. In presidential elections and in highly contested congressional contests, that could mean a dramatic increase in television advertising competing for time and public attention.

In the long term, corporations, their industry associations and labor unions are free to tap their treasuries to assist candidates, although the spending may not be coordinated with the candidates.

Some might wonder how this is different - worse or better - than the corporate- and union-sponsored PACs that we have right now. Well, those PACs aren't affected at all by this decision. PACs can still give money directly to candidates and support them in other ways (while falling under the regulatory guidelines of the FEC) and they can still promote "issue advocacy" campaigns; however, that money has to come voluntarily from employees, members, and other parties. It can't come directly out of the corporation's or union's treasury. Now, coprorations and unions can draw from their vast reserves to spend as freely as they please to support or oppose specific candidates.

Here are a few quotes from key players:

- ''The censorship we now confront is vast in its reach,'' Justice Anthony Kennedy said in his majority opinion. (Really? Vast?)

- Justice John Paul Stevens said in his dissent, ''The court's ruling threatens to undermine the integrity of elected institutions around the nation.'' (True, and one might add that said "integrity" is already pretty weak.)

- ''It's going to be the Wild Wild West,'' said Ben Ginsberg, a Republican attorney who has represented several GOP presidential campaigns. ''If corporations and unions can give unlimited amounts ... it means that the public debate is significantly changed with a lot more voices and it means that the loudest voices are going to be corporations and unions.'' (This would seem like an obvious problem in a government "of the people.")

- Sen. Mitch McConnell of Kentucky, the Senate Republican leader who filed the first lawsuit challenging the McCain-Feingold law, praised the court for ''restoring the First Amendment rights'' of corporations and unions. ''By previously denying this right, the government was picking winners and losers,'' McConnell said. (Is he saying that up until now, corporations have been losing? If that's the case, I'd hate to see what the world looks like when they're winning.)

- Chief Justice John Roberts, in a separate opinion, said that upholding the limits would have restrained ''the vibrant public discourse that is at the foundation of our democracy.'' (That's right, your honor, you can't spell "vibrate public discourse" without "unlimited corporate influence." Thanks for the reminder.)

Perhaps the most repugnant element of this decision is that there wasn't actually a case before the court that required them to answer this issue. Really, the question was a rather narrow one about whether or not a particularly new type of campaign "message" should fall under FEC regulations. But some justices wanted to go a little further:

Stevens, in a 90-page opinion that dwarfed Kennedy's, complained that the court majority overreached by throwing out earlier Supreme Court decisions that had not been at issue when this case first came to the court.

''Essentially, five justices were unhappy with the limited nature of the case before us, so they changed the case to give themselves an opportunity to change the law,'' Stevens said.
The case began when a conservative group, Citizens United, made a 90-minute movie that was very critical of Hillary Rodham Clinton as she sought the Democratic presidential nomination. Citizens United wanted to air ads for the anti-Clinton movie and distribute it through video-on-demand services on local cable systems during the 2008 Democratic primary campaign.

But federal courts said the movie looked and sounded like a long campaign ad, and therefore should be regulated like one.

The movie was advertised on the Internet, sold on DVD and shown in a few theaters. Campaign regulations do not apply to DVDs, theaters or the Internet.

The court first heard arguments in March, then asked for another round of arguments about whether corporations and unions should be treated differently from individuals when it comes to campaign spending.

I'd be interested to know what some of you lawyers or soon-to-be lawyers think of this.

Go see "Avatar." In IMAX.

2009-12-21T22:11:00.003-05:00

James Cameron's new sci-fi CGI epic was pretty amazing. I've told several people that about 80-85% of the movie is CGI, and it all looks spectacular. From my frame of reference, in terms of the way that Avatar seems to represent something truly new in moviemaking, I would compare it to Jurassic Park. Those dinosaurs - both the robots and the CGI ones - were like nothing I had ever seen before. Older people might compare it to Star Wars, Blade Runner, or 2001: A Space Odyssey.

The "creatures" (for lack of a better word) and the fictional planet of Pandora on which Avatar takes place are remarkable. The plants, animals, and topographic features in Avatar all look other-worldly, and yet, at the same time, they are completely believable. Cameron imagined a fantastical world that was vastly different from ours and then proceeded to make it feel like a world that was somehow also real. Avatar, like all of those other groundbreaking movies, aims high, and it hits its mark. And with Avatar, the mark is really, really high.

See it in theaters.

A 70-minute assault on "Star Wars: The Phantom Menace"

2009-12-21T21:58:00.001-05:00

Some guy named "Mike" put together a 70-minute long, brutalizing video review of the first of the new Star Wars movies.

Part 1 of the takedown:

See the rest here.

Gay Marriage, Equal Protection, and Polygamy

2009-12-09T10:45:00.000-05:00

Last night, I listened to a presentation on the struggle for same-sex marriage and how sweeping change would likely come, if it ever came at all. The presenter explained that first the Defense of Marriage Act (a federal law defining marriage as between a man and a woman and exempting states from the full faith and credit clause in same-sex marriage cases) would need to either be repealed or struck down by the courts. The justification for this would be that the Constitution does not give the federal government the power to regulate marriage and that the exemption from full faith and credit would violate the full faith and credit clause.

The presenter then went on to describe how the Supreme Court could strike down state bans on same-sex marriage by incoprorating the equal protection clause of the 14th Amendment. While I am a proponent of same-sex marriage, I asked the presenter how, if the Court uses equal protection as its justification in forcing states to allow same-sex couples to marry, states could bar polygamous marriages. I generally don't like this line of argument ("if you allow the gays to marry, soon you'll have polygamy and bestiality and on and on") and I don't think this logic would necessarily apply in cases where states are determining who can get married. That is, if states are allowed to restrict marriage, one could argue for explanding it to same-sex couples while, for various reasons, barring multi-partner unions of the same kind. But if the Supreme Court were to say that the "equal protection of the laws" means equal right to marry who you please (so long as they are consenting adults), I struggle to see how polygamous marriages could be exempt.

My professor stepped in at that point to point out what he thought was a key difference. First, he referred to the fact that the "equal protection" justification has usually been applied to groups whose "differentness" is not based on any choice they made (race, gender, disability). He reminded us that one of the key arguments for same-sex marriage opponents has been that they believe homosexuality to be a matter of choice and thus not subject to the same constitutional protections as race, gender, and disability. Presumably, if the Court were to apply equal protection in terms of same-sex marriage, it would first have to find that homosexuality is not a choice. And there, said the professor, would be where the line is drawn between same-sex marriage and polygamous marriages. Same-sex attraction and love would be found to be "natural" and innate, while polygamous attraction and love would be defined as a choice, something unnatural.

That may be so, and the Court, if this were to happen, may fashion the rule in that way. But is it true that polygamous love and attraction is unnatural or even, not beneficial? Evolutionary biologists and psychologists would certainly argue that polyamorous relationships - and especially opposite-sex polyamorous relationships - can carry significant benefits for both men and women. Many would also argue that same-sex polygamous relationships could be beneficial for many individuals . Furthermore, who are the members of the Court to say what constitutes "real" love between a man and a woman, or between a man and two women, or two men and a woman, and so on? In examining polygamous relationships, how would the Court suggest we go about determining whose love is genuine and whose love is just mere physical attraction?

As I said before, I don't actually think this should be used as a justification for banning same-sex marriage. All I'm getting at is that if you use eaual protection to force states to allow it, how do you then turn around and say that those same protections should not apply to partnerships between more than two people?

I'd be interested in hearing what everyone thinks about this.

Hmm

2009-12-03T13:26:00.000-05:00

"Among Americans polled, 44 percent said China was the world's leading economic power compared with 27 percent who named the United States."

Discuss. I disagree strongly. I can only hope that this poll was conducted only in some small southern town and not the entire US.

(Source: http://www.msnbc.msn.com/id/34255911/ns/world_news/)

Why do conservatives and Republicans blame Obama for out-of-control spending?

2009-11-30T17:42:00.000-05:00

At some point, I'll have more to say in answer to that question. For now, though, this chart illustrates why I ask it in the first place:

Cato ("Individual Liberty, Free Markets & Peace") Institute's Daniel Mitchell explains:

...the 2009 fiscal year began on October 1, 2008, and the vast majority of the spending for that year was the result of Bush Administration policies. Yes, Obama did add to the waste with the so-called stimulus, the omnibus appropriation, the CHIP bill, and the cash-for-clunkers nonsense, but as the chart illustrates, these boondoggles only amounted to just a tiny percentage of the FY2009 total — about $140 billion out of a $3.5 trillion budget.

So, why aren't we seeing pictures of George W. Bush in Hitler-stache at these "Tea Party" rallies?

In which Mike Pence lies about the Democratic reform proposal's effect on families' premiums

2009-11-30T15:49:00.008-05:00

Marc Ambinder hi-lites an obvious case of partisan cherry-picking from our very own Representative:

Here's the latest health care reform claim, by Rep. Mike Pence:

"The CBO has confirmed what every American already knows, the Democrats' plan for a government takeover of health care will dramatically raise health care costs on working families. This latest CBO study reveals that the health care bill before the U.S. Senate will raise individual insurance premiums by up to 13 percent. That means every family that refuses the government's one-size-fits-all plan, will be forced to spend an additional $2,100 a year to keep their current health care.

Pence doesn't say, but here's where he gets the figure:

Average premiums per policy in the nongroup market in 2016 would be roughly $5,800 for single policies and $15,200 for family policies under the proposal, compared with roughly $5,500 for single policies and $13,100 for family policies under current law.

Fairly clear, right? Only if you're suddenly blinded.

The very next sentence in the CBO report is: "Those figures indicate what enrollees would pay, on average, not accounting for the new federal subsidies. The majority of nongroup enrollees (about 57 percent) would receive subsidies via the new insurance exchanges, and those subsidies, on average, would cover nearly two-thirds of the total premium, CBO and JCT."'
For those receiving subsidies -- the people who Pence's statement is targeting because they're the most vulnerable -- the CBO says that "...the amount that subsidized enrollees would pay for nongroup coverage would be roughly 56 percent to 59 percent lower, on average, than the nongroup premiums charged under current law."

Just to re-hash: Pence claimed that the CBO said that the Democratic plan would raise premiums by 13 percent. In the real world, the CBO said that the Democratic plan would reduce premium costs by somewhere between 50 and 60 percent.

Opposing liberal policies for legitimate reasons is one thing; lying outright about said policies is another. Is this the best we can do?

Mike Pence is very concerned about rising health insurance costs...so what has he done about it?

2009-11-30T11:51:00.000-05:00

I had the opportunity two weeks ago to attend a panel discussion on health insurance reform. Representative Mike Pence was one of the panelists. His opening comments intrigued me, as they included a number of interesting assertions.

First, Pence said unequivocally that the current system was flawed and not working for consumers. Second, he said that he believed rising health insurance costs constitute a "crisis" and offered an impossible-to-substantiate claim that in 2005 he had urged President Bush to take on health insurance rather than Social Security. Finally, Pence claimed that this was an issue he had been working very hard on ever since he was elected 9 years ago.

All of that was news to me. I went home from the panel and began researching Pence's legislative history on health insurance reform. I found that he had voted to cap medical malpractice damages (2003-2004 session) and had twice introduced bills that would create small business associations that could purchase insurance across state lines (2003-2004 session, and 2005-2006 session). Neither of the small business association bills even made it out of committee, and at both times you had a Republican-controlled Congress (which means that not even the Republicans think these were good bills). Of course, this may be because there are significant problems with this type of "plan" for making health insurance more affordable.

I e-mailed Mr. Pence's office to ask what else he had done to address this crisis and why he thought his own party had failed to do anything meaningful to solve the problem of skyrocketing health care and insurance costs when they were in power. That was about three weeks ago. I am yet to hear back from them, even though they promise a response in "ten business days." I'll let you know when we're finally able to get in touch.

P.S. For those of you who are curious about what your legislator(s) do while they are in Congress, this website can be very helpful.

A military surge provides space for - but no guarantee - of political reconciliation

2009-11-30T10:58:00.003-05:00

From the NYT:

As the Obama administration prepares to unveil a new set of “benchmarks” to measure political progress in Afghanistan — and to prod President Hamid Karzai to improve governance there as he anticipates more troops from America — Iraq’s experience can serve as a cautionary tale.

Much of what has stalled the election law stems from the failure to achieve the same sort of benchmarks, which Congress imposed when President Bush ordered a “surge” of American forces here in 2007 to stanch an incipient civil war.

Adopting legislation to knit the country together; reforming the Constitution; strengthening independent security forces; reconciling Iraq’s Shiites, Sunnis and Kurds — all were benchmarks, and all remain partly or wholly unmet, despite the security gains that were supposed to create the space for political progress and thus peace.

Local post: Muncie Action Plan meetings

2009-11-30T10:52:00.002-05:00

If you're in Muncie and want to be involved in the process, here are the meeting place and times for the Muncie Action Plan community meetings:

December 1st – Ball Memorial Hospital Auditorium, 2401 W. University Avenue – 5:30 PM to 7:30PM
December 2nd – Southside High School Cafeteria, 1601 E. 26th Street – 5:30 PM to 7:30 PM
December 2nd – Muncie Area Career Center President's Room , 2500 N. Elgin Street – 5:30 PM to 7:30 PM
December 3rd – Forest Park Senior Center, 2517 W. 8th Street – 1:00 PM to 3:00 PM
December 3rd – Northside Middle School Cafeteria, 2400 W. Bethel Avenue – 5:30 PM to 7:30 PM

Here's the website.

A thought for the holidays

2009-11-30T10:35:00.000-05:00

I know a number of individuals and families who already do this sort of thing. It's a good idea:

...this holiday season we will spend excessive amounts of money on trivial and momentary entertainment. Instead, we could make contributions to local organizations that make long-term investments in our communities.

Want to do something important? Cut your spending on gifts for the family and give a generous check to your local adult literacy program. Write a check to a conservation group, like the Sycamore Land Trust. Donate to your local public library or school foundation. These groups will keep your money working for years to benefit many, not for just several hours to benefit a few.

Brule's Rules

2009-11-30T10:27:00.002-05:00

Worth your while:

h/t: John C.

Evan Bayh: You have to pay for everything, except wars, which are awesome.

2009-11-30T10:24:00.000-05:00

Glenn Greenwald, who is occasionally prone to hyperbole, lays into Senator Evan Bayh (D-IN) over Bayh's proclamation that he is a deficit hawk, even though he thinks wars should be started without any thought to funding them:

Bayh wants to send other people into every proposed war he can find and keep them there forever ever without ever bearing any of the costs himself -- not in military service for him or his family nor even in higher taxes to pay for his glorious wars. Sacrifice is for everyone other than Evan Bayh and his friends. He runs around praising himself as a "deficit hawk" while recklessly supporting wars and indefinite occupations that the country can't afford and which drive us further into debt. He feigns concern over the "deficit" only when it comes time to deny ordinary Americans benefits which he and his family already possess in abundance.

Much of this comes from Bayh's appearance on Fox News Sunday, which included this exchange with host Chris Wallace:

WALLACE: Senator Bayh, you brought up the question of cost, and the administration has put the cost -- and this is kind of astonishing to, I think, a lot of people -- $1 million per soldier per year, so if you sent 30,000 soldiers, that would be a $30 billion price tag.

Now, some top Democrats are talking about the idea -- the new idea of a war tax to pay for the escalation in Afghanistan. Good idea?

BAYH: No, I don't think it's a good idea, not at this point, Chris. First of all, you need to provide for the nation's security regardless of your financial situation, and there's no bigger deficit hawk in Congress than I am.

I think we need to start coming to grips with this. We're going to have a big vote coming up on the debt ceiling. I don't think we should vote to raise the debt ceiling until we have a strategy in place to get our deficits down.

So we've got to take the fiscal situation seriously, but, number one, national security comes first.

Number two, we've got to look at cutting spending in other parts of the budget before we even talk about raising taxes.

If these wars were not wars of choice (and, in fact, all wars involve some degree of choice about how resources are allocated and utilized), it would be easier to argue that the cost is not something we can worry about at the moment; but seeing as Iraq turned out to be the textbook case of a war of choice and Afghanistan has increasingly looked like one, it's hard to argue that we simply must fight these fights without any concern over the cost in blood and treasure.

On Football Power Rankings

2009-11-25T02:06:00.000-05:00

As a follow-up to C's football-related post, here is a quick complaint about sports journalism:

Every week I kill time by reading NFL "Power Rankings" on various sports websites. I'm sure you are all familiar with what these are.

For the last few weeks, the Colts have squeaked through with wins while the Vikings look dominant. The Colts are 10-0, the Vikings 9-1. Every power ranking I have looked at has the Colts #2 and the Vikings lower.

My complaint is this: the accompanying comment for the Colts is always something like, "That was a subpar performance; they have a lot of problems to fix or else they won't be undefeated much longer."

The accompanying comment for the Vikings is something like, "These guys are unstoppable. Another outstanding all-around performance. Nobody's playing better right now."

THE VIKINGS SHOULD BE RANKED ABOVE THE COLTS IN THESE POWER RANKINGS, IF THAT'S HOW THEY FEEL. THAT IS WHY THEY ARE POWER RANKINGS AND NOT STANDINGS. EVERY SPORTS JOURNALIST SORTS THE TEAMS BY RECORD FIRST FOR 90+% OF THEIR POWER RANKINGS. THIS IS NOT HOW THEY SHOULD WORK. I WOULD LOOK AT THE STANDINGS IF I WANTED TO KNOW WHICH TEAMS HAD GOOD RECORDS.

That's all.

Dallas Clark is a really good football player

2009-11-23T07:45:00.002-05:00

Re: Taxing health insurance benefits to pay for reform

2009-11-17T17:52:00.000-05:00

In comments, B wonders whether or not President Obama will end up supporting a tax on health insurance as part of the Senate health care bill, primarily because Obama lambasted McCain's health care plan during the campaign for including pretty much the same tax. As I've said before, there are significant differences in the overall packages and what they'll do for working- and middle-class families and, as they say, therein lies the rub. From October of 2008, Harvard University's Jeff Liebman on the effect of McCain's plan to tax health insurance:

Here's how the McCain plan works. Every family receives a refundable tax credit of $5000 that can be used only to purchase health insurance. Individuals receive $2500. McCain's advisers say the cost of this tax credit is $3.6 trillion dollars over ten years. They also say that their plan is revenue neutral because they introduce a new tax on employer-based health insurance that the Joint Committee on Taxation scores as raising $3.6 trillion over 10 years.

Currently, employee compensation in the form of employer-provided health insurance is exempt from both the personal income tax and FICA payroll taxes. Most employee payments for employer-based health insurance are also tax preferred. McCain's plan would eliminate these and other health-related tax expenditures.

The fact that the plan is revenue neutral means that the tax savings for families receiving tax cuts are exactly balanced by the tax increases for families whose taxes go up. But because the tax cuts are front loaded, after just a few years most American families will see their tax bills go up under the McCain plan.

What does this mean for a typical family? In 2009 the average premium for a family health insurance policy will cost about $13,600. With McCain's new tax on employer-provided health benefits, families in the 25 percent federal income tax bracket (which starts at taxable income of $65,100) will pay additional income tax of $3400, additional payroll tax of $1040, and will have their earnings cut by $1040 as their employers pass on the increase in the employer portion of the FICA tax. So the total tax on health insurance will be $5480, $480 more than the value of the new health insurance tax credit.

Because the McCain tax credit would be indexed only to inflation while the cost of health insurance has been rising at around 7 percent a year, the net tax increase will rise rapidly over time. By 2012 this typical family would receive a tax credit from the McCain plan of about $5337. But with premiums rising in that year to over $16,600, the new McCain health insurance tax would reach $6699 - for a net tax increase of $1362. By 2016, the tax credit would be $5823, while the new tax would be $8782 - a net tax increase of almost $3000.

Families in lower tax brackets will initially receive a tax cut from the McCain plan, but after a few years, they too will pay higher taxes. And millions of families with better than average health insurance plans or living in states with higher than average health care costs will see their taxes go up under the McCain plan by substantially more than is illustrated in the example above. In effect, the McCain plan punishes families with good health care by raising their taxes the most.

Lady GaGa and Christopher Walken do "Poker Face"

2009-11-17T16:47:00.000-05:00

h/t: The Daily Dish.

KSM in NYC: What do you think?

2009-11-17T09:09:00.000-05:00

Khalid Sheik Mohammed, known as one of (if not the) chief planner of the 9/11 attacks, will be tried in federal court in New York City. The right is incensed. William Kristol published an e-mail from a sister of one of the victims:

Today Attorney General Eric Holder will announce that Khalid Sheikh Mohammed and several of his fellow 9/11 co-conspirators will be brought to New York City and tried in federal court. No doubt the Attorney General will invoke the phrase, "Swift and certain justice." This is a sham. There will be nothing swift and nothing certain about it.

The trial will be a travesty. The prosecutors at the Southern and Eastern Districts fought over these career-making cases like vultures at a kill. But who will be the vulture? In open court, it will be Khalid Shiek Mohammed who will hold forth, mocking his victims, exulting in the suffering of their families, ridiculing the judge, his lawyers and the American justice system, and worst of all, rallying his jihadi brothers to kill more Americans as the men and women of the US military risk their lives in the mountains of Afghanistan and the sands of Iraq. All, just blocks from where 20,000 body parts were dug out of the rubble of the Twin Towers.

Remember KSM's famous opening line when he was grabbed in Rawalpindi? "I'll talk to you guys after I get to New York and see my lawyer." Thanks to the Obama admnistration, it looks like he’ll get his wish. And he’ll do his best—with the help of this top-drawer lawyers and much of the media—to make the real defendants at the trial the CIA interrogators—and the American government.

How will this help achieve what our president claims he wants to achieve--"restoring respect for America"? Is that what he really wants?

I am of the opinion that this particular court setting is most appropriate. After all, New York was far and away the community most affected by these attacks. Also, I'm not particularly worried about what KSM will reveal about the CIA interrogators that has not already come out (we know pretty much all there is to know about how he and others were treated during their detainment). And of course the interrogations did not concern the investigation into whether, in fact, KSM helped with 9/11, but with ongoing security concerns regarding future terrorist attacks. I doubt that the prosecutors will rely very heavily - if at all - on evidence obtained during KSM's detention, primarily because they won't have to.

Anyways, I gotta run. Particularly for any lawyers out there, what do you think of all this?

Cost-control: House vs. Senate

2009-11-17T08:53:00.000-05:00

The House bill has been taking some criticism lately because it expands coverage without doing very much to cut costs. Ezra Klein explains the ways in which the Senate Finance Committee's bill compensates for that weakness:

The Senate Finance Committee's bill, which will be quite close to the merged Senate bill, allows you to tell three credible stories on cost control that the House bill simply doesn't.

The first comes from the excise tax on high-cost health insurance plans. The idea here is simple enough: you're taxing any growth in health-care premiums that's faster than the rate of growth in GDP plus one percentage point, which is going to make people a lot less accepting of premium increases and unchecked growth. This is, in the simplest sense of the term, a cost control. In theory, it controls costs by taxing one of the drivers of cost growth into submission. It is, by far, the policy economists are most united on, and the one that works in the most straightforward and blunt way.

The second comes from the newly formed Medicare Commission, which is a lot stronger than people realize. The idea isn't simply that a panel of experts gets to dream up interesting reforms to try out in Medicare. It's that they are charged with making sure that Medicare hits certain growth targets, and their package of reforms has to achieve that goal. Those reforms are then sent to Congress, where Senate debate is limited to 30 hours, and amendments must be both budget neutral and "germane." This report, in other words, is exempt from the filibuster. So far as anything is ever easy to pass, this is easy to pass. If Congress cannot manage action even within this streamlined process, then it simply cannot cut health-care costs at all, and our federal government will go bankrupt.

The third is the delivery-system reforms. The House bill has these too, though they're a bit weaker. They key alchemy, however, is the interplay of the delivery-system reforms and the MedPAC commission. The Senate builds in a lot of pathways by which an idea that starts in Medicare through the commission and proves successful can be brought to pilot and then brought to scale across the health-care system. Medicare serves as the laboratory, but other institutions created in the bill serve as the factory.

All three of those stories make sense, and any of them, on their own, would represent the most significant effort at cost control in a generation, if not ever.

The 100 Greatest Quotes from the Wire

2009-11-17T07:48:00.000-05:00

For all you fans out there (NSFW - cursing, violence, etc.):

Local post: Teacher licensing and school funding in Indiana

2009-11-16T17:21:00.001-05:00

Indiana State Superintendent of Schools Tony Bennett recently proposed a series of changes to the ways in which teachers are educated (briefly: more subject mastery, less pedagogy) and how licenses will be granted in the state (again, briefly: make it easier to transition into teaching from another career). Many teachers, ed. school folks, teachers-in-training do not like the reforms. The manner in which this all unfolded was not very surprising.

The proposed changes are not as bad as many say they are, but they are also not a solution to the problems with Indiana's - and the country's - public education system. They may attract some people from the professional world with expertise in particular areas into the teaching profession, but this kind of thing is already happening. Nonetheless, these changes may be necessary in order to compensate for the looming teacher shortage that will come as more and more boomer-teachers retire. It might weaken the ed. schools, which may or may not be one of the governor's goals. It might affect teachers' unions, though there is no reason to believe that this new kind of teacher will have any less incentive to join than one who is traditionally-trained. It won't attract a huge swath of talented and motivated people to the profession who otherwise wouldn't teach - only money would do that. As things stand, most teachers in Indiana - even if they are the best-educated, most successful, and most experienced teachers in their districts - will not make half of what the average superintendent makes in a year.

Following the jump, three videos that make up a segment from WFIU on the current funding formula used by the state DOE and on Bennett's proposed changes:

'B' 2012 Watch

2009-11-13T03:20:00.001-05:00

As I began my health care analysis to be posted Sunday, I realized that I should start a new tradition: the 'B' 2012 Watch. I will periodically post opinions of prospective candidates for the 2012 election. Given the radical shift in my views between 2004 and 2008, I figured it might be funny to look back on this when 2012 is actually upon us. Although I am a registered independent, I intend to vote in the Republican primary...

Top 5 Preferred Candidates for GOP Nomination

~~Greg Ballard~~ Condi Rice
John Thune
David Petraeus
Mitt Romney
Mitch Daniels

Distribution of Likelihood of Vote (out of 1)
[Prob. candidate runs * Prob. candidate is preferred|Candidate runs]

Romney (.6)
Thune (.1)
Pawlenty (.1)
Jindal (.1)
Palin, Daniels, Petraeus, Cantor, Rice (.02)

Likelihood of Final Vote:

GOP (.8)
Democrat (.2)

Approval of Obama (1-10/Binary): 3/Nay

Addiction, Drugs, and Guns

2009-11-11T15:14:00.003-05:00

For those of you interested in addiction issues, prohibition, or guns, here's an intriguing (and old) bloggingheads discussion. This Kleiman guy knows his stuff.

The Brookings Institution responds to Rahm

2009-11-11T14:51:00.001-05:00

I earlier linked to this statement from Rahm Emanuel, which was basically taken as a defensive reaction to the concerns of liberal policy wonks who don't "get it":

“Let’s be honest, the goal isn’t to see whether I can pass this through the executive board of the Brookings Institution. I’m passing it through the United States Congress with people who represent constituents.”

William Galston, a Brookings senior fellow, responds:

Dear Rahm,

It may surprise you to learn that many of us here at Brookings like politics as much as you do, and some of us even know something about it. But we don’t understand it exactly the way you do.

Yes, politics is the art of the possible. But leadership is the art of expanding the possible. Leadership without politics is futile. But politics without leadership is blind.

If you define “success” as a bill—any bill—you (and by implication, the man you serve) are telling your former colleagues in Congress that they are free to do whatever suits their short-term political convenience. This all but guarantees that their work product will duck the hard issues. In the case of health care, it means that they won’t embrace real, guaranteed, and substantial long-term cost reductions throughout the entire system, private as well as public, without which universal coverage will quickly become unsustainable.

It’s time for the White House to step in and speak out. That means publicly specifying the essential elements of meaningful health care cost containment. And it means insisting that they are included both in the Senate bill and in the conference report. I think you know what they are. If not, call Peter Orszag.

Sincerely,

William A. Galston, Senior Fellow

The infamous den of useless utopian thinking known as the Brookings Institution

David Leonhardt on what should change in the House health care proposal

2009-11-11T14:09:00.000-05:00

Over at the NYT, David Leonhardt has an interesting column on what could - and should - change in the health insurance reform bill. A few of his ideas:

THE EASY STUFF Each year, about 100,000 people die from preventable infections they contract in a hospital. When 108 hospitals in Michigan instituted a simple process to prevent some of these infections, it nearly eliminated them.

If Medicare reduced payments for the treatment of such infections, it would give hospitals a huge financial incentive to prevent them. The Senate bill takes a small step in this direction by cutting payments to hospitals with high infection rates by 1 percent. The House bill merely requires hospitals to report their rates publicly. There are also other basic patient safety areas in which the bills can do much better.

WHAT WORKS? Earlier this year, I used prostate cancer as an example of how our fee-for-service medical system leads to higher costs and worse outcomes. There are a handful of possible treatments for early-stage prostate cancer, and the fastest-growing are the most expensive. But no one knows which ones work best.

Modern medicine is full of such uncertainty. Again, the federal government could make a big difference here by giving Medicare a moderate amount of money for research, which would pay for itself many times over. The stimulus bill began paying for such research, but the health reform bills fail to pick up where the stimulus leaves off.

A FED FOR HEALTH Twice a year, an outside advisory board sends Congress a list of suggestions for Medicare payment rates, based on the available evidence. Congress generally ignores them, in deference to the various industry groups that oppose any cuts to their payments.

We already have a wonderful model for how to avoid such interference. It’s called the Federal Reserve. The Fed is charged with setting interest rates based on economic conditions, not politics. The Senate bill would create such a commission for Medicare. Unfortunately, it initially applies to doctors and home health care providers but not hospitals, thanks to a deal between the hospitals and the White House. It expands to include everyone in 2019. The House bill has no such commission.

Whether one ends up in the final bill will be a good test of Mr. Obama’s endgame leadership.

THE MCALLEN PROBLEM Both bills would create some promising voluntary programs meant to reward doctors and hospitals that provide good care rather than more care. But the doctors and hospitals providing the most expensive, wasteful care — like those in McAllen, Tex., described by Dr. Atul Gawande in a recent New Yorker article — surely will not sign up for these programs.

And the language in the current bills suggests that Medicare officials cannot make the programs mandatory without new legislation from Congress, which is an invitation for lobbying from places like McAllen. Giving Medicare the authority to expand even a single successful program would be a big improvement.

CHOICE Last week, the Democratic leaders in Congress sent out another e-mail message bragging that for people who didn’t like their insurance, health reform would provide “affordable choices for you that can’t be taken away.” That isn’t true. The bills would do nothing to expand the choices of people with employer-provided insurance.

Senator Ron Wyden, an Oregon Democrat, has been obsessively trying to change this — to give even a small slice of people with the most expensive employer plans a chance to buy insurance on the exchange for small businesses and the uninsured. It’s not yet clear if he will succeed.

THE CADILLAC TAX Along with the Medicare commission, this tax is the biggest single difference between the Senate and House versions. Right now, health insurance — unlike income — is not taxed, effectively creating a subsidy for the costliest plans and health care providers. Labor leaders have helped persuade the House to keep the tax exclusion intact, largely because many of the most generous insurance plans are heldby older unionized workers, who, in turn, have a lot of influence in their unions.

But the tax exclusion is terribly costly for the rest of us. If it were to disappear, employers would have an incentive to sign up for well-run insurance plans, leaving more money available for workers’ salaries. If the Senate’s tax on so-called Cadillac plans were enacted, the average household would be making an additional $1,000 every year (in today’s dollars) by 2019, according to an analysis of Congressional estimates by Mr. Gruber. In my house, $1,000 a year counts as real money.

The GOP Alternative

2009-11-11T14:06:00.000-05:00

A week and a half ago, House Republicans finally unveiled their proposal for reforming the health insurance industry. According to the GOP website, there are four basic principles at the heart of their proposal:

* Number one: let families and businesses buy health insurance across state lines.
* Number two: allow individuals, small businesses, and trade associations to pool together and acquire health insurance at lower prices, the same way large corporations and labor unions do.
* Number three: give states the tools to create their own innovative reforms that lower health care costs.
* Number four: end junk lawsuits that contribute to higher health care costs by increasing the number of tests and procedures that physicians sometimes order not because they think it's good medicine, but because they are afraid of being sued.

I'm no expert, so I'm interested to hear what people know about these proposals - good and bad. Here's my understanding of some of the potential drawbacks at play here.

Number(s) one and two (portability): The problem is that different states have different regulatory systems for insurers, some much more lax than others. Let's say that Montana has the weakest laws for insurance companies. In a national system, insurance companies would have an incentive to locate and sell their insurance packages out of Montana. In so doing, they would evade the stricter consumer protections that many state legislatures have enacted for their citizens, and over time, consumers would have fewer and fewer protections as more and more insurers work out of Montana. Thus, a Hoosier purchasing insurance might have more choices to pick from, but at a significant cost to her rights as a policy holder. More expensive plans would likely have more protections, but those would not be available to most middle-, working-, and lower-class consumers.

Number three (state innovation): This sounds great, but from my reading of the commentary - and also from Mike Pence's statements at last night's health care panel, this seems to simply be a plan to enlarge and give additional funding to state high-risk pools. These pools tend to have higher premiums, less generous benefits, and they also (usually) adjust premiums based on age.

Number four (tort reform): Most states have already done this by placing caps on damages that can be recovered for medical malpractice. It has not brought down the cost of care or the cost of insurance. This discussion at the NYT health care blog was interesting.

Again, these are my very basic understandings of some of the potential problems with the GOP alternative. I welcome corrections and clarifications on this stuff.

Lifestyle choices and health care costs

2009-11-11T13:36:00.000-05:00

I agree with B's concern about government getting too involved in our private lives, especially regarding what we eat and drink, and I think we should be careful to draw intelligent notches in that slope. That said, I think the lifestyle and cost comparison presented is too unrealistic to be helpful in thinking about this (I understand B. was using hyperbole on purpose here). The problem, really, is that most of the obese and otherwise unhealthy people in this country don't die at 40; rather, the many wonderful medicines, surgeries, and treatments that we have available to us are able to keep people like this alive, many well into their 60s, 70s, and 80s. This places an enormous burden on our health care system, and especially on Medicare. Perhaps the solution should focus less on punishing individuals and more on incentivizing institutions - rewarding doctors and hospitals, maybe even employers for better health outcomes (target weights/BMIs, etc.).

My Dear Friend C.

2009-11-11T13:20:00.000-05:00

Kudos to my friend C. for his recent post on health care. A few comments:

none of the reform efforts have done anything to address how the personal choices people make - in their diet, exercise, and lifestyle habits - affect the cost of health care and health insurance.

This is extremely difficult ground for the government to tread on, and I fear that most "solutions" to this problem would represent far too great an intrusion of government into our private lives. Tax on soda and candy is one thing...but it's not too hard to imagine where the slippery slope leads.

Moreover, let's look at two people:

Person A sits around watching TV all day. He eats Domino's Dots and drinks giant screwdrivers. He stays out drinking til 3 a.m., even when he has work the next day. He weighs roughly 400 pounds. He drops dead of a heart attack at age 40 while playing tennis for the first time in 17 years.

Person B is the picture of health. He lives to be 90. Along the way he has various health problems associated with growing older, but thanks to modern modical innovations is able to beat them. He passes away peacefully with his wife by his side.

While Person A will live an uncomfortable life, his medical costs will be nothing compared to Person B's chemotherapy or whatever. We are living longer thanks to medical innovation, but many of these treatments are extremely expensive.

The point is that "rising health care costs" are not solely linked to unhealthy behaviors like being fat and not exercising. I believe this has to be taken into consideration when crafting policy to correct unhealthy lifestyles - if dictating lifestyle choices is an acceptable role of government in the first place.

First and foremost, there will be tangible benefits to a reformed system that will outweigh the corresponding costs

I would interject here that the Democratic cost estimates will almost surely be lower than the actual costs. The CBO and others have commented on how many of their assumptions do not hold up to political reality.

I wouldn't call it a "right," but I would say that it is in our national interest to pursue such a goal. B and his conservative allies might disagree, or say that it is pie-in-the-sky idealism to believe that our nation is even capable of achieving anything near universal, quality coverage.

Conservatives have offered a number of ideas for how to expand coverage (e.g. portability of coverage). I think conservatives are more inclined to say that if the costs associated with expanding care are too high, universal coverage becomes neither attainable (due to limited resources) nor desirable.

---

In sum, I believe C. and I have the following disagreements on the House health care bill:

Since expanding coverage is C.'s primary interest, he is willing to accept a flawed bill in order to get momentum in the direction of universal health care. I value expanding coverage, but not as much as C.
Since I disagree with quite a few provisions of the House bill, I fear the same momentum C. craves for fear of a "runaway freight train" of government control/intervention and a ruinously expensive new entitlement.
C. appears ready to accept the Stupak amendment, whereas if I were a pro-choice liberal, I would not find the House bill worth the cost in terms of reproductive rights.

I'm sure there are quite a few more, but the soda machine broke and I have to type a sign. I welcome further discussion on this issue.

B.

Flawed reform vs. No reform (Block Quotes Edition)

2009-11-11T11:38:00.002-05:00

To start, Rahm Emanuel stated quite clearly why, whenever one sets out to change a system, the reforms will not be perfect:

“Let’s be honest, the goal isn’t to see whether I can pass this through the executive board of the Brookings Institution. I’m passing it through the United States Congress with people who represent constituents.”

He went on: “I’m sure there are a lot of people sitting in the shade at the Aspen Institute — my brother being one of them — who will tell you what the ideal plan is. Great, fascinating. You have the art of the possible measured against the ideal.”

The bill we get is not going to be perfect. In fact, it will be far from perfect. The key issue, it seems, is whether doing something imperfectly is preferable to doing nothing. On this point, the essential question is, Will the situation worsen, improve, or stay the same if flawed reforms are enacted?

Harvard Medical School's Marcia Angell has argued that the bill is not better than nothing, emphasizing that health care costs will continue to rise and insurance coverage will not improve for many Americans:

It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we've tried health reform and it didn't work. But the real problem will be that we didn't really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

John Cohn, writing at for The New Republic, takes issue with Angell and other liberals and progressives who are dissatisfied with the present reforms, arguing that, in fact, a number of good things will come from this bill:

According to the Congressional Budget Office, the House bill would mean about 36 million people get health insurance, reducing the number of uninsured by around two-thirds. People who had pre-existing medical conditions would, finally, have the ability to get insurance just like the employees of large companies do. The insurance would not always be as generous as it should be, but the government would prohibit lifetime caps, place some limits on out-of-pocket spending, and establish a basic benefits package that makes sure all policies cover a broad range of services.

The studies--which, I know, Angell has seen--suggests tens of thousands of people* die or go bankrupt every year because they can't afford to pay their medical bills. Countless more suffer. The House bill wouldn't stop such hardship altogether. But it would reduce it significantly--arguably, by as much as any single piece of domestic legislation since the Great Society. Surely that qualifies as something more than "a few improvements around the edges."

The House bill would do many other things, too, familiar to the readers of this space--from the creation of a public plan to the creation of pilot programs that would begin to change the way we deliver medical care. And while it wouldn't do nearly enough to make health care less expensive--the drug industry, among others, remains a source of untapped savings--the House bill certainly wouldn't cause the cost of medicine to go up even more quickly. If anything, it'll cause the cost to go up a bit more slowly.

Besides, says Cohn, reform can be revisited and adjusted down the road:

As I've argued repeatedly, the House bill is not close to perfect. Neither is its Senate counterpart. But we don't pass perfect laws in the U.S. We pass imperfect ones and then do our very best to improve them over time.

It happened that way with Social Security and Medicare. It can happen that way with comprehensive health care reform, too. But only if we do something, rather than nothing.

Ezra Klein piles on with more historical perspective:

As any scientist will tell you, it's much easier to encourage something to evolve in a certain direction than it is to create it anew. The idea that a high-profile failure in a moment where a liberal Democrat occupies the White House and Democrats hold 60 seats in the Senate for the first time since the 1970s will encourage a more ambitious success later does not track with the history of this issue, nor with the political incentives that future actors are likely to face. If even Obama's modest effort proves too ambitious for the political system, the result is likely to be a retreat towards even more modest efforts in the future, as has happened in the past.

I'm with Cohn and Klein on this one.

Sure, the present House bill is flawed. One of the most significant problems that goes largely unadressed here is the fee-for-service system that we presently have, which creates perverse incentives for doctors to "over-treat" their patients. The public option will offer insurance to people who might otherwise be unable to find a reasonable plan, but this option could potentially turn into a dumping ground for applicants who would make poor clients for private insurers. Another concern I have (and one I am not altogether clear on) is the fine structure for non-compliance with any mandate provisions; very low fines could incentivize employers and individuals to pay the fine and cut insurance, and very high fines might allow insurers to jack up their prices. I'm not sure how one goes about determining the optimal fine to produce the desired behavior on the part of individuals, employers, and insurers. Finally, none of the reform efforts have done anything to address how the personal choices people make - in their diet, exercise, and lifestyle habits - affect the cost of health care and health insurance. The system we have at present fails to address this issue. Greater transparency in terms of the cost of care might help here, but I don't know that much the issue to come down firmly in favor of specific solutions.

That said, I still think it is better to pass a flawed bill than to do nothing at all. First and foremost, there will be tangible benefits to a reformed system that will outweigh the corresponding costs, some of which Cohn outlined. Also, B's suspicion that "Democrats want to pass a bill simply to say they have 'passed health care reform'" is not without some justification, for Democrats may benefit from being a party that "gets things done" (of course, they may also suffer from some backlash for being "big-government liberals"); however, this does not mean that this is the primary or sole reason for acting on this issue. Many liberals and progressives believe that this is a human rights issue, and that as a nation we have a moral obligation to make sure that everyone has access to quality health care.

I wouldn't call it a "right," but I would say that it is in our national interest to pursue such a goal. B and his conservative allies might disagree, or say that it is pie-in-the-sky idealism to believe that our nation is even capable of achieving anything near universal, quality coverage. Indeed, there is a certain element of fatalism and determinism to the conservative philosophy, just as there is more than a shred of idealism and, at times, naivete, in progressive liberalism. I'm no utopian, but I think there are reasonable things we can do to achieve more universal coverage and lower costs. In the real world of political maneuvering and congressional logrolling, people like me will take what we can get on this issue. This bill is not perfect, it's a start.

Veterans Day

2009-11-11T09:09:00.002-05:00

To all those who have served, thank you.

Response to L

2009-11-11T02:20:00.000-05:00

A quick challenge to my dear friend L's recent post:

I will admit that there are flaws, as every single piece of legislation passed in American history has had. I think Democrats understand this point: “Our plan is not perfect, but it is a good start toward providing affordable health care to all Americans,” said Representative Peter A. DeFazio of Oregon in the NYT article.

What do you believe are the biggest flaws of this legislation? Everyone agrees there are flaws, but the solutions would pull the legislation in different directions. I am curious to hear exactly what L and C consider the biggest flaws of the House bill to be.

Consider the recent "Stupak amendment." This would go a long way towards denying coverage for abortions to those who need it most. Is the flawed bill worth such a drastic step back on reproductive rights?

I am suspicious that Democrats want to pass a bill simply to say they have "passed health care reform." Much like I am suspicious Republicans want the bill to fail because it would be a blow to the President.

For the longer Obama waited, the more criticism he would endure from those who elected him partially (primarily, for many) to deliver on this promise.

I strongly disagree that health care was a primary reason Obama was elected. I googled a CNN exit poll, and only 9% listed health care as the most important issue. The economy was at 62%.

Even if we accept that the economy and health care are inextricably linked, the House bill does not address the overlapping parts. As far as I know, it does not even purport to lower costs (bills with a public option at least claim to do so) or create new jobs. It simply creates a new entitlement by taxing the rich.

Looking for debate in all the wrong places

2009-11-09T10:57:00.000-05:00

Ezra Klein makes a point that is often forgotten:

The reality is that the debate that led to this bill did not really take place across congressional committees and floor speeches. It took place in think tanks and campaigns. In policy forums and among experts. The basic shape of the House's bill is virtually identical to the bills we saw during the campaign, and they were all expressions of the ideas being developed and refined in think tanks and policy shops and advocacy groups ever since Clinton's effort failed.

When people complain about Congress "rushing" health insurance reform, or refusing to "debate" it in substantive ways, they fail to acknowledge that there are many academics, economists, policy wonks, and government staffers who have spent huge chunks of their lives working on - and debating - this issue. The problems have been indentified. Solutions have been modeled. This bill will bring significant changes to the health insurance system in this country. It will affect who wins and who loses. But a grand, mysterious, and wild experiment it is not.

Health Care Reform Bill Passes House

2009-11-08T15:29:00.004-05:00

America is now one very big, very important step closer to realizing its greatness.

This New York Times article does a nice job exploring the jubilation of the Democrats and the absolute terror of the Republicans, who are understandably frightened that rich people will have to shoulder some higher taxes so that poor people -- although health care costs are daunting for the middle-class as well -- can get medical coverage in the world's richest nation.

Of course, objections to the legislation are much more numerous than this, and generally cloaked in more nuance: it's bad for the economy; it will destroy America's medical ingenuity; our quality of care will diminish; and it's just too damn expensive.

My closest Republican friend, an able and witty contributor to this blog, has warned that this "bill is a disaster" and opined that there are "better ways to do" health care reform. He is convinced that the "particulars" of the bill will prove very harmful to and costly for America. I think he's wrong.

I will admit that there are flaws, as every single piece of legislation passed in American history has had. I think Democrats understand this point: “Our plan is not perfect, but it is a good start toward providing affordable health care to all Americans,” said Representative Peter A. DeFazio of Oregon in the NYT article.

But my good friend surely understands that political capital is not inexhaustible and certainly not interminable. Those who call for delaying passage of this bill and demand more and more changes often seem to be less interested in creating a more perfect piece of legislation than in stopping its passage altogether. For the longer Obama waited, the more criticism he would endure from those who elected him partially (primarily, for many) to deliver on this promise. He has been chided unfairly for months about his inability to follow through on campaign promises, and the more unpopular his performance in office becomes, the more probable it is for a few allies here and there to cast their lot elsewhere.

Waiting one more month to vote on this could have been a disaster to Democratic efforts. It passed the House just barely, and the opposite may have been true one month later. Further changes to the bill would have likely accomplished the following:

1. Upset its current supporters.
2. Somewhat assuaged its opponents, though probably not enough to convince them to vote otherwise.
3. The changes would have been so substantial as to render the bill a hollow piece of legislation that does not bring the needed reform. The winner: no one.

Oh, and one last thing: Kudos to Representative Anh “Joseph” Cao of Louisiana, the lone Republican to vote in favor of the legislation.

Now, onto the Senate...

Lieberman Discussion continued

2009-11-04T13:10:00.000-05:00

My dear friend C. recently wrote:

2) If Lieberman is just a half-smart legislator, he will realize that the opportunity to pass major health insurance reform comes along rarely. So, "coming back to the public option 3-4 years from now," will be difficult if not impossible. If he helps the Republicans filibuster the bill, who knows when the next opportunity to do something about this issue will present itself.

I tend to disagree - not about the public option, but about the "opportunity to do something about" major health insurance reform. I think a qualification is needed: this may be the last opportunity for Democrats to pass a bill that needs not include the Republicans in any way. Republicans are more than willing to work towards a better health care/insurance system. For now the Democrats are not interested in working with them, but bipartisan reform will always be an option in the future.

A little perspective...

2009-11-02T10:42:00.001-05:00

h/t: Susan G.

Explaining liberal "apoplexy" over Lieberman

2009-11-02T10:19:00.000-05:00

A couple of days ago Joe Lieberman said that he would join a filibuster to oppose any bill containing a public option. As any reasonable observer might expect, liberals were upset by this development, as Lieberman's "bold stand" could scuttle the entire effort at health-insurance reform. Lieberman, though an independent, caucuses with the Democrats and has generally been reliable as the Democrats' 60th vote in the Senate on domestic matters, which is important because 60 votes are required to break a filibuster. By putting his vote in play on this issue, Lieberman is basically holding the bill hostage to his own personal desires and concerns.

Some have championed Lieberman's independence on this as a sign of his personal fortitude and integrity, a commitment to principles of some kind - even though these principles are unstated and unknown. Lieberman said yesterday that he doesn't think that the a "government-run health insurance plan that puts the taxpayer on the line" is not something he can support "at this point in our nation's history." Does he have a problem with any government insurance plan? Just with plans that "put the taxpayer on the line"? On the line - through subsidies of any kind, higher taxes, or premiums? If his concern is not with those issues, is it just not the right "time in our nation's history?" One is only left to wonder.

Liberals are fired up about this for several key reasons:

1) Lieberman has frequently stated his support for large-scale health insurance reform.

2) If Lieberman is just a half-smart legislator, he will realize that the opportunity to pass major health insurance reform comes along rarely. So, "coming back to the public option 3-4 years from now," will be difficult if not impossible. If he helps the Republicans filibuster the bill, who knows when the next opportunity to do something about this issue will present itself.

3) Lieberman is just wrong about a lot of the elements of the public option.

4) Lieberman used to oppose the filibuster, in principle.

5) Lieberman, like some other public officials, seems to be doing the bidding of the private insurance industry.

6) Even though he lost the Democratic primary in 2006, Lieberman caucuses with the Democratic party and was allowed to keep his chairmanship of the Homeland Security committee. Some expected Lieberman to repay graciousness with graciousness, and the filibuster threat is not very gracious.

If you prefer video, the following segment from Rachel Maddow hits on a lot of these points.

Visit msnbc.com for Breaking News, World News, and News about the Economy

Bayh semi-redeems himself

2009-10-30T17:20:00.002-04:00

Semi.

A Senate insider has been pushing the first five minutes of this segment from last night's "Rachel Maddow" show:

Visit msnbc.com for Breaking News, World News, and News about the Economy

On Afghanistan

2009-10-28T21:41:00.003-04:00

It's hard for me to say clearly and with great specificity just what we should do in Afghanistan. It is much easier to just put out there some of the things I've been reading, seeing, and hearing that are affecting my thinking. Here are some key items.

- A PBS Frontline documentary, called "Obama's War," that paints what seems to be an accurate picture of the situation in Afghanistan and Pakistan, and the options that the President is considering.

- An article from Peter Bergen - who as far as I can tell, has been and is one of the most knowledgeable commentators on Islamic fundamentalist terrorism and the ongoing war - which argues for increasing the American troop presence in Afghanistan, especially in the more remote tribal regions.

- A letter of resignation from a state department official who wrote, "I fail to see the value or worth in continued U.S. casualties or expenditures of resources in support of the Afghan government in what is, truly, a 35-year old civil war." This part especially gives me pause: "...I have observed that the bulk of the insurgency fights not for the white banner of the Taliban, but rather against the presence of foreign soldiers and taxes imposed by an unrepresentative government in Kabul."

- A Fareed Zakaria interview of foreign policy expert Thomas Ricks, in which Ricks seems to argue in favor of counter-insurgency in the Afghan cities (Kabul and Kandahar, for example) and counter-terrorism (lighter troop presence focused on tactical strikes on terrorist targets) in the country-side. You can watch it below (the interview with Ricks ends around the 10-minute mark):

- Another bloggingheads episode in which Bob Wright airs some of his concerns about Afghanistan with Mickey Kaus, who is more eager to try some kind of Afghanistan surge and see how it works.

As I said before, it's hard for me to say exactly what I think we should do in Afghanistan. I find the Ricks approach, which has been termed the "Biden in the country, Petraeus in the city" strategy, to be on the surface more promising than Bergen's idea of surging into the remote tribal areas. As I've said before, I just think that kind of effort would require a commitment of huge amounts of troops and resources, as well as a slimmer chance of success. The Ricks strategy, in the long term, should result in a strengthening of the Afghan government in the most heavily-populated areas, with an ongoing effort to destabilize and disrupt terrorist activities in the countryside (which could be carried out by the American military until the Afghan military is better prepared to take on the task). This strategy seems to accomplish the major goals of a) significantly limiting the capabilities of terrorist organizations like al Qaeda, b) securing a democratically-elected central government with limited support and power in the countryside, and c) showing Pakistan that we are seriously committed to a stable Afghan state that will act as a partner in their war against radical militants. It's not a perfect solution and it would not result in a "Mission Accomplished" banner, but it might be the best choice we have to pick from.

Senator Bayh (and his wife), the Insurance Industry, and Reform

2009-10-28T18:17:00.002-04:00

Sen. Evan Bayh (D-IN) is one of the "conservative" Dems that has been - at best - luke-warm on health insurance reform. Here's why Bayh's reticence on these issues seems a little suspect:

When he was governor, Bayh's wife, Susan, was a lawyer for Lilly. After it became clear he was going to be a senator, she started stacking up memberships on the boards of health-care corporations.

Susan Bayh got paid a little over $2 million for her service between 2006 and 2008. Her husband had a good 2008 also, collecting more than $500,000 in campaign donations from the health-care industry.

There are scores of relatives of well-placed national lawmakers who are well-placed in enterprises seeking favors. To a man and woman, they would scoff at the notion of being influenced by anything but the burning desire to serve the commonweal.

Let's go on. Susan Bayh's largest reward for her impartial board deliberations came from WellPoint, another Indianapolis-based company that happens to be the nation's largest for-profit health insurer. WellPoint paid Director Bayh nearly $1 million over two years to exert no influence over Sen. Bayh.

WellPoint, of course, proudly notes that it was among industry folks "at the table" with President Barack Obama early on in the health-care "reform" process.

Lieberman's Stand

2009-10-28T12:20:00.000-04:00

Hi everyone, "B" here. I thought we could get the conversation started by continuing our e-mail debate over Joe Lieberman's threat to help filibuster any health care bill with a public option. I heartily applauded this move, while my more liberal friends seem downright apoplectic about it.

I'll start by posing three sets of questions. Feel free to respond to all, some, or none:

What is the overall goal of health care reform? Is it just some combination of (lowering overall health care expenditures; lower premiums for working class families; decreasing the number of uninsured; correcting perceived unfairness in the insurance industry)? Do you think any one of these is more important than the others?
Why did President Obama not fight harder for the public option?
To what extent is the relationship between Sen. Evan Bayh (D-IN) and the health care industry affecting Bayh's positions on health care reform?

I will post my thoughts on these within a reasonable time frame; I look forward to hearing from you all as well.

B

Bob Wright and Robert Kagan on Afghanistan

2009-10-28T12:15:00.003-04:00

You may not be familiar with bloggingheads.tv, but if you are one (like I am) who enjoys listening to intelligent people debate and discuss important issues, you might want to check it out. In this webisode, bloggingheads' Bob Wright discusses the conflict in Afghanistan with surge proponent and military analyst Robert Kagan. It's worth a few minutes of your time.

The rest of the video can be seen here.