Wednesday, July 08, 2009 - Posts
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As a health care non-maven, I have four problems with the New Republic's strangely ungalvanizing description of a world without a "public option":
1) Jacob Hacker and Rahul Rajkumar suggest that, without a public option, a "59-year-old self-employed man with diabetes, or a 48-year-old single mother with breast cancer" won't be able to find private insurance "they can afford." But under the Dem reform plan, even without a public option, wouldn't "[i]nsurance companies ...be required to offer the same coverage to everyone, regardless of medical history"? If so, why won't these 59-year-olds with diabetes be able to find plans they can afford as much as 59-year-olds without diabetes? Is it because private insurers will resort to subtle tricks--e.g. offering free workout rooms, or long steep stairways--to attract only the healthiest customers? Which brings us to ...
2) The existence of a public plan--sustained "completely through enrollee premiums and federal premium assistance"-- is supposed to "keep the private insurers honest" and "control costs." OK. Suppose the public plan uses its purchasing power and lower administrative expenses to cut its prices to 20% below the leading private plans. What will the private plan do? Will it match the public plan by cutting costs--or pursue even more vigorously subterranean strategies to cherrypick the healthiest customers with perks? Or a combination of both? Clearly, faced with pressure on profits, it can respond with "good" behavior or "bad" behavior. But if we could rely on private insurers to have only "good" responses, we wouldn't need health care reform, right?
3) What of the 59-year-olds with diabetes? Well, they always have the non-cherrypicking public plan! Which they will presumably choose, raising the public plan's costs. So there are two forces at work on the public plan's pricing.
One lowers costs, perhaps--an ability to forego administrative and marketing expenses and an impulse to use purchasing leverage to bid down payments to doctors and hospitals.
One raises costs--the tendency of public plans to attract the sickest patients.
Which of these forces will be greater? I don't know. But Hacker and Rajkumar don't tell me. It's not inconceivable that the public plan will confront a vicious circle of adverse selection, in which it attracts sick patients, driving up costs and premiums, which causes healthy patients to flee, requiring even more premium hikes, etc.--right? Remember that according to Hacker & Rajkumar the public plans will operate on a level playing field with no special subsidies from the government. If they have higher costs how are they going to avoid charging higher prices? And then how are they going to keep the private plans "honest"?
4) TNR's whole disaster scenario--what will happen if there's no public plan to provide competition--seems beside the point. If the disaster starts to happen, we can always set up the public plans later, no?
What am I missing? ... P.S.: I'm still for a "public" alternative, just so everyone has the security of knowing there's at least one insurer they can go to who won't try to game them out of coverage in the fine print of a 25 page agreement. I just don't understand how the economics is supposed to work. ... 9:00 P.M.
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Has Steve Rattner gone native? ... 11:59 P.M.
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If you unimmerse yourself in the Ricci commentary, including Richard Thompson Ford's smug, reified** apocalypticism, and just look at John Rosenberg's solution for the vise-like conflict between preventing reverse discrimination and stopping non-reverse discrimination in cases of "disparate" racial impact ... well, what's wrong with it?
[T]he solution to this dilemma is conceptually (if not politically) easy: demote disparate impact to its proper role, which is suggestive evidence of the possibility of disparate treatment, a possibility that can be successfully refuted by an employer's production of credible evidence that the challenged test, policy, or procedure bears a reasonable relationship to the organization's activities. (Of course, credible evidence that an employer adopted even such a reasonable test for a discriminatory purpose would also be barred as disparate treatment.) [E.A]
Would that be so terrible? We couldn't live with that? We'd be racist if we did? Note that there would still be race discrimination suits, presumably plenty of them. They would just be easier to defend against. ... P.S.: Ford worries about an explosion "disparate impact" of lawsuits from disgruntled whites--but this rule would make those suits less easy to win too, along with suits by disgruntled blacks (and other minorities). Everyone would have to calm down! ... P.P.S.: Rosenberg notes that his solution is similar to one adopted by the EEOC in 1989, but then overruled by Congress (and the first President Bush). ...
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**--Why "reified"? Because it falsely treats the circumstances that gave rise to "disparate impact" law as more or less permanent. In reality, the arc in which race preferences are initially regarded as a necessary remedy and then gradually regarded as toxic and stigmatizing and finally as unconstitutional seems like a natural one. ... Reification #2: In predicting a hellacious gridlock of discrimination litigation from whites and blacks, Ford also seems to assume that Congress can't or won't relax the "disparate impact" test along the lines suggested by Rosenberg and the 1989 EEOC case. ... 5:38 P.M.
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No saintlier man has ever walked the earth than the brilliant and beloved David Bradley.** That goes without saying. But how, exactly, would it help solve the ethical problems created by his corporate sponsored "salons" to put them on the record--as TPM's Zacary Roth, Slate's Jack Shafer and Bradley himself seem to believe?
The problem with Bradley's salons, like the problems with WaPo's similar, now-cancelled events, is that they create two big conflicts: 1) The need to avoid pissing off the corporations who fund (and then some***) the salons in the hope of getting access to influential journalists and administration bigshots; and, even more corrupting, 2) the need to suck up to the administration bigshots to get them to show up at the salons where they can be accessed by corporations who are paying for them. ...
Shafer argues that making the "salons" off the record is a key part of Bradley's marketing strategy--it convinces the corporations that they are getting something special.**** Shafer's no doubt right. And generally, "on the record" is good (though "off the record" can be valuable too). Putting the salons on record would also help solve the Atlantic's seemingly congenital "We're Insiders, Aren't We Great, Look at Us" problem. But I don't see how it would do anything to remove conflicts 1) or 2). ... Plus, even if the meetings themselves are on the record, there would still be plenty of time for off-the-record lobbyist-to-player contacts in the halls or at any pre- or post-event cocktails. (Even if there isn't, just encountering someone face to face can make it easier to "access" them later.)....
P.S.: Marc Ambinder's post quoting Bradley's response without daring to link to what Bradley is responding to is a little creepy. Who is this guy, L. Ron Hubbard? What is Ambinder scared of? At least he gets beaten up in his comments.
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**--He's also the Last Sucker "ridiculously generous" in his willingness to pay big bucks for opinion journalists, but that in no way influences my opinion of him.
***--Bradley says openly that the salons are "one of our revenue streams."
****--I suspect that the privately funded, non-profitmaking salons Bradley also gives might be another part of the overall effort: If you are a policymaker and you show up at one of his profit-making confabs do you then you get invited to the more exclusive and legit private confab? If your corporation funds one of the profit-making salons do you find yourself invited to the more intimate event? But I am being entirely too suspicious. Bradley is just a wonderful, wonderful man. I am the one who should be concerned--for thinking such bad thoughts. My apologies. ... 4:09 P.M.
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