-
sponsorship
The Virtuous Social Egalitarian Circle: Whether or not it's accurate, Scott Gottlieb's op-ed on whether you'll be able to buy your way out of Obamacare (answer: only if you're willing to pay 100% cash for treatment) made me feel better about our impending health regime. Why? 1) Gottlieb argues that the upper middle class will be stuck in the system. Assume he's right. The upper middle class has a lot of political power. It will not allow itself to be screwed by cost-saving federal bureaucrats! (Exhibit A: Mammmograms!) 2) Gottlieb charges the system will likely have the same sort of restrictions on buying private supplemental insurance that Medicare has. Is the upper middle class unhappy with Medicare? No. If Medicare started denying treatments right and left, would they be unhappy? Yes. And they would rebel on election day. Which is why Medicare doesn't deny payments right and left. When it comes to protecting my insurance, whom would I rather rely on--angry affluent aging boomers or Aetna adjusters? It's not even close. 3) The same political dynamic should serve as a check against setting Medicare payments so low that all the good doctors leave the system and go private. Of course, that's already happening to some extent. (The top hip-replacement guy on L.A.'s West Side just stopped taking Medicare.) But I don't think voters will let it go much further, to the point where they are routinely denied access to the docs they want to see. (Exhibit B: The doctor's fee cut, which Congress repeatedly refuses to OK). 4) The very egalitarian impulse that Gottlieb ridicules--the desire to prevent the system from becoming a "lower-end benefit" like Medicaid--will force the government to keep benefits generous enough that the second-to-top decile (and the third, and fourth) don't bolt. That serves both the anti-rationing cause (you think the top 40% will stand for 'death panels'?) and the social-egalitarian cause (rich and non-rich in the same waiting room). The enemies of this generous approach won't be the "egalitarians." They will be the cost-cutters. They will lose.
Doesn't that mean we'll spend more and more on health care, without reducing federal outlays by "bending the curve"? Did somebody say something about "bending the curve"? Really? Social egalitarians should not want to bend the curve. (We should want to find a way to pay the bill. One idea here.)... 3:07 P.M.
___________________________
Nobody Expects the Pong! Reader C. asks a good Question: Many people--e.g., Paul Starr, Bill Galston, me--have urged the House to just pass the Senate bill intact, word-for-word, which would have the effect of sending it immediately to the President and avoiding a House/Senate compromise that would then require a second Senate vote. It doesn't look like the House is going to take this approach--there are going to be negotiations on a compromise, negotiations that may extend into February. But what if the negotiations bog down? Can the House just go back and pass the Senate bill? Or is the "pong" strategy somehow voided once House-Senate negotiations start? ... Specifically, what if it begins to look as if Obama won't get the necessary 60 votes the second time around? (Suppose, for example, that Sen. Nelson gets such an earful back in Nebraska that he says he won't vote for the bill a second time.) If the Senate looks like it's changing it's mind, can the House just pass the existing Senate bill and end the game anyway? ... Even better, if the Senate actually tries and fails to pass a new House-Senate compromise, can the House then go back and just pass the original Senate bill? ...I don't know the answer, but some parliamentary experts out there probably do. ... 2:22 P.M.
___________________________
TNR Brings 'Da Noise! Jonathan Chait declares that the Fed-like "Medicare advisory commission holds the greatest potential to drive transformation of the system, but that "[i]n its official budget estimates, CBO credits these experiments with virtually no budget savings." [E.A.] The implication: CBO's projection of a deficit decline is conservative--there's likely to be even more savings once the unelected experts on the advisory commission start denying payments for "wasteful" treatments and medical devices.
But Chait is wrong, I'm pretty sure. The CBO credited the Medicare advisory commission with large savings. Indeed, the reason the final Reid bill (the "manager's amendment") was originally deemed to have greater savings than the first Reid bill was, according to the CBO, precisely because the "manager's amendment" seemed to fix the trigger that causes the less-than-democratic Medicare advisory commission to swing into action. Then the CBO read the fine print and discovered that the trigger was only half-fixed--it comes unfixed in 2019--and as a consequence CBO corrected its original estimate from "a broad range around one-half percent of GDP" to "a broad range between one-quarter percent and one-half percent of GDP." In other words, it cut the lower bound of its already incredibly vague estimate by half.
Obviously, if the CBO revised its savings score from the Medicare commission downwards that means, contra Chait, there were savings there to begin with. Lots of savings-- a potential quarter percent of GDP. Half of all the savings in the bill
Where did Chait get his bogus assertion? 1) He was going off the CBO report of the old Reid bill; 2) He heard it on JournoList!
P.S.: Chait declares "totally false" the GOP argument that Congress' unwillingness to carry out cuts in doctors' salaries might presage unwillingness to make other scheduled Medicare cuts. He then cites a report from the Medicare actuary, Richard Foster, to show that--contra Republicans--if the Medicare cuts are approved, the "rate of growth" in health care spending will slow. But this same Medicare actuary, Richard Foster, worried in that same report that Congress' unwillingness to carry out cuts in doctors' salaries might presage unwillingness to make the scheduled Medicare cuts (see page 9). Doesn't that suggest that the original GOP argument wasn't "totally false"? Maybe had a germ of truth!
That's the trouble with Chait. GOP claims are always "totally false" or "thoroughly debunked pseudo-factoids." Republicans always act in venal bad faith--they never have even a half-a point. It's why I don't trust him. ... 2:07 P.M..
___________________________
-
sponsorship
"Conservatives are blowing it" on health care. So argues Marc Ambinder. Republicans are turning town halls into general "anti-Obama venting sessions," he twittered on Sunday. All that shouting-down was turning people off. "[T]his trend favors the left." It certainly wasn't going to cause the Blue Dogs, whose votes are crucial to reform, to vote against it.
Ambinder elaborated on Sunday's instant analysis today:
At this same hour last week, several of the President's top political advisers were meeting in a White House conference room to discuss the appearance, over the first weekend in August, of a coordinated effort to scare Democratic lawmakers who planned to attend town hall meetings into a state of panic. A week later, and the Atlantic's tricorder readings are picking up much calmer electromagnetic energy from the White House. ... Democrats are beginning to notice that opponents of health care reform have discredited themselves. They ramped up much too quickly. When smaller, conservative groups Astroturfed, they inevitably brought to the meetings the type of Republican activist who was itching for a fight and who would use the format to vent frustrations at President Obama himself. ...[T]the loudest voices tended to be the craziest, the most extreme, the least sensible, and the most easy to mock. ...
A coherent, organized effort would have recognized that the moment the media began to take sides was the moment that the entire enterprise could be damaged. The media, being a collection of different megaphones, reported on the town hall meetings in one of two ways, both damaging to Republicans. Either they credulously reported the louder, angrier voices (inherently damaging to Republicans in this case) or they reported on the political architecture of the town hall meetings, which plays down the substance of the protests.
Remember, the target audience for Republicans is Blue Dog Democrats in Congress. They won't panic unless they perceive organic anxiety. The White House's goal was to prevent the Blue Dogs from panicking. The swing constituents in these congressional districts aren't angry Republicans, and the Blue Dogs know this. They're political independents for whom the sanctity of the process is important. .... Unrestrained, these town hall meetings are going to turn off the type of voters Republicans most need to pressure Blue Dog Democrats -- independents who don't have red genes or blue genes.
These are good points--possibilities, at least. They're the possibilities you'd want to emphasize if you were, say, a Democratic aide talking to Marc Ambinder. But are they the most important possibilities? For example, anti-Obama activists indeed seemed uncouth and even thuggish in some early townhall MSM coverage. But how many people watch the MSM in the middle of August? (And anyway, Obama has now shown that these meetings aren't that uncivil!)
The bigger picture is whether support for health care, already too weak, builds over August or shrinks, no? Does Ambinder really think it's going to build simply because GOPs ramped up too quickly and got too loud last week? Doesn't the latter criticism, however valid, have the half-life of either a twitter item or Rahm Emanuel's attention span, whichever is shorter?
Ambinder seems to be operating on the premise that all Obama needs to do is convince a finite number of Blue Dogs to vote with him and a "comprehensive" health reform will pass--the way a few more delegates once enabled him to lock up the nomination. But lawmaking isn't that cleanly mathematical. When the general public sours on a bill, it affects more than a few swing votes. Unpopular bills have a way of magically bogging down in Congress even if a majority technically favors them and regardless of what happens with Senators and Congressman whose votes were once considered "crucial." (There were crucial swing Senators on Clinton's health care reform too, at one point. And on "comprehensive" immigration reform in 2007.) The White House aides whose temperature Ambinder's taking certainly have an interest in making it all seem like simply a battle for the Blue Dogs, because that seems more like a battle they can win.
If Ambinder were any easier to spin, he'd be a dreidl. ... Update: See also Patrick Ruffini. ...
P.S.: Ambinder says the GOP effort was not "coherent, organized." Doesn't that undercut the left talking point that it was secretly, centrally controlled by sophisticated DC corporate lobbyists? ...
P.P.S.: A more interesting, though equally spinnish, Ambinder post makes some subtle points about the real views of Obama health care adviser Ezekiel Emanuel (Rahm's brother).
a) For example:
Hospice care costs more than hospital care in most circumstances, Emanuel found -- and so the end-of-life counseling that a doctor provides has little to do with saving money.
But if that's true, then why doesn't Obama calm everyone down by ostentatiously dropping the end-of-life- oriented parts of the bills? ...
b) I knew it was all Michael Sandel's fault! On Ezekiel Emanuel's "communitarian" world view:
Emanuel sketches out a "civic Republicanism" telos -- that is -- our health care decisions as a society should be yoked to a system that "promote[s] the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic." He notes that such a system would deny "services provided to individuals who are irreversibly prevented from being or becoming participating citizens."
Emanuel is setting up a contrast: our health care system today treats everyone equally -- as if they ought to have equal access to every possible procedure or treatment. To most of us, the status quo seems intuitively right. Everyone is equal -- equal under God -- Emanuel doesn't say this, but he might as well -- and therefore it would be evil to make distinctions. What Emanuel is arguing, here, is that this liberalism substitutes one goal -- equality -- for another -- a healthy society -- and that substitution may be responsible for the limited choices that policy-makers confront. [E.A]
Well, if you put it that way ... I'm for equality! For a health care system that "treats everyone equally," even if it's expensive. Against a system that would deny "services ... to individuals" who won't ever achieve "full and active participation .. in public deliberations."
Like I said, Sarah Palin had a point. ...
P.P.P.S.: Who said social equality would always be cheap? ... 8:59 P.M.
___________________________