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Musings on Health Care

August 23, 2009

The present health care debate illustrates – in my opinion, at any rate – the best and worst aspects of our particular republican form of government. Those who contend that the discourse has gone beyond the pale are both right and wrong. Right in that it has, in that certain actors are making bad-faith arguments, distorting the truth and telling outright lies. Wrong in the assertion that all of this somehow signals the collapse of civilized public discourse. If anything, I believe history has demonstrated time and again that civilized public discourse is the exception, not the rule. Change – and particularly institutionalized change – is always feared and resisted. It was by the Romans (to the dismay and death of many a tribune of the plebs). It was by monarchs and by slaveholders in the southern states.

Fortunately, for all the fear-mongering and heated words and personal attacks, I think we’re still some ways from outright armed conflict.

None of this means we can’t be mad as hell though. For my part, I’d love to put the nonsense about death panels and socialism aside and actually see a reasoned debate, and so I was pleasantly surprised to read Peggy Noonan’s latest editorial. Finally, amid all the static, a good-faith argument! Something I can sink my teeth into!

Below the fold I’ll take a look at Peggy’s column, and offer my own thoughts. Feel free to chime in with your own. My only request is that you keep things civil.

Okay, let’s get started.

Looking back, this must have been the White House health-care strategy:

Health care as a subject is extraordinarily sticky, messy and confusing. It’s inherently complicated, and it’s personal. There are land mines all over the place.

I want to zero in on this for a moment. Health care is sticky, messy and confusing. I would add that, for most people, it’s impenetrable. I know I go all glassy-eyed when benefits enrollment time rolls around every year, and I can’t imagine I’m the only one.

Add to that the fact that most of us don’t know the true cost of our insurance. We have a certain (and always rising) amount deducted from our paychecks, we pay copays, we have deductibles, but that’s it. So we don’t realize a trip to the emergency room for what amounts to two aspirin and a band-aid can easily run up to $1000 for the uninsured. And we don’t realize that the rising health care costs we don’t see are eating away at our compensation. There’s a reason most wages have flatlined over the last decade – and its name is health care. If we had to pay out of pocket, if we had to make the choice between getting a physical and paying the bills, there’d be a massive hue and cry to control costs. But because we don’t, there isn’t.

Don’t make the mistake the Clintons made and create a plan that gets picked apart, shot down, and injures the standing of the president. Instead, push it off on Congress. Let them come up with a dozen plans. It will keep them busy. It will convince them yet again of their importance and autonomy. It will allow them to vent, and perhaps even exhaust, their animal spirits. Various items and elements within each bill will get picked off by the public. Fine, that’s to be expected. The bills may in fact yield a target-rich environment. Fine again. Maybe health care’s foes will get lost in the din and run out of ammo. Maybe they’ll exhaust their animal spirits, too.

Summer will pass, the fight confined to the public versus Congress. And at the end, in the fall, the beauty part: The president swoops in and saves the day, forcing together an ultimate and more moderate plan that doesn’t contain the more controversial elements but does constitute a successful first step toward universal health care.

I’m sure this – or something very much like it – was the president’s plan. But I would offer two comments. First, the president has to let Congress write the bill. It says so in a little document called the Constitution. Second, Obama has played a major cheerleader role from the beginning, even while letting Congress hash out the details.

Honestly, I would have preferred a different route. I’d have liked to have seen a public debate first, before any bill (or bills) was on the table. I’d have liked to have seen consensus that something has to be done first (because it does – health care is bankrupting us). Build the consensus, and then start figuring out what steps need to be taken.

That’s not what happened.

It all got hotter, quicker than the White House expected. The many plans of Congress congealed in the public mind into one plan, and the one plan became a poison pool. The president is now immersed in it.

I’ve read this may have happened because the actual drafting of a bill has taken so long (not to mention organized GOP resistance). Whatever the case, the White House should have seen it coming and taken a different approach. Namely, building consensus that something must be done, identifying desired outcomes, and then developing proposals to reach said outcomes.

Here’s another thing that didn’t work. (I write as if health-care reform or insurance reform or whatever it’s called this week is already a loss, a historic botch, because it is. Even if the White House wins, they lose, because the cost in terms of public trust and faith was too high.)

I don’t know about that. There were (and are) a lot of people opposed to the stimulus plans enacted by Bush and Obama, but the evidence is pretty clear that the stimulus has staved off a catastrophic collapse.

Every big idea that works is marked by simplicity, by clarity. You can understand it when you hear it, and you can explain it to people. Social Security: Retired workers receive a public pension to help them through old age. Medicare: People over 65 can receive taxpayer-funded health care. Welfare: If you have no money and cannot support yourself, we will help as you get back on your feet.

These things are clear. I understand them. You understand them. The president’s health-care plan is not clear, and I mean that not only in the sense of “he hasn’t told us his plan.” I mean it in terms of the voodoo phrases, this gobbledygook, this secret language of government that no one understands—”single payer,” “public option,” “insurance marketplace exchange.” No one understands what this stuff means, nobody normal.

Three things.

First, I don’t think it’s fair to apply 20/20 hindsight to long-established entitlements and then compare them with the present debate. The past is always clearer than the present.

Second, Peggy is right. Nobody has managed to encapsulate the planned health insurance reforms into a single, unifying idea (the Healthcare Napkin series is the best attempt I’ve seen). Part of that has to do with the sheer complexity of health care as it exists in the U.S. But part of it must lie at the feet of the administration.

Third, the voodoo phrases. Sigh. None of this was ever mentioned regarding “enhanced interrogation techniques” or other examples of doublespeak stretching back to the 50s. And none of the referenced terms are really that difficult to understand.

Single payer basically means “government-financed health insurance”. Basically, instead of being reimbursed by UnitedHealth or LifePoint or whoever else, doctors and hospitals would be reimbursed by a government-sponsored insurance entity, like Medicare. This is NOT socialized medicine. Socialized medicine entails the government paying medical salaries directly.

Public option means exactly what it says. A government-run or –sponsored insurance entity, as opposed to a private insurer.

And the exchange refers to an exchange where individual consumers could shop for insurance. Personally I’d refer to it as “LendingTree for health insurance” and organize it as such. Insurers compete, you win.

And when normal people don’t know what the words mean, they don’t say to themselves, “I may not understand, but my trusty government surely does, and will treat me and mine with respect.” They think, “I can’t get what these people are talking about. They must be trying to get one past me. So I’ll vote no.”

Which is why the Obama administration needs to find a simple message out of this health care morass. Though, being honest, I don’t know how much good it would do with the GOP basically playing the role of the “nuh-uh” party.

In a more beautiful world, the whole health-care chapter could become, for the president, that helpful thing, the teachable moment. The president the past month has been taught a lot by the American people. It’s all there in the polls. He could still step back, rethink, say it didn’t work, promise to return with something better.

When presidents make clear, with modesty and even some chagrin, that they have made a mistake but that they’ve learned a lesson and won’t be making it again, the American people tend to respond with sympathy. It is our tradition and our impulse.

Such admissions are not a sign of weakness. John F. Kennedy knew this after the Bay of Pigs. He didn’t blame his Republican predecessor, Dwight Eisenhower, or the agencies that had begun the invasion’s tentative planning under Ike. JFK made it clear he’d learned a great deal, which increased confidence in his leadership. His personal popularity rose so high that he later wryly noted that the more mistakes he made, the more popular he became.

I’ve said this time and time again about businesses, but it applies to government as well. The “never show weakness” mantra is bullshit. It may work in the short term, but in the long term it will come back to bite you in the ass.

What Peggy doesn’t say, and what desperately needs to be said, is that acts of contrition are necessary from both sides of the political aisle. What we have, what we’ve had for a long time now, is this sort of political shoving match, with neither party willing to step back and say “you know what, maybe we dug our heels in a bit too hard”.

The really ironic thing is that that is EXACTLY what we’re doing on the international front these days, and it’s paying off in spades. The poison of the Bush years is washing away. Would that we could see the same reconciliation domestically.

8 Comments leave one →
  1. August 24, 2009 12:43 am

    On public discourse – never should discourse be viewed as bad, on this I wholeheartedly agree. While preferable to have civil discourse, it is cathartic for people to release the animal spirits by venting frustration. I would argue that public discourse is not the norm, not just “civilized”. Historically, it became uncivil and public when the anger became too much to keep private (and the people safe) – when people were willing to put their lives on the line due to a long and grievous list of offenses.

    You are right on about the Congress being who actually writes the bills. But that is where some of the problem comes in: Obama says what he wants, but Congress inserts what it wants. In other words, he is effectively talking about a bill that doesn’t really exist, except in his own mind when he says “in my health care plan…”. The bills floating around Congress aren’t exactly his.

    Secondly, it wouldnt exactly be the first time a bill is crafted that functions as a trojan horse. Case in point: California’s privatization of energy. While Enron caused some problems, it’s proximate cause was that the privatization plan was doomed to failure. When it came to needing extra electricity, Enron stepped in to game it. But the shortage/brownouts were a consequence of a poorly constructed market. Furthermore, it is widely presumed to be a trojan horse by both the left and the right – a system that will naturally evolve into single-payer health care.

    death panels – while inflammatory language, and I think specifically said to be that way, needs some clarification. first off, if someone actually bothers to read what she wrote, it becomes evident that she was talking about the rationing that is necessary under a single-payer system. People understand the reality of triage in a battle situation, but don’t want anyone being left to suffer/die in normal situations. And as that rationing would not be determined by the individual (and their doctor), but by government bureaucrats, it gets mocked as a “death panel”.

    On socialized medicine – there are different degrees of it, and it kinda depends upon the definition of socialism. The closest true examples are CanadaCare and the VA. Something like Medicaid/Medicare (single-payer, but private ownership of hospitals) would better be described as economically fascistic in nature – there is still nominal private ownership but government dictates everything, and in those cases as a monopsony. Basically imagine if Walmart was able to set the rules so that every supplier in the country could only sell to them, meaning you could only shop there and nowhere else. Set aside any hyperbole about them and imagine if you purchased anything from anyone else, both you and the supplier would be fined and go to jail. Which, btw, was the case in Canada until recently courtesy of their Supreme Court.

    And you said socialized medicine is government paying the salaries of doctors. what would you call it if the government set their salaries? HR3200 has elements in it that would do just that.

    Which brings us to the exchanges. the big difference between lending tree and the exchange is that the federal government is setting the rules rather than it being an open auction. I get the impression that it will be closer to federalizing what already occurs as the state level – the states say what has to be covered in the insurance and then insurance companies sell policies that comply with the laws. Its one thing to set the ground rules, its another to dictate what can legally be sold.

    Politicians do exhaustive studies looking for the right words to describe things. Not based upon accuracy within normal english. But what will be best received by the audience. “social security”, “great society”, “for the children”, “bridge to the 21st century”, “ownership society”, “patriot act”, etc. all are designed to illicit an emotional reaction to them. same with the demonization of people by using certain words like “racist” or “swastika”. So ultimately it is a question of do you trust the particular politician. I dont trust any of them, so their words and their deeds are divorced in my mind.

    The way the Congress functions is that the minority party is basically relegated to being “the party of no”, at least functionally. I mean really, other than advocating a military defeat in Iraq, the Democrats didnt really do a darn thing nor advocate much until they got back control in the 2006 elections; aside from the bills Bush brought them in to co-write (education, medicare expansion, And even after then it was mostly “Bush is Hitler” and “Bush is causing all your problems”, though they had all the constitutional power to write laws and control the purse strings. Now that being said, Republicans have offered competing solutions, they just basically do not get to see the light of day because Democrats hold strong majorities in both Houses. That leaves any suggestions dying in committee. That means the only time Republican ideas really matter is come election time. And I suspect that when Republicans were in control of Congress in the past, the Democrats had similarly limited power.

    One example of ‘competing solutions’ would be for the stimulus. ‘No’ is a legitimate position because it can be argued that the current setup is better than any alternative. Even if a plan would be stimulative, it has to be determined if (a) its justified, (b) if the disruption to the market will be too destructive (changes to the market create new winners and losers), and (c) the costs are too destructive (inflation, debt). I heard several variants of a ‘payroll tax holiday’ being offered as alternatives. As to the actual results, any benefits we have received are likely near 100% a result of the financial stabilization. The Democrat stimulus has spent about 10% total thus far, doesnt really start picking up til next year, and most spent so far has been to shore up (non-federal) govt budgets. So any benefit we might receive wont be felt until the 2010 elections. For a situation supposedly so dire, the delay sure is odd. That is, unless, it was for political purposes.

    The international situation is something we will have to wait and see. While Bush was criticized for souring our relations with others, it is a bit more complex than that soundbite. We were hardest hit in the international media and in western Europe. On the other hand, we have never had better relations with Poland and the rest of E. Europe, Russia, China, India, Pakistan, Japan, South Korea, Libya, Jordan, Iraq and Afghanistan for obvious reasons, much of Africa, Columbia, et al. And while Obama has been heralded as the 2nd coming, I dont know if his results could justify that. Ultimately, I will have to wait to see the end results of his interactions with other nations, but I will point to a few problems. A list of some of the countries: Japan, Poland, Russia, Iraq, England, Switzerland, Ireland, the Philippines, Israel, Columbia, and Honduras. I dont know how well Africa took his speech there recently, though I thought it was good. And he did make some headway with the Arab street with his speech in Cairo. If you want specifics, holler at me.

    One last thing on health care. The reason there is a problem with prices is something that is generally being ignored though you did touch on it briefly when you mentioned the disconnect between costs and the recipients of the service. Its called ‘tragedy of the commons’ – i.e. we do not have a functioning market for health care because there is no pricing function. Personally, I cannot think of any other purchase we make in which we have no idea what the cost is until after we have acquired it. Other than what Walmart has done recently for a few prescription drugs, I have never seen a price on a pharmaceutical until it got rung up. And I have never heard of any price availability except with stuff that usually gets paid out of pocket (stuff like massage therapy and cosmetic surgery). But that is, at least in part, a result of our comprehensive health insurance policies. If the four main goals of reform are (a)universality, (b) portability, (c) cost-controls, and (d) maintaining/improving quality, then there are alternatives. One such would be to allow everyone to have HSA’s and catastrophic coverage. Catastrophic (i.e. high-deductible) is considerably cheaper – about 3k/family nationwide and maybe half that there in Texas, thanks to Texas laws. We currently spend about 850 billion each year between Medicare and Medicaid alone. If we gave everyone vouchers for the cost of cat. coverage, then they could go out and buy it, and for only 300 billion. 2000/year/person into an HSA to help cover the difference. In other words, under this basic framework I came up with, we could cover everyone, restore markets to health care, and all for less than the government spends now. And the absence of artificial controls from government will allow for quality to continue and advancements to be made. Dont know if you read it, but I was pleased to see what the CEO of Whole Foods wrote in the WSJ recently.

  2. Bonnie MacDougall permalink
    August 27, 2009 3:15 pm

    I am the proverbial ant, the C on the DISC Behaviorial Profile where the rubber meets the road, so of course I have had decent health insurance for years. It, like social security and Medicare, has been in the kernel of my futuring. The contractual obligation of my employer-state to provide healthcare coverage for life after 25 years was a critical reason I took the job I have had for 23 years now. You can guess my first, but not only, reaction to grass hoppers, and my sense of well-being that I was set for life regarding health insurance.

    However, like a tornado barreling down on my right side, the dismantling of state healthcare assurances, bada bing, bada boom, has distracted me, and now I have to think, and in order to clarify my thinking, discuss health insurance. Not my thing, but unless I do, every thought I have collapses into a mush mess of cynicism. How can I discuss healthcare?

    Definitely civilly. There’s no point in being in any other verbal neighborhood.

    However, everyone seems to agree that language surrounding healthcare ideas cannot at the moment be decoded at all or well. Along these lines, I’m grateful to know that ‘single payer’ means that a fed. govt-fronted insurance co. instead of BC/BS will pay my drs. and that ‘public option’ means I can choose between a fed. govt-fronted co, or stay with BC/BS, and perhaps select another co. In this respect, my options might increase because in my employer-state I am forced into only one co.

    These clarifications help, but are they going to be viable in a year? Noonan says that social security and Medicare are clear ideas that are easy to understand. Yeah, but they’re also not necessarily going to be true or as true as they once were by the time I get to fully using them, so what good is it that I can understand the language that describes them?

    One huge problem in discussing healthcare is this lack of faith in the long term viability of what we’re discussing. Another huge problem is what Noonan describes as “inherently complicated…and personal” health plans. Except for these last few weeks, the only information about my policy I have ever sought were facts that I needed to process for one specific medical incident.

    Maybe the hugest of all problems is “the fact that most of us don’t know the true cost of our insurance.” And could we also add that we don’t know the true value of some of our medical services. We, the “normal people” these healthcare plans must ultimately make sense to are just really in the dark about what exactly we might be getting, maybe because of the “‘tragedy of the commons’ – i.e. we do not have a functioning market for health care because there is no pricing function.” Or maybe we could also say that there doesn’t seem to be any common sense involved in pricing healthcare services.

    By contrast, the post office is easy. I don’t need this package to go overnight, partly because I can see that it would cost $39 for that to happen. And no I don’t want to buy the frills and thrills of tracking this package and knowing exactly when it arrives. In fact, since I’ve had the experience of insuring a package to no avail, I don’t even want to insure that it will arrive at all. It simply enters the cosmos and will arrive or won’t.

    But how in the world could anyone be asked to figure out that “a trip to the emergency room for what amounts to two aspirin and a band-aid can easily run up to $1000 for the uninsured.” Does that pricing make any sense at all? If I had known before-hand that the arthroscopic surgery on my destroyed meniscus would (a) cost someone more than $7000, (b) be, essentially, a vacuum-cleaning to remove the broken cartilage, but by no means a repairing of any part of the knee, and (c) add to future problems caused by misalignment, I might not have put myself in the care of a doctor who, as I was going under, asked which knee it was and said that his assistant was “clean.” No one in his right mind would think that 30 minutes of such vacuum cleaning should have cost the universe $7000 fifteen years ago. It is easy to see that “health care is bankrupting us.”

    Maybe we can’t reach a consensus about the necessity of change until we can talk about getting doctors’, pharmaceutical, and hospitals’ charges more in line with what normal and common people can understand those services are worth.

    I understand that doctors took years to train, but, hey, so did I. I understand that hospitals are competitive, but I do not welcome glossy mailed brochures that come about every other month. I understand that research is costly and do not mind paying a reasonable surcharge on medicine for research. I just want everything to make sense, common sense.

    So yeah, I’ve come to the conclusion here on these pages that the starting point for this national conversation that needs to happen in order to build consensus about changes that are coming should be about controlling and in fact pushing back the prices for medical services and accoutrements. Before I will willingly be boxed into any‘comprehensive’ plan, I will need to see common sense about pricing come to the table. Andrew moves way too fast for me in his last paragraph, but he’s got an idea to put on the table, and it smells like common sense to me.

    I’m not the only one who is like me.

  3. August 29, 2009 7:46 pm

    Of course we need Health Care reform, but don’t let yourself be fooled into thinking that those people who go to the emergency room for aspirin and a band-aid will all of the sudden make better decisions because now they have free Health Care (which in essence they do now any way). I am not a claiming to be the smartest guy on the planet, but I do live in the “blue collar” world and it seems to me that one of the major issues is the government continues to take from the working class, people that have worked hard for their money, paid their taxes and are generally productive members of society (Most – but not All) and give to the non-working class, people who expect others to continually provide for them, don’t want to work and are allowed continue to take and never give back (Once again Most – but not all). I realize that these are just my opinions, but i have personally dealt with many people/families on welfare or government assistance (A mother choosing to have more kids just so she can get a bigger welfare check, a good employee not wanting to go into management (even though it was a lot more money) because he would rather work less and collect welfare, countless numbers of applicants trying to collect applications so they can prove they were looking for a job just so they could get unemployment/welfare checks. I could fill pages with all of the stories that I have witnessed first hand), and I can say this without reservation – more people are taking advantage of and abusing the government assistance/welfare programs than people think. Once again these are just my personal feelings, but I do base them off of actual experiences and I am tired of working my tail off to provide for others to sponge off society. Every day I try and provide help and a future for people. Some jump in a work hard to build themselves a better future, but many more simply just don’t want to work hard for it. They would rather take their welfare check and blow it on unneeded items than put in the effort at a job and work their way up to providing themselves a better future. There are a lot of people that do need welfare, but (and once again, this is just my personal experience) there are a lot more taking advantage of the system and we are being now forced to continually fund it.
    When the majority of the population says that they do not want this plan, and the President says – we will have this plan – I get scared. But if I voice my opinion, the same people who did nothing but continually slam Bush (I am not trying to defend Bush here – just call out the hypocrisy) label me as UnAmerican – Come on!!
    Matt I wholeheartedly agree with you – if we could just get to an open honest debate on both sides -we might be able to accomplish something. Unfortunately on this topic -both side are acting like spoiled kids – “If I don’t get my way, I taking my football and going home!”

  4. August 29, 2009 7:53 pm

    PS- what is with the White House secret 80 Billion PhRMA deal? So much for unity with congress and transparency.

  5. Matt permalink*
    August 29, 2009 8:51 pm

    Wow…not one, but THREE comments that I believe may be longer than my original post!

    A part of me is tempted to respond in detail, but I fear doing so might destroy WordPress…

  6. September 3, 2009 8:54 am

    Your posts are just so thought provoking!! PS – and we are a wordy group!

  7. October 5, 2009 3:41 pm

    I’m a little late here..but this made for some great reading.. the post as well as the replies were all well written. I know you of course..I know JB.. I am assuming Bonnie is family of some sort….who is Andrew?

  8. Matt permalink*
    October 11, 2009 9:13 pm

    That would be Drew, who you met out at Vanderbilt when you visited (at least I’m 99% sure you did…but it’s been what, 10 years now?)…

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