Today I Choose Not to Celebrate: Bittersweet Thoughts on Health Care Reform

I originally intended to post this before the bill passed, but I clearly missed that deadline. I think it is still relevant so I am sharing anyway. I apologize in advance if this isn't the most well researched, fact based post in the world. The basic ideas have been kicking around in my brain for a couple of weeks. Maybe if I had been working less hard, I could have done some real research. I'm sure it would have made my basic argument stronger. Nevertheless, this is the best you are going to get from me.

Part 1 – Is it a Good Bill?

I should start by saying that my general opinion about health care reform is inherently contradictory. On one hand, at a very principled level, I find it morally reprehensible that every single American doesn't have access to high quality health care. While lack of insurance or lack of ability to pay isn't the only factor preventing access to high quality care, it is one of the primary factors.

It is probably worth pausing for a second for a parenthetical aside long enough for its own paragraph. My politics are left of center. In fact, they are probably farther left of center than almost anyone else I know. I am not a communist or a socialist (at least not as a political scientist would define them; I am sure that Rush Limbaugh or Sarah Palin would disagree). I don't believe in equalizing outcomes, but I believe strongly in equalizing inputs. I attribute much of my personal success in life to two things: (1) access to great schools and a high quality education; and (2) growing up healthy with access to great medical care. The goal is to start things on a level playing field. If the outcomes are uneven that is ok as long as everyone had a fair chance at the start. By the way, I know this raises interesting questions about things like inter-generational transfers of wealth, but that is a topic for another day. Bottom line from this long aside, giving citizens access to health care should be at the top of every society's (and more specifically every government’s) to-do list. The aside is now over and I will return you to your regularly scheduled blog post.

On the other hand, I believe that one of the reasons why our health care system is screwed up is because the incentives are a mess. Supply and demand don’t work in the health care market; the payer is not the purchaser which removes the ability of pricing to limit consumption which drives up costs. We have broken the linkages between cost and quality. Higher costs make it more expensive (and by extension harder) to provide broad coverage. For a more coherent articulation of this argument, I strongly recommend reading, “How American Health Care Killed My Father” by David Goldhill from the September 2009 issue of The Atlantic. He mines this topic in great depth and does a great job discussing our inability to limit basic medical mistakes which kill a 100,000 Americans every year.

At this point I am sure you are saying to yourself, “Jon, you can’t argue for a single payer universal coverage system at the same time you criticize the distortive effects of bad incentives” (or maybe you are saying to yourself, “why am I reading this stupid blog in the first place?”). A couple of thoughts:

1. I agree which is why I started this entire discussion by admitting that my position contradicts itself.
2. Given a choice between a moral, inefficient system and an immoral, efficient one, I will choose the moral system every single time.
3. I believe that it is possible to control costs and fix incentives within the context of a system that provides broad coverage.

This is a long lead-up to the fact that I am very disappointed in the health care reform bill that passed the Senate.  The bill is not a complete failure.  There are some good elements:

• Eliminating bans on pre-existing conditions (for children in 2010 – it is unclear to me why adults have to wait)
• Eliminating annual and lifetime caps on benefits
• Regulating the medical loss ratio requiring carriers to pay-out 80% of premiums for individual plans and 85% of premiums for group plans. If they don’t hit this cap they have to issue rebates to policy holders. It is a shame that the Secretary of HHS can gut this rule, but something is better than nothing.
• If you believe the CBO, the bill will reduce the deficit over both the medium and long term.

The bill also provides some unintentional comedy with the tanning salon tax.

The problem with the bill is that it doesn’t cover enough people.  The estimates I have heard vary but in general the bill leaves approximately 24 million people without coverage. Leaving just under 8% of Americans without health insurance is morally unacceptable to me.

Another aside – I know that there is some debate on if illegal immigrants should be included in the calculation. That is a topic for another debate and another blog post so I am only going to offer two thoughts: (1) illegal immigrants are people too and have the same moral right to health care as everyone else; and (2) even if you don’t share my point of view in (1), there are still American citizens not covered under the plan.

Personally, I would have solved the coverage problem with some form of a single-payer system. Recognizing this was politically unattainable, I would have settled for a robust public option. The narrower public options and early Medicare buy-in proposals were not on the table long enough for me to form a coherent opinion.

My other concern (and I have to admit that I really need to research this more to confirm that I am right) is that the bill doesn’t do enough to address out-of-control costs. It leaves many of the flaws in the system that create high costs in place.

So the question we need to ask is, is something better than nothing? Put another way, is a flawed bill that has some good points but ultimately fails to address significant issues worth passing or should we hold out for something better, for something more comprehensive?  The something is better than nothing argument is being made by a lot of people: Rahm Emanuel, Vicky Kennedy on behalf of Ted,  and even Barack Obama himself.  The essence of Obama’s argument: “Nowhere has there been a bigger gap between the perceptions of compromise and the realities of compromise than in the health-care bill," Obama said. "Every single criteria for reform I put forward is in this bill.”

I will get back to Obama in part 2. For now, I have to admit that I am torn. At the end of the day, something is better than nothing, but at the same time, I feel that if people in critical positions had tried harder we could have come up with something better.

Part 2 – Who is to Blame?

So, who are the mythical people I believe should have tried harder? Who are the people that are to blame? More than anyone else I blame President Obama. I believe he was the only person who had the combination of a position, intelligence, and personality to get the American public (and more importantly Congress) behind a more comprehensive reform bill. Everyone else in the process – Reid, Pelosi, etc. – probably did the best they could given their position and skills. In particular, I fault the President for three things:

1. He didn’t sell the bill. He needed to be out in front of the issue continually making the case to the American people on why this was necessary. He should have forcefully made the moral argument and clearly put opponents of the bill on the wrong side of a fundamentally moral issue. He did this once or twice but never did it strong enough and didn’t do it often enough.
2. He should have drafted a bill. By not putting pen to paper and putting a stake in the ground on the components of a bill, he created a vacuum. For an issue this complex, with this many competing issues,  Congress was never going to craft a bill that accomplished enough. I am not the only one who has this opinion; it is also shared by members of Congress including Senator Jim Webb. Senator Webb (or his press secretary) eloquently makes the point that by not drafting a bill, the administration created the confusion that resulted in the mess we are in today. President Obama did a great job during the campaign and in the early days of his presidency defining how important health care reform is. Where he failed was drawing a clear picture of what success looked like. This was the safe strategy – by never defining success he could claim whatever bill ultimately passed was success (by the way, this is exactly what he is doing this morning). He would have been called a failure if his bill didn’t pass. By not introducing a bill, he avoided this outcome – an approach which let the American people down.
3. He allowed the process to overwhelm the bill. One of the reasons why I think this bill is going to get criticism from the general public is the way it came together in the last several weeks with a series of backroom deals and compromises. I know that this is the way most legislation gets passed, but the average American is not comfortable with this approach and on a high profile issue like this it makes criticism easier.  As a result, President Obama lost the moral high ground that he had claimed during the campaign. Paul Hogarth makes this argument much much better than I can in a recent opinion piece, “2009: The Year Change Fell Prey to Backroom Deals”.

I voted for President Obama for many reasons. One of the primary reasons was I thought he had the courage to take a different approach to tackling hard issues. This is the first issue where he wasn’t cleaning up a mess he inherited from the previous administration; this is the first issue where he could define his own path. He failed to live up to my expectations; he let me down. Knowing everything I know today I would still vote for him (the prospect of a McCain/Palin administration was so horrid he would have to screw up much worse than this to lose my vote), but I would do it less enthusiastically.

While I honestly believe that a different approach would have produced a different outcome, people smarter than me have come to a very different conclusion. Nate Silver may be one of the smartest political commentators working in American today. He has been a vocal advocate of the “something is better than nothing” argument (and I am in awe of his math and statistics skills). In a recent article, he acknowledged (1) and (2) above but came to a different conclusion on whether it matters. His basic point is that given all of the variables at play (particularly the political landscape), there is little that Obama could have done to produce a different outcome.

One of the most interesting aspects of this discussion is to what extent did President Obama let Candidate Obama down. As I shared above, I like Candidate Obama better. Maybe this is an inevitable outcome of the transition from candidate to President. This is a topic worthy of its own blog post but who knows when I will get to writing that one. Besides David Sirota has already written it for me.

Part 3 – No Wonder Nothing Gets Done

If there is one link in this entire article that I am going to insist you read it is this one. Slightly off topic (the issue is bigger than health care reform) but with this type of bureaucracy, it is amazing Congress ever passes any laws.  This is certainly very different from how Schoolhouse Rock described how “A Bill Becomes a Law”.

Part 4 – A Subversion of Democracy

What this entire debate has highlighted for me is how dangerous the filibuster is. Bottom line, it is a subversion of democracy. We have a system designed around the concept of majority rule. There are lots of checks and balances designed into the system and in my humble opinion they work well. To be clear, a super majority requirement in one of our legislative bodies is not part of the system. In case you didn’t realize it, the concept of the filibuster is not in the constitution. Let me repeat that for emphasis:

THE FILIBUSTER IS NOT IN THE CONSTITUTION

Fundamentally, the filibuster vests too much power in individual Senators by making it impossible to even pass bills that have the support of a clear majority of the Senate. On the issues that truly matter to our country, it will be very hard (if not impossible) to reach agreement among 60+ Senators on what to do. The result will often be achieving nothing and even when we do achieve something, it will be very watered down (with the current health care reform bill exhibit A).

The filibuster was made theoretically possible under Senate rules in 1806 but the first filibuster didn’t occur until 1837. The concept of cloture (a vote to stop the filibuster) wasn’t introduced until 1917. From 1917 until 1975, a cloture vote required a 2/3rds majority to pass (alternating back and forth between 2/3rds of Senators voting and 2/3rds of all Senators). In 1975, the threshold was reduced to the current standard of 3/5ths (60 Senators).

The idea of a filibuster conjures mental images of the lone senator standing on the floor giving an impassioned plea against the bill or sometimes just reading the phonebook to block legislation they disagree with. This was the dramatic scene in one of my favorite episodes of The West Wing – The Stackhouse Filibuster. In this episode, an older Senator is filibustering against a health care bill. Ironically his filibuster is because the bill doesn’t go far enough to protect children with autism. In case you are curious, Strom Thurmond set the record for longest individual filibuster – 24 hrs against the Civil Rights Act of 1957.  The longest tag team effort was when southern Democratic Senators filibustered for 75 hrs against the Civil Rights Act of 1964.

By the way, are you starting to see a pattern here. Senators aren’t using the filibuster to line up against war or other bad bills. It is mostly a tool to subvert controversial improvements in our society.

At least in the old days, cranky Senators had to work to block progress. Today they just have to raise their hand. Senate Rule 22 permits filibusters where continuous floor speech is not required – never let it be said that legislators won’t find a way to avoid hard work. I believe the entire concept should be abolished, but if we are going to keep it, at least make people talk until they are blue in the face. I don’t think that Joe Lieberman has it in him.

As our country becomes more divided, the negative impact of the filibuster is growing. It has always represented a subversion of democracy but the problem is getting worse. In the 1960’s, no Senate term had more than 7 filibusters and they affected less than 8% of major legislation. By the 1980’s it had crept up to 27%. In 2006, things went completely off the rails. Since then, when Democrats took control of the Senate, Republicans have filibustered over 70% of all major legislation. The same party that wanted to abolish the filibuster in 2005 when it was being used to prevent them from getting what they wanted on a single narrow issue (the nomination of judges) now use it to block everything of substance. As long as they aren’t sore losers or anything (sorry, did I say that out loud?).

Abolishing the filibuster has replaced abolishing the election of judges as the #1 flaw in our system which needs to be corrected. Care to join my crusade?

Before I move on, two sources were very helpful in learning more about the filibuster (and increasing my ire when thinking about the topic): Paul Krugman’s recent op-ed in the New York Times and the Wikipedia article on the filibuster.

Part 5 – Who is the Biggest Asshole in this Whole Mess?

This entire process has produced more assholes than heroes. The interesting question is, “Who is the biggest asshole?” Without further adieu, the nominees are:

• Joe Lieberman who is well on his way to a lifetime achievement award in this category and his “sins” are too many to list. He clearly has no principles anymore (nothing like threatening to filibuster something he supported 3 months ago) and personally I believe he makes trouble just because he likes the attention and no, Joe, you can’t have a pony or be made senator for life.
• Tom Coburn who suggested that Americans pray for the death of another Senator. Of course Coburn did inspire this prank which is a great send-up of the nut jobs who listened to him. By the way I fell for this.
• Anyone who has the nerve to compare health care reform to the holocaust – best exemplified by Laura Ingraham (fast forward to 2:46 in the video).
• Ben Nelson for selling out his moral principles for everyone to see. I don’t agree with Nelson’s opinion on abortion but I recognize for many people that abortion is an absolute moral issue. I respect this point-of-view and understand that this position can’t be compromised. In the spirit of the Winston Churchill quote, we know what Nelson is and now we know the price. Nelson’s absolute moral principles can be bought for the price of the Medicaid program in Nebraska.

And the winner is – on this issue I am not going to help, you have to decide for yourself.