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March 04, 2006

How Scared Are We?

Mark's post responding to my case for universal health care raises some good objections that, I think, deserve consideration. He argues that this era's economic insecurity and benefit deterioration has left the middle classes cowering in the corner, flinching from friend and foe alike lest they lose the little they already have. Democrats may be trying to help, but they'll get snapped at all the same. Remember, Mark cautions, that Kerry had a rather incremental plan, and Bush effectively attacked it as a big government takeover.

But did he? This is a point Garance made on Dick Gephardt's plan, that it was widely-panned and went down with its candidate. But like with Gephardt, I fear folks have a correlation/causation problem. Both Kerry and Gephardt gained substantial political benefit from their plan despite losing their respective races. Here's ABC News:

Among likely voters, Kerry leads Bush by 50 percent to 38 percent in trust to handle health care, up from an even split in early September. Among movables, Kerry's lead on health care is wider still, 59 percent to 17 percent, with the rest undecided or distrustful of both.

Democrats with health care plans often see their plans attacked and their campaigns foiled. But that's because Democrats lose elections. If they didn't have health care propping them up, they'd lose a lot more of them, and do so by larger margins. Election losses are multicausal, just because a losing candidate got attacked for their health plan doesn't mean their health plan harmed them.

That said, Mark's point is a serious one, and it should be considered:

[Voters] are more nervous about keeping whatever they have, and easily spooked. The suggestion that you might not be able to choose a doctor (not that you can under many employer systems these days anyway) or that certain procedures might not be covered, or that the system will be too complicated are likely to scare people who are already worried.

Pay special attention to that point on choice. That's the argument used to sink ClintonCare, the argument singularly responsible for the perpetuation of our crazy-quilt system. And it's exactly the argument that, I think, has changed, rendering health care reformable for the first time since the 70's.

What scared voters about Clinton's plan was managed care. It was a political fight over whether or not Americans wanted their traditional insurance plans transformed into HMos. They didn't. They got it anyway, albeit through the private market, which adopted managed care en masse. But where traditional insurance truly did offer choice and freedom that Clinton's plan would restrict, you'd have to go door-knocking in the Appalachians to find an insured American who retains traditional insurance.

And that was okay for awhile. The rise of managed care created a period, during the mid-90's, of blissfully slow growth in health spending. But those were one-time savings, and costs are, once again, accelerating beyond all comprehension. Since 2000, premiums have risen 74%, wages 15%, inflation 14%. Health costs, then, are increasing a full five times faster than wages. Folks may be afraid of losing what they have, but I think Mark underestimates the rapidly dawning realization (seen in all polling on the subject) that, in the near future, they won't be able to afford what they have.

That doesn't mean Mark's wrong: voters are looking for security, and nothing that can be easily demagogued or misunderstood will survive. As ClintonCare, Bill Bradley's plan, and Medicare Part D proved, a surfeit of complexity will kill any reform. The politics of health care are the politics of economic security, and no one is comfortable with what they don't understand. So as much affection as I have for all the FEHBP expansions and tax credits proposed by various think tanks and pols (see PPI's new proposal for a good example), the way forward is not a technocratic compromise that cleverly mixes market mechanisms with regulated insurers and individual mandates in order to emerge as ideologically indistinguishable as possible. Single-payer, presented without compromise or apology, is simplicity itself. And if, in the end, we're too scared to pursue it, then why should we ever expect anyone to elect us ever again? It's one thing not to stand for anything; you can at least fake convictions, then. But Democrats do have core principles, they're just afraid to fight for them. It's time they stepped back in the ring.

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Comments

"Medicare for All" is a simple, appealling, and understandable slogan (though not exactly what I'd propose -- e.g. the 20% co-pay is a major issue).

Posted by: Ted | Mar 4, 2006 6:23:54 PM

The Way Forward! Roberto Unger!!!

Posted by: cliff | Mar 4, 2006 6:36:00 PM

Ezra: But where traditional insurance truly did offer choice and freedom that Clinton's plan would restrict, you'd have to go door-knocking in the Appalachians to find an insured American who retains traditional insurance.

Not so.

Much of employer-provided insurance is, in fact, traditional insurance (fee for service). Most large employers provide a limited menu of choices for their employees and retirees, including fee for service plans and HMO's. The larger companies often self-insure, and use firms like Blue Cross or United Health Care to administer the programs while the company foots the bills for service. These traditional programs are often called comprehensive access plans, or network access plans, but the networks include most service providers in an area, and the patient chooses - including specialist care, without referral required.

Ezra: Single-payer, presented without compromise or apology, is simplicity itself. I'd luv me some single payer if we were starting from scratch.

But, as I commented upon for your post here

Jim: - how to get private insurers out of the health care administration business and control over Congress , and...

Perhaps a buyout of the health insurance companies (at huge cost) might work to mitigate their power,

and...
I can think of no precedent for a huge business sector [health insurance companies] that would just be swept out of existence - they must be dealt with just to get the program passed. What's the solution to this major roadblock?

It just isn't in the cards to try to enact single-payer universal coverage (as wonderful as that would be) without an answer in hand on how the Congress would deal with and replace the current insurers.

I don't like FEHBP-like solutions as well as single-payer, but they do keep the insurers in the game. To get them out, with single payer, please explain what will happen to these huge corporations (like United Health Care, Blue Cross, etc.).

In the time since I posed this question, the only solution I can see is a split system:

(1) Single payer for Medicare, Medicaid, currently insured, and those who choose this alternative to an HSA, or whatever they have they don't like.

(2) Multi-payer (private insurance companies) for current FEHBP recipients, current HMO users, current employer-provided plans, etc.

Can anyone explain how to get the private insurance companies out of health care (except a buyout) AND get a bill to do so passed by Congress?

Posted by: JimPortandOR | Mar 4, 2006 7:30:28 PM

"AND get a bill to do so passed by Congress?"

I agree with Jim, and I suspect Schmitt has the same thing on his mind. Your single-payer will not only require a new Congress, but a Congress of a sort not currently imaginable. I like both the ideas of single-payer and a revolutionary politics, but am also about to abandon the Democratic Party.

If you are not, then some sort of incrementalism or attractive transition will be necessary.

Posted by: bob mcmanus | Mar 4, 2006 8:29:14 PM

It just isn't in the cards to try to enact single-payer universal coverage (as wonderful as that would be) without an answer in hand on how the Congress would deal with and replace the current insurers.

I think the insurance industry is a good place to begin challenging the "business always good; government always bad" meme. Both have their roles to play. I just don't want more of either one than absolutely necessary. And one question I would really like answered is just why businesses think their right to profit is greater than our right to choose a better way.

Posted by: Emma Zahn | Mar 4, 2006 8:56:49 PM

What is the significance of the 1970s, Ezra? 1965 was a year of substantial reform, marked by the passage of Medicare itself, but I can't see what you're referencing in the 70s.

If I have my history correct, that decade was marked by Medicare as a failure, not a trophy of progressive reform, since its retrospective payment system lead to massive cost inflation.

Trapier K. Michael
www.marketplace.md
www.blog.marketplace.md

Posted by: Trapier K. Michael | Mar 4, 2006 8:58:01 PM

Yeah man, if only you had your history correct. As for universal health care, the tension between Carter on the left and Kennedy on the lefter represented one of the few times you had an effective coalition that could've passed reform -- too bad the left was busy arguing amongst themselves.

Posted by: Ezra | Mar 5, 2006 12:59:37 AM


After retiring from 35 years in the health care industry, I'd make a couple of comments. (And yes, it is no longer a humanitarian service; it is a profit-making industry, and a very profitable one at that!)

There are really two issues: Why is health care so costly in the first place, and what is the best and most humanitarian way to deliver it?

It is costly as hell because Congress has changed many of the rules at the behest of a major contributor of campaign cash. Over $100 million per year from health care interests (hospitals, medical associations, HMOs, insurance and the pharmaceutical giants) is not something to sneeze at. Why else would they allow hospitals to convert from non-profit to profit status? Or for hospitals to buy up physician practices and control their referral base? Or for physicians to build their own hospitals and drive up unnecessary testing to make them profitable? Or to allow physician offices to purchase expensive diagnostic systems for their offices and use them as cash cows? And the most recent biggie, creating a whole new privatized industry called Medicare Part D (for drug plan) that will shell out over $780 billion to the drug industry over the next decade?

It's called *Follow the Money*, and the public is rightfully mad as hell. But until the flow of campaign cash is stopped, don't even think about fixing health care (or any other societal issue for that matter).

And with all of the profit in our "market-driven, for-profit system," why else would Canadian physicians not flock to America? They certainly cannot become multimillionaires under their own system.

The Canadian system is not perfect, and will surely go downhill as the for-profit interests in that country lobby their parliament to under-fund it even further, thus causing longer wait times. But even as it is, 90% of their public prefers their system over ours. Their life-expectancy is two years longer than ours, infant mortality is 35% less than ours, administrative costs are 9% compared to our 30%, and their overall costs are 40% less than our even though they cover 100% of their population compared to our 85%.

What's not to like about that?

What we need is a Medicare-for-all system. It's not perfect but is an excellent model for our own system. Since going on Medicare I see the same doctors as always, go to the same hospital, but have a different insurance payor: a private administrator under contract to the government. This system should replace Medicaid and other state medical services to the poor, and it would reduce worker compensation costs by 40% since all injuries would be handled by Medicare.

And employers should not pay for it, the public should! Actually, we already pay for health care when companies add their medical costs to the price of their product and we pay at the cash register. So let's remove this burden from businesses and encourage more to keep their jobs in the US. They surely can't compete with product coming from countries with universal health care systems. Why else can we expect than to lose 60,000 Ford and General Motors jobs in the US? Ontario now makes more Big Three autos than does Detroit, all because their health care costs are $6500 per employee in Michigan compared to $800 in Canada.

Why have our business leaders not demanded a national, universal health care system like that in Canada? Why has the American public not demanded full public funding of state and federal campaigns (which would cost $15 per taxpayer per year but would eliminate the over $4000 per year we taxpayers are charged to offset the government giveaways to the special interests who do fund the elections? Only then will politicians start voting for policies that are in the best interest of the public.

Jack Lohman
www.WiCleanElections.org

Posted by: Jack Lohman | Mar 5, 2006 12:32:04 PM

Re: "As for universal health care, the tension between Carter on the left and Kennedy on the lefter represented one of the few times you had an effective coalition that could've passed reform -- too bad the left was busy arguing amongst themselves."

So, then, it wasn't much of a coalition, was it? Are you comparing today's universal healthcare coalition to that?

Trapier K. Michael
www.marketplace.md
www.blog.marketplace.md

Posted by: Trapier K. Michael | Mar 5, 2006 2:02:23 PM

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Posted by: peterwei | Oct 22, 2007 7:26:14 AM

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