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January 14, 2007

"Seriousness" on Health Care

By Ezra

Matt Stoller:

Opposition to single-payer health care and muddled plans like [the Hacker plan] or the Wyden one will be the same in intensity. And this one is weird and complicated, like every other plan that isn't single-payer. This is an issue for the voters. We will have to go to the voters and basically ask them to vote to end the health insurance industry. Barring that, and you're just not serious about universal health care.

Yikes. Can Stoller really mean that? The last time the "seriousness" attack was in vogue was the run-up to the Iraq War -- either you were for invading Iraq, or you weren't serious about the War on Terra'. This conversation -- particularly when between progressives -- should operate on higher ground.

So first, let's get something straight. This isn't about "universal" health care. Absolutely nobody who's "serious" about these issues thinks the insurance industry itself is the main barrier blocking universal health care. The insurance industry, after all, has a plan for universal health care, and it would work just fine: We, the taxpayers, would pay them to insure everyone. Universality achieved! And believe me, they would love it.

The reason this country lacks a universal health system is that progressive reformers have been unwilling to sacrifice a just, decent, affordable, humane system for a merely universal one. Universality, after all, is easy. Widespread cost control and quality are not. And demanding a perfect system is easy. But as Presidents Roosevelt, Truman, Johnson, Nixon, Carter, and Clinton have found, achieving such a system is not. Now, the argument over which type of system is the most worthwhile, and which sort the most possible, is a worthy one, and it's perfectly defensible to argue -- as Stoller does -- for nationalized care in that context. But to accuse Hacker, and Wyden, and Pete #*$&*% Stark, and so many others who've devoted their lives to the study and struggle of this issue "unserious" because they don't believe we'll dissolve the multibillion dollar insurance industry in a single legislative penstroke is profoundly, well, unserious.

And a quick note on the politics of this issue. Those of us in the progressive echo chamber tend to hear little but calls for comprehensive reform -- and we naturally believe everyone thinks like our commentors. But two caveats: 1) As many have said before, the operative fact in American health care politics isn't that 15% don't have coverage, it's that 85% do, and they're scared to lose what they've got. 2) Nearly 90 percent of Americans are satisfied with the care they personally receive. Read that again.

Awhile back, I dug deeper into the most current polling on attitudes towards the health care system and concluded that "Folks don't like the high costs and fear they'll soon be overtaken by bills, but they blame all manner of minor and moderate contributors for the problem, not their own health choices, overtreatment, or new technologies. Universal care is heavily desired, but only if it doesn't cost anything or demand any sacrifices. In other words, the appetite for reform outpaces the realism of would-be reformers. The tradeoffs of the current system seem poorly understood, and attitudes towards its desirability are contradictory. Not a whole lot of hope in here for anyone." Serious people may want to take a look. And I also recommend this post by Mark Schmitt, which is damn important for young snotnoses like me who see health care primarily as a fascinating policy issue and important moral crusade.

January 14, 2007 in Health Care | Permalink


Agree with Matt or not, but your comparison with Iraq is specious. The industry stakeholders in this battle will fight to the end any plan which reduces the size of the pie they expect to receive under the status quo, and absent a clear public mandate they'll likely win.

Matt's argument is that a clear public mandate is easier to achieve if you have a simple plan people understand, and a simple plan also has the merits of being a better one. This may be a bad argument, but it isn't a purity argument.

As for SChmitt, someone should tell him that the liberal blogosphere and its readers is not disproportionately young and childless. It's not actually true.

Posted by: Atrios | Jan 14, 2007 7:04:21 PM

"The insurance industry, after all, has a plan for universal health care, and it would work just fine: We, the taxpayers, would pay them to insure everyone. Universality achieved!"
Whoa, whose blog am I reading? You of all people should know this isn't true- we just heard in the last week about professions or conditions the industry will refuse to insure on an individual basis. If the government agreed to pay the insurance companies, they would take the money and still try to cherry pick or refuse to cover certain procedures or conditions. They exist to make a profit however they can, changing who's paying the premiums doesn't change that- that's why you can't just say "Uncle Sam pays the bill," you have to mandate things like community rating.

Posted by: SP | Jan 14, 2007 7:23:53 PM

Yep. The key points to get in our reform are near-total universality and community rating--which is why California's idea is so good.

Right now, we control costs by throwing sick people out of the system--either we price 'em out, trick 'em out, or we won't let 'em buy in. Once we close that mechanism of cost containment, we can start looking at the other means of cost containment.

But we have to set the fundamentals. Social Security's fundamentals are everyone pays in, everyone gets out similar to how they paid in. We need to establish healthcare's fundamentals as well--universal & community-rated, so we all go down together or come up together.

Best use of reform right now.

Posted by: anonymous | Jan 14, 2007 7:45:51 PM

Stoller is expressing something very important, very badly. The fact is that if you want any real improvement in care by the usual progressive metrics (universality, affordability, quality, social justice) which have come to be known in the blogosphere by the shorthand "universal coverage" then you are going to have to take on the insurance industry. When I say "take on" I mean "fight and win." They are not going to roll over and allow their profit to be cut without such a fight.

It's a political point more than an economic one, but it's pretty much the most important point in the whole business. You even sort of refer to it yourself when you look at the polling.

Posted by: Meh | Jan 14, 2007 7:49:19 PM

It is easy to conflate two different "simplicity versus complexity" comparisons. One is, "how simple/complex is this system". The second is, "how simple/complex will it be to work with this system?"

Policy wonks will be drawn to thinking exclusively about the first simplicity/complexity question, when it is likely to be the second one that dominates most people's gut reactions to a proposed new system.

Whether we have an opt-in or an opt-out version of Hacker's plan, what will stick in people's mind is, "if you prefer your present coverage, you can keep it, but if you don't have coverage, or are threatened with losing it, you have guaranteed access to this system".

Posted by: BruceMcF | Jan 14, 2007 7:54:35 PM

The other thing is, of course, whether we like it or not, "Overton Window" is pretty much a factual description of politics these days. The more people advocating more extreme "medical socialism" the more chance the debate will centre on something other than the interests of the private industries involved. As an aside, this really is a chance to really influence the culture of the US in a big way. Health care that isn't massively stacked against the poor and the unlucky is one of the few things that can give "progressive views" some credibility in what is basically a right-wing culture.

Posted by: Meh | Jan 14, 2007 7:56:14 PM

That's certainly true with the insurance industry. What their universal plan entails is to have the government (and taxpayers) basically underwrite those folks at a profit to the insurers. Again, it's bad, but it's universal. And they would love it. Everyone, after all, is insurable at some price, particularly if insuring them ends the calls for substantive reform.

Meanwhile, here's the thing: There is a history of health reform in this country. And it's one of failure. And that failure, as often as not, came when liberals wouldn't compromise. Most experts and historians of the issue believe the last real shot at reform was 74 under Nixon. He proposed a genuinely liberal plan, one that we'd recognize today as rather progressive. Liberals blocked it believing they could do better. They couldn't. And such failures are rife in the literature. So it's one thing to believe single-payer is the best way to go forward, it's another thing to write off those who disagree -- and set the boundaries as single-payer or nothing.

It's worth noting, by the way, that it doesn't necessarily follow that because liberals have lost when they've compromised within a plan, they're more likely, or as likely, to win with unadulterated legislation. At some point, the American people weigh in here too, and I'd be surprised if you could convince vast swaths of, say, the Interior West, that they should trade in their Blue Cross for a new government insurer that'll now be their only choice. Folks remember the awful Besty McCaughey smear job in The New Republic. It was called "No Exit," and the attack was -- falsely -- claiming that the Clinton plan would allow "no exit," it would end the option of private insurance -- government care is all that would be available. It was, folks should remember, a very effective line of attack, which is why it's so famous. And in this case, unlike in that one, it would be true. Now, maybe it could be overcome, but it's part of the history that liberal legislation has been torn apart based on the argument that it would do what Matt's saying it must do.

Meanwhile, the Iraq analogy is about language. This "seriousness" stuff has to end. I've been guilty of it too (in other contexts), but we should have arguments, not just marginalize those who disagree by terming them "unserious." I'll say this again: Matt's formulation calls Pete Stark unserious. Stark, who passed a Medicare-for-All plan out of committee when Matt was (if my math doesn't fail) either 15 or 16, is about as serious as you get on this stuff. So believe what you want, uphold the plan of your choice, but don't write out allies in the progressive movement who are fighting the same fight and have a slightly different tactical conclusion.

Posted by: Ezra | Jan 14, 2007 8:14:00 PM

Stoller's objections seem very scattershot - and very "I'm opposed to the system, man" which is entirely the rad progressive I dream of being... but then woke up. I think he's right that by focusing on insurance, progressives negotiate themselves out of considering other ways of attacking the problems in health care - and again, it's health care you want to fix, ultimately, not insurance.

Otherwise, Ezra, I'm damn impressed by your points here - I've been a longtime wet blanket on healthcare issues over just these concerns - people are resistant to change, and many do not understand the extent of the issues involved and the changes required. I think you can work within the challenges we've got (employer-based insurance, multiple systems, poor cost controls), or as Stoller suggests (badly) you can blow up the system and start over. Time and aging have made blowing shit up less attractive to me. But it's worth discussing, if only to help drive some creative thinking around this issue.

Posted by: weboy | Jan 14, 2007 8:18:44 PM

the liberal blogosphere and its readers is not disproportionately young and childless

Really? I would think it is. What do you base this denial on?

SP, the insurance industry would accept and has actually endorsed universal insurance coverage. It would involve mandated community rating if it was going to work well, and insurers have made ir clear they can live with that.

Posted by: Sanpete | Jan 14, 2007 8:41:54 PM

It should be said that Mark, in that response, was issuing a devastating critique of me in particular -- and I really am quite young and childless. I tend to think the echo chamber effect is more distorting than demographics, but I think his post is a useful corrective on both fronts. We're in bad shape if we assume that Americans, in some sort of durable and sustained way, want to eliminate all insurers and move to a government-run system without alternative options. Again, we all lament the smears of TNR's "No Exit" article during the Clinton fight, and that's because it was an effective attack that genuinely scared people. That seems soem history worth looking at more closely.

Posted by: Ezra | Jan 14, 2007 8:48:32 PM

I agree with Meh about Overton's Window - we should have people demanding "socialized medicine" of every possible kind, just to make it sound more reasonable.

I want a whole think tank that is dedicated to pushing NHS-style (original version) healtchare (and maybe even another one that really does demand "no exit"), just to make it clear that single-payer is really the centrist option.

The Overton Window.
You can't go to the bargaining table and just ask for the "reasonable" outcome, or you'll be haggled down to the unreasonable one. You start with unreasonable demands, then you dicker.

Posted by: Avedon | Jan 14, 2007 9:03:09 PM

> There is a history of health reform in
> this country. And it's one of failure.
> And that failure, as often as not, came
> when liberals wouldn't compromise.

The problem, as I noted over on deLong's site, is No Child Left Behind. It _appeared_ to be a compromise. Many liberals signed up. Ted Kennedy helped push it through.

But it turned out that NCLB was filled with stealth time-bombs specifically designed to create non-liberal secondary effects. These time-bombs are actually activating right now, and doing great damage to the liberal idea of public education.

So perhaps this is a case of "fool me once, shame on you; fool me twice, shame on me".


Posted by: Cranky Observer | Jan 14, 2007 9:06:43 PM

It is indeed the case that you probably shouldn't compromise when your opponents own the Presidency and Congress (or even part of Congress). But we're not getting single-payer in those cases either. You can't bargain from a position of total impotence.

Posted by: Ezra | Jan 14, 2007 9:09:33 PM

There is a history of health reform in this country. And it's one of failure. And that failure, as often as not, came when liberals wouldn't compromise.

Ok, I give: why is Medicare a failure?

Posted by: calling all toasters | Jan 14, 2007 9:21:18 PM

Mostly the necessity for compromise is the sticker. It is actually likely more cost-effective to cover basic health care costs out of general revenue and not set up a whole accounting system dealing with state tariffs and collections. The question is what will be covered.
Emergency services, inoculations, etc. are already dealt with one way or another. Rolling them into a general program is no big deal. Workmen's Comp can be considered a separate proposition or not.
It has to be no more radical than a proposal to have Public Liability Auto Insurance mandatory as part of Motor Vehicle Reistration.

Posted by: opit | Jan 14, 2007 9:25:17 PM

It's not; it's a case in point: Medicare was a compromise. Johnson went for elderly care because he didn't think he'd be able to get it across the population. And that was the finest legislative tactician ever to hold the presidency operating in the aftermath of a popular president's murder and a liberal landslide in Congress. Now, the underlying spending trends have rendered UHC more achievable, not less. But the fact that liberals actually decided to create universal care for a specific group (and a group that, in many ways, was uninsurable) is evidence that they couldn't get it for everyone.

Posted by: Ezra | Jan 14, 2007 9:27:11 PM

As has been pointed out, the opponents of major change will fight, and judging from the Harry and Louise ads from 92/93, they will be mostly factual, but very misleading. Fear will be their friend.

So, where, if anywhere, will the counter argument come from, whether we liberal/progressives settle on Wyden, Hacker, or whatever?

Until the left is willing to raise enough money to speak loudly and carry a big stick, the public will be frightened into the status quo. It might take $100 million on hand to launch a education/advertising plan to support whatever we end up supporting on the left. That has to be private money, not governmental. If we don't organize to raise that money, any new plan is doomed, because only the corporate voice will be heard.

I'm not enthralled about incrementalism on health care, but a clean, comprehensive, universal, community rated plan with unified backing on the left will be lost in the dust UNLESS the public and businesses that pay for healthcare are offered a real choice of staying with what they have (like Hacker's proposal), - maybe temporarily, until they change their mind - or going to a new plan.

The opposition to Social Security and Medicare will be not good reference points. Retirement Income, and Health care in the 30's and and 60's were not huge portions of the GDP - now they are.

I really hate the thought of private insurance being in the health care equation, but they won't be forced out, and the price for buying them out is far too high. But we can compete public vs private, and offer a genuine choice - but only if our voice isn't drowned out by the corporate and right-wing megaphones, including media that luvs to stir up conflict because it sells eyeballs.

Who is going to raise the $100 million that selling even an alternative choice program will cost in education and advertising? Without it, Congress will not touch the third rail of substantial change in healthcare and we won't get universality of coverage, we won't get community rated fees, and we will have lost again.

Posted by: JimPortlandOR | Jan 14, 2007 9:30:19 PM

Cranky, let's hope that liberal public education has taught Johnny Progressive to read legislation by the time health care is on the table.

Posted by: Sanpete | Jan 14, 2007 9:36:29 PM

We're in bad shape if we assume that Americans, in some sort of durable and sustained way, want to eliminate all insurers and move to a government-run system without alternative options.

Exactly. Look at what's happening in Canada. The Canadian public is surely more supportive of single-payer and government-run health care than is the American public, but even in Canada an increasing share of health care services is provided by private clinics and funded by private insurance because the state system is unable to satisfy public demand. Even Britain has a large private health insurance industry. The idea that there's any realistic chance in the forseeable future of dismantling the U.S. private health insurance industry, or even of reducing it to a small role, and replacing it with "Medicare For All" or somesuch is a liberal fantasy.

Posted by: Jason | Jan 14, 2007 9:43:08 PM

I can't be the only one who is sick of hearing the word "serious" get seriously misused as a rhetorical device on a regular basis.

Posted by: Rebecca Allen, PhD, ARNP | Jan 14, 2007 10:01:36 PM

Posted by: Meh | Jan 14, 2007 4:49:19 PM:

They are not going to roll over and allow their profit to be cut without such a fight.

And the more disruption that is created by the proposed plan, the more weapons are placed in their hands by the fight.

In that fight, how do we get the doctors, hospitals, nurses, lawyers outside of work hours, small business, and big business on our side, and the health insurance companies in the other corner with their paid advocates.

"Threaten as much wrenching change possible to as many as possible" would seem to be the strategy that Matt Stoller is proposing for that necessary fight.

Posted by: BruceMcF | Jan 14, 2007 10:32:34 PM

Ezra: "Universal health care isn't really the issue."

I'd add to Ezra's observations that you could argue we already have universal health care today: the emergency room. Go in, they have to take you. It's just the least efficient, least effective, least humane vehicle you could deliver universal care with. The problem is containing costs, and there, the chief problem is how the health care dollar has to travel through all these boxes marked "HMO", "PPO", "PDB", "TPA", and so forth before it ever gets to a patient. And every time the dollar travels through one of the boxes, a little piece comes off and stays there and does basically nothing except enrich the people who own the boxes. The single-payer idea of just wiping out the boxes has a lot of appeal to me, although I don't think it's the only way to do universal care, for heavens sake. And I'm skeptical of trying to do single-payer - or any universal health care plan for that matter - in one big leap all at once.

On the idea that single-payer will sell because it's simple to explain, Oregon had a single-payer health care bill, Measure 23, on the public ballot in 2002. It failed by 21.5% to 78.5%. California had a single-payer bill, Proposition 186, on the public ballot in 1994. It failed by 27% to 73%. If this is such a great idea that everyone supports and is so easy to sell, how come it's failed among the public by 50 points in two Blue states?

I agree that this problem isn't limited to single-payer, and that any universal plan would face very similar PR problems. People have a hard time believing it when you tell them your big mammoth health care plan is going to cover everyone and save money at the same time. It may be the truth, but it's a very counterintuitive idea for most people. It requires a big leap of faith from people who are afraid of losing what they already have.

That's the main selling point behind approaches like "Cover All Kids First", that children are cheaper to cover, and more sympathetic figures in the publics mind, and therefore, it's potentially easier politically to get a plan covering them passed. So you try and do them first, and then show people that you can save money this way. Trumpet the savings constantly each year. Earn the people's trust. After the failure of ClintonCare, and the California and Oregon initiatives, there was this attitude like, "Man, what's wrong with people? They need to get over their distrust of us if America's ever going to move forward." That's putting the burden of proof in the wrong place. The burden is always on the people making the proposal to prove that it'll work. Progressives should embrace that responsibility.


Want to see Stoller's head explode? Al Wynn was a cosponsor of single-payer health care last session of Congress.

Posted by: Chris | Jan 14, 2007 10:41:34 PM

I'd add to Ezra's observations that you could argue we already have universal health care today: the emergency room.

Actually, we're already a lot closer to "universal health care" than just guaranteeing the right to emergency care. There is a large network of public and private programs and institutions that provide a variety of free or low-cost health care services to the poor and uninsured. In addition to Medicaid, there are things like the federal government's Community Health Centers program, which provides free primary care for the poor, and SCHIP, which provides low-cost health insurance for children, and the BCCTA, which greatly expands the eligibility of poor women for treatment under Medicaid for breast and cervical cancer.

Posted by: Jason | Jan 14, 2007 11:23:01 PM

I'll quote the guy who gets held up as the gold standard for fighting progressives.

"I want to say -- and I want to say to Minnesotans, I believe that it's just wrong that people should go without health care. [Applause. Cheering.] We must have universal health care coverage. But if we can't -- but I understand what I'm hearing from people in Minnesota. You need to listen to people. And if we can't do it all at once, then let's at least move forward. Let's make sure that we have affordable health care for children, [Applause. Cheering.] let's have home-based health care, let's have health care for elderly people with dignity! [Applause. Cheering.] And veterans -- and to the veterans -- and to the veterans in Minnesota, oh how you've stayed with me! I'll stay with you, and we'll make sure there's good health care [Applause. Cheering.] for veterans in Minnesota!"

--Paul Wellstone, Election Night Victory Speech, 1996.

Also note Wellstone's Health Care page on his 2002 reelection website. No mention of single-payer or big universal health care plans.

But yeah, it's typical of Stoller to think he knows more and has more moral authority and political smarts on whatever the subject is than people who have been fighting these fights for decades.

Posted by: Chris | Jan 14, 2007 11:24:39 PM

He has a point that the industris involved in healthcare aren't interested in reducng costs. Look at the pharmaceutical industry- they have a vested interest inthe status quo. Surely, you don't deny that?

Posted by: akaison | Jan 15, 2007 12:16:04 AM

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