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March 24, 2005

The Beauty of Mediocre Policy

Responding to my health care post earlier, both Brad Plumer and Kevin Drum argue against incremental strategies and for a campaign towards single-payer. With such opposition, I think I should spend a few moments saying why I disagree. I recently read The System, an exhaustive account of the 1994 health care battle. Also recently, I've watched Bush's Social Security plan -- and yes, he has a plan -- get strung up by its thumbs. Taking the two together, I've basically concluded that it's impossible, in non-crisis (i.e, non New Deal or post-9/11) situations, to push sweeping legislation through Congress. The System, excuse my Broderian terminology, is really set-up, and at this partisan moment, primed, to resist and demagogue such change. And it succeeds.

Americans didn't want Clinton's bill to be defeated. Which is to say, they wanted Clinton's bill to be defeated, but only their perception of it. If you actually polled them on what they wanted in a health care system, it tracked their wishes quite precisely. And if you asked them whether or not we needed reform, they were all for it. But Clinton's plan was complex, hard to explain, and easy to destroy. After all -- selling a proposal like that requires explaining it, killing one merely demands you characterize it. The latter can be done simply -- big government! -- the former, not so much.

Similarly, I don't think voters are against Bush's plan. I think they would be if they understood the long-term economics of it, and they are when it's characterized as a benefits cut (which it is), but if you poll them, they repeatedly say Social Security is headed for a crisis and majorities continually support proposals allowing partial, optional investment of Social Security returns in the stock market. Which is what Bush is proposing. But Democrats have, without really trying, been able to destroy Bush's ability to push his ideas. Americans rightly don't trust him, and so anything that emerges from his desk or party faces enormous skepticism. Even though they still say they want what he says he's pushing. It's quite strange.

Which brings us to the CAP proposal. I agree that, as policy, it's less desirable to simply rejigger, rework, and expand what we have. But it's also simple. The beauty of FEHBP is less the program than the idea -- this is what the Senate uses. And if you want, you can have it too. It's easy to understand and it ties into the "classless" image people want to have of America, a land where the peasants are treated like the kings. Medicaid too is easily understood and already functioning, nothing new nor scary there. And the idea that the government will guarantee premiums don't rise beyond 7.5% of income, that's completely comprehendible and damn attractive. It all works rhetorically -- it can be sold as simply as it can be demonized.

Now, Kevin's fears are not misplaced. It's still a big program and it might lose. But I've become convinced that the only big programs we're able to pass are big expansions of old programs. So you can add a drug benefit onto Medicare, but you can't change Social Security or remake American health care. Down the road, I think, these changes can lead to others shifts: people become familiar with government involvement in their health care and so they're not as stunned by more government involvement in their health care. For now, I think this incrementalism using the familiar is all that can survive the PR wringer. Big, new ideas get shredded, with Social Security privatization and Clintoncare being examples of varying quality, but big, old ideas can be accepted, like the massive expansion of Medicare.

And that's why I support CAP's proposal -- it's a big, old idea that I think can lead to big, new ideas. Brad's no fan FEHBP, and I trust his judgment. On the other hand, what I've read on it has been different, so I'd need to see some pretty damning evidence. For now, I'm not convinced that it's an undesirable tent for health care -- though it's certainly not the most desirable tent -- and I'm quite impressed with it as a politically sellable program. And that, in the end, is what I'm looking for: a way to break the health policy deadlock. I think this sort of proposal is it.

Update: Sorry about the acronym confusion. For some reason, I mentally merged CHIPS and FEBHP to create CEBHP. The joy of alphabet soup. Anyway, the program is actually FEHBP -- Federal Employee Health Benefits Plan. Also, changed the last few sentences for clarity.

March 24, 2005 in Health Care | Permalink

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Comments

I dunno. Maybe that's generally true, but if care were taken to unite none-medical business behind this legislation, I thought it ought to be possible. Single-payer has kind of a unique advantage in that. It might require concessions on other fronts to put together such a coalition, though.

As for social security - I would disagree. Obviously it is true that there is support for a partial investment in the stock market, but you and I know that Bush's plan is a... little different than that.

Posted by: Sandals | Mar 24, 2005 7:39:50 PM

I agree. But I have you and I aren't the median voter on this.

Posted by: Ezra | Mar 24, 2005 7:46:54 PM

Utta Boy, Ezra! Good defense of your ideas and the CAP health proposal.

Brad Plumer's distaste of the health insurance program for the Senate, House, Judiciary, and all executive agencies doesn't appear to be bolstered by any references. The program is formally called the Federal Employees Health Benefit Program (FEHBP) (I don't find CEHBP - to which your referred- when I google).

I've never heard any complaints about FEHBP, probably because the many insurance companies that provide options under the plans are the same companies that provide health insurance to large companies.

I receive health insurance through a large Calfornia corporation from United Health Care (UHC) - which does a super job from what I've heard from everyone I know that they insure. If I were a federal employee, I would have a choice of 22 plans under FEHBP in my city (Portland OR, zip 97201), but not UHC. About half of the FEHBP plans for my area are nationwide plans.

The public has been made even more sceptical of change by the recent social security privatization proprosal from BushCo, so your comment in the post is on-spot.:

For now, I think this incrementalism using the familiar is all that can survive the PR wringer.

Maybe ANY change now to health insurance is off-the-table for a while (due to the public distate for BushCo social security privatization), but surely the CAP plan is the easiest to explain and less threatening.

Another factor to consider is the new Medicare Drug Plan, not yet in operation. I think the 'donut' hole in the coverage is likely to arouse outrage in Medicare participants when it goes into operation next year and seniors realize how much they will have to pay out-of-pocket.

So, modest, easy to understand plans that offer lots of choice, and not much change are the best that can be sold, IMO.

If the Dems got behind this, perhaps a CAP-like plan could be sold to enough Republican moderates to pass (without major poison pills). Even if not, the Dems would gain points for proposing a moderate, easily understood approach which would help regain creditability for the Congress lost by BushCo/Republican social security schemes.

Dems can't lose by by being responsible on this issue. But neither can we gain by inaction or for bringing forth a proposal for total redo (single-payer) of an industry that is 7% of the GDP, and would affect every citizen in the country. That is just too much change for a polarized electorate.

Thanks Ezra. for taking on this complex topic with some ideas that sound too moderate to some, but will also sound to ambitious to others.

Posted by: JimPortlandOR | Mar 24, 2005 8:27:41 PM

Ok, I'll try to write up more on the FEHB program later tonight or tomorrow and resolve (or rekindle!) this little wonky controversy.

To be clear, though, I don't "hate" the FEHBP, nor do I have a "distaste" for it, and I especially don't think it's "evil" -- the program does a lot of good for a lot of people, and of course, as JimPortlandOR says, many people enrolled in it absolutely love it. For what it does, it's fantastic. As a model for broader reform, uh-uh. But crikey, it's not like I'm against federal employees getting health care... heh.

Posted by: Brad Plumer | Mar 24, 2005 8:38:50 PM

One of the center-left econobloggers -- I can't remember if it was DeLong or the folks at angry bear -- has pointed out that FEHBP expansion is a trojan horse for single payer health care. That is, once the FEHBP is made available to the public and subsudized, it will rapidly become the only game in town. After all, why stick with the private system when it doesn't have the cost controls. I'm hunting around for the post but I keep getting articles about how the Bush AHP plan destroys the health care system.

Posted by: niq | Mar 24, 2005 9:13:29 PM

You have to watch that no program competes with private plans. Any government supplier group can be ruined by political means, there's no level playing field. That means restricted monopoly.. something I can't see flying...not that it shouldn't.

Posted by: opit | Mar 24, 2005 10:22:57 PM

I've been thinking about this very thing, recently.

Why not have a governor of a smallish state -- one in which the Dems control the state legislature -- solicit bids from the big insurance companies for a policy that would cover everyone in the state? The Canadian single-payer system is administered on a province-by-province basis, from what I remember, and the Canadian movement toward single-payer became national only after other provinces realized what a great idea it was. Any Canadians out there know a more detailed history of the single-payer movement? We might start by studying how the Canadian movement reached critical mass, and go from there.

As to the state we should target? New Jersey, I'm thinking. It's on the small side, but it has some political pull, nationally; it has odd-year elections for state leg. and gov., which means we can get good people on the ground who wouldn't be otherwise occupied with federal campaigns; and Corzine is a pretty good guy who might be amenable to spear-heading such a campaign.

I wonder what a group policy that insures over eight million people would go for?

This idea is probably hopelessly naive, but it might be worth kicking around.

Posted by: braincramp | Mar 24, 2005 11:18:37 PM

opit,

I think most of these plans will conflict with private insurance in some way or another. If the ultimate goal is nationalized health care, they must. Just having the government require enrollment in a health care pllan is going to shake up the administration of hospitals and practices nationwide.

Good posts Ezra. Got me thinking. I agree we can't push for single payer right now (especially not with this president and congress) but I'm really uneasy about CAP's approach.

Posted by: Kate | Mar 24, 2005 11:26:29 PM

I can see my personal clock getting cleaned on this. I am a retired NASA engineer and have FEHCP and Medicare coverage. Bundle everyone in those plans and I will be so screwed by the process. Us retirees, US gov version, have been riding under the radar so far and hopping that the politcos don't put us under the microscope or more accurately under the crosshairs. Hope to hell they don't screw up my long term care plan too.

Posted by: dilbert dogbert | Mar 25, 2005 10:43:55 AM

Most of this is, well, naive. Fundamentally, what Americans want - or, as Ezra does so adroitly observes, what Americans have been told to want - is a relationship between them and a doctor. Anything that smacks of getting in the way between them and a doctor - managed care, subsidized plans, what have you - is perceived as damaging our system, touted as the best in the world (it's not, but that's another issue). Their doctor, furthermore, should be able to prescribe whatever care he (or she, but mostly he) deems necessary, be it expensive drug therapies or needless tests or pointless surgery. To do otherwise jeopardizes, in this meme, all of our ability to get that best healthcare in the world. Which we don't have, but that's still another issue.

Look, I think there are some things around "single payer" that are interesting, and moving FEHBP to cover more people has some good things in it, but the "problem" of health care is something more fundamental - a really, really broken model for delivering appropriate care to most people with an understanding that to care for all, care will most likely need to be rationed in some form or fashion. Many good, thoughtful liberals who support, ultimately, a single-payer plan tend to lose their way when confronted by the fact that people want to be able to choose a provider and expect heroic efforts even when they aren't necessary, won't help, and may cost too much to be generally feasible.

If all we do is tinker on the insurance side of the equation, doing nothing to rein in pharmaceutical costs, or look at best practices and mandate specific treatment modalities where appropriate, while reducing America's reliance on hospitals in favor of other delivery systems, we aren't going to get anywhere. Really. The insurance system we have is in place partly because the costs for health care are completely out of whack. Price controls aren't the answer. And any solution that forces greater cost on fewer insurers (or worse, makes our government the main payment source) will make things demonstrably worse.

And most pointedly, Americans won't buy into it. There are too many vested interests - doctors, hospitals, and pharmaceuticals, to start with - with competing goals playing on Americans' - mainly middle and upper middle class professionals - fears that their quality of care will decrease with every plan to change insurance. Until someone cuts through some of the clutter about cost, and quality, and rationing, and gets Americans to face some hard truths, there won't be much change, incremental or otherwise. And I worry that by making it central to the party, Democrats set up a revolving door of problems - reminding Americans that something is broken, and then lacking the will to do a real fix. Because Americans, who most prefer sunny upbeat presentations of solvable problems, will be really unhapy with anyone who tells a really unpleasant truth - that our health care system is not only deeply flawed, but also often does a poor job of caring for people; and therefore it is not the best in the world.

Sorry to drone on so, but the issue, while it fascinates me, also concerns me.

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Posted by: peter.w | Sep 15, 2007 4:16:44 AM

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