Why Can't My Team Do Whatever It Wants!?

Ezra Klein is annoyed with the Obama adminstration’s pusillanimous pussyfooting. Even that foul-mouthed hard-guy Rahm Emanuel is a squish these days. Why are the Democratic powers-that-be willing even to entertain the lame “trigger” public plan, which kicks in only if private plans fail to hit certain benchmarks for performance. Klein:

What Emanuel is saying here, however, is that in 2009, when Democrats control the White House, the House of Representatives, and the U.S. Senate — and have larger margins than Republicans ever did in the latter two — that they are interested in settling on the same policy compromise [behind Medicare Part D, a product of a Republican president and Congress]: a weak public plan that would be activated if certain conditions aren’t met by private industry. That’s a bit weird. Weren’t elections supposed to have consequences?

Policy follows public opinion, more or less. And the public hasn’t really changed much since 2003. This is something partisans have to learn and relearn again and again. If a policy was unpopular before a change in the party controlling government, it will probably remain unpopular after. And politicians like getting reelected. It’s pretty simply, really.

Bush couldn’t reform Social Security because his plan was unpopular. Obama won’t be able to deliver a health-care bill ideological Democrats want, because what they want is unpopular and legislators know it. So Congressional Democrats want something they can cast as “victory” while doing nothing that could hurt their noble struggle for ongoing political self-preservation. Right now, strongly ideological media liberals like Klein have to decide whether they’re going to (a) act as enforcers, sending the signal to the powers-that-be that they will vocally and publicly count a “trigger” plan as a pathetic failure, or (b) sigh and prepare to declare whatever legislation passes a profound victory for ordinary Americans that shows just how great Democrats are.

But I imagine this one’s a tough call. For lots of ideological Democrats, the point of preserving political capital is to secure real universal health care. So I expect to see a fair amount of (potentially counterproductive) enforcer rhetoric.

Author: Will Wilkinson

Vice President for Research at the Niskanen Center

23 thoughts

  1. Jen, Yes. Reform is very popular in the abstract. Even a government-run system. But most people are quite satisfied with their current plans. So support for systemic changes turns out to be shallow. This is what Clinton learned. As soon as people get the sense a new policy will force a change in their own situation, they break off. That's what Obama's people are worried about, and why the constantly return to the “you won't have to change anything” refrain, even though the goal is to have everybody change into the government plan sooner or later.

  2. Will, what's the downside to the government buying everyone under a certain income level a catastrophic policy with a low premium and high deductible? That way, everyone gets insurance that prevents them from being bankrupted by disease. Obviously, they would have to force insurers to accept all kinds of insured, but at least they could keep an environment of competitiveness along other variables, besides refusing service to the chronically ill.

  3. Sounds better than what is being proposed. The downside for many Democrats is that it's not universal, which they think we need to lock in political support for the benefit.I'd prefer a Singapore-ish mandatory high-deductible risk-rated insurance policy with forced savings into HSAs, and transfers into HSAs for people under a certain income level.

  4. A high deductible plan won't insulate people from much of their health care costs. That's the downside: people will have to decline treatments or tests that their doctors have recommended.

  5. I must be the only person in America without strong views on what federal health care policy is most desirable. The US is an astonishingly rich country, and will be for the foreseeable future, and rich people pay medical professionals scads of money to keep them in relatively good health. Sure, Canada spends less, but they still spend a lot. Canada rations, but we do, too — through HMOs (though I have to say, if the HMOs just stopped nickel-and-diming people at the margins on things like pre-existing conditions, systematic and overbroad denials of coverage, and policy recission, they could take the wind out of the Democrats' sails at the cost of taking only slightly smaller profits). We can use policy to play around with what gets rationed, or we can have the public sector take over more or less of the HMOs' business, or we can pass laws that make it more or less profitable to run an HMO, but the actual amount and kind of medical services provided are going to be roughly similar in all possible worlds. We'll still spend a lot, and doctors will still be pretty wealthy, under Ezra Klein's very zaniest scheme. And we aren't going to devote 100% of GDP to achieving the maximum possible life-extension. (Though maybe in the future when we develop replicators and the like, and develop extremely expensive technology that enables us to live greatly extended lives, roughly 100% of the economy will be consumed by health care, very broadly understood, with other professional services and a rump manufacturing sector comprising the remainder.)Of a piece with that rambling, Will, I do think you overestimate public satisfaction with the current health care system, unless you're trying to say something about the public's revealed preferences. You're confusing satisfaction with risk-aversion. “I could get treatment for X horrible catastrophe now, but I have no idea what those penny-pinching bureaucrats will do to me!” The public may be excessively sensitive to risk, or their risk-aversion may be perfectly understandable, and maybe even rational — precisely because we're talking about potential catastrophes. In fact, one of the reasons that this whole discussion is so confused is that no one comes out and says, “I think we should adopt this policy, because it appropriately deals with the risk of medical catastrophe in our lives.” Also people have really, really confused ideas about risk. And I suspect that different segments of the population have different attitudes toward risk. Do Republican small-business owners have a hugely positive risk assumption regarding the likelihood of their getting incredibly sick, or of being able to deal with the bills of the bankruptcy? I don't know, but sounds like it might be true. What about different classes? Do men and women, marrieds and unmarrieds (and POSSLQs!), or parents and the bravely single (and, for that matter, what about mothers vs. fathers)? Again, I don't know, but I suspect that attitudes toward risk have something to do with the underlying rhetorical dynamic here.My point is that all those surveys showing that people are dissatisfied are surely sensitive to something. I even saw one in which “socialized medicine” polled above 50%! And you don't see Republican politicians, who presumably know something about public opinion, going on TV to stick up for HMOs.

  6. I just want everyone to get covered, and soon. The problem is that any particular policy proposal has downsides which can be exploited in argument, but simply saying that you see a vast need and responsibility to provide coverage gets you labeled unthinking. Meanwhile, a genuine crisis that causes a really tremendous amount of human suffering continues. It's tough.

  7. I love the gold-plated union bargained-for insurance that (most of) my family enjoys right now. Would I hate to go to something worse? Sure, and that includes high-deductible plans. However, as the recession continues and layoffs increase, I suspect more Americans will start to wonder “what if that happened to me?” and look around to discover that many of them will be absolutely screwed if they lose their jobs and get kicked to the individual market. It's what Steve M. says below–Americans are risk averse. If the risk is they get something worse, they don't want it. But I think this time is different because more people see the bigger risk as losing their insurance b/c of economic changes anyway, and they want some sort of alternative to the brutal individual market rife with recissions, denials for pre-existing conditions, outrageous premiums for families, etc. That's why we're seeing polling this time that is quite different than what we've seen in the past.

  8. I understand the sentiment behind this view, however it belies the problem of the path not taken. I can avert this problem here in front of me by clear means. But what is wholly unclear is the new human suffering now or in the future that will be created by doing so. Your logic seems to be consequentialist in nature, and to justify this on a consequentialist level you have to show that this change will not cause some other worse consequences elsewhere.

  9. Considering that Medicare, and social security, enjoy broad popular support, it looks to me as if reform is quite popular in the concrete as well.

  10. This is something that I have argued with Megan McArdle about before. It's true that there is a certain rhetorical advantage in arguing in favor of filling tangible need over theoretical need– “let's feed this starving person” is indeed easier to argue than “but doing that might create more suffering down the road.” But I argue that there is a parallel advantage in arguing the other side; as long as a need is theoretical, you can assert it's size and strength without any basis in reality. In other words, there's no referent to real life, so there's no evidentiary basis for someone from my side to refute it.Of course, this is all pretty damn theoretical anyway, at this point.

  11. I like your analysis very much, Will. Related to your “unpopularity” point, there is a symmetry also with “starve the beast”, which says ratchet down the taxes because people don't like them raised, so you'll put tax-and-spend liberals in a box. This could be called “gorge the beast” (in this case the beast is the American taxpayer), where you ratchet up benefits because people don't like their benefits cut.Either way, the notion is that once you get over the hump of popular squeamishness, you'll have made a near-irrevocable change in public policy. Essentially both political parties are playing on a prospect-theory-based model of the American voter.Bush succeeded in doing this. Of course, it was seen as very irresponsible and eventually everyone hated him (but they still don't want their taxes raised!). I guess Obama's willing to take the risk because as you said, this is the whole domestic-policy raison d'etre of many liberals, and it's the best chance to get it in a long time.

  12. This is quite theoretical indeed, and if we're going down the road of theory, let's push it all the way. John Broome is one of the more notable ethical philosophers who deal closely with healthcare, and is a consequentialist, which I gather from your reasoning above you are (or at least are sympathetic to) as well.One of the problems Broome notes (in Weighing Lives) is the question of discounting over time. If you discount for the future, you seem to be valuing future lives less in a way Broome finds quite repugnant. That is, saying someone's life is worthless because of when they happen to live it. If you don't discount for the future though you end up in situations where present information is woefully inadequate to guide actions.

  13. Singapore's system is irritatingly MIA in this debate. Their health system is cheaper than any in Europe, and with outcomes at least as good.But its arguably more free-market than the status quo so the Democrats don't bring it up. And advocating it requires a measure of coherent thought so the Republicans don't bring it up.

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