24 December 2009

Health Care Reform: the Optics of Success

I've had a couple of days off work now, and it being close to Festivus, I've spent a fair amount of time driving back and forth from the mall, parties, various errands, etc.  I tend to listen to news radio (at least until the commercials start driving me crazy and I have to turn on my iPod), and I've also caught some of the nightly teevee news. The lead story, of course, has been the deal and imminent passage of the Senate health care bill.

Now, I've been like, all-health-care-reform, all the time for about eleven months now, and so deep in the weeds that, for me, the big news was that Wyden got a modified version of his "Free Choice" amendment into the bill.  Woo Hoo, amIright?  But being so deep into things, I rarely gave much thought into the "How's this going to play in Peoria?" argument.  Further, since the Senate deal involved a gutting of the most progressive provisions, which has sparked the traditional round of fratricide in Left Blogistan, it certainly has not felt exactly like something to celebrate so much as something to swallow.

So I was a little surprised by the tone of the Emm-Ess-Emm's coverage.  It was laudatory, even triumphant.  It intoned gravely about the "historic" passage of reform.  There were clips of Obama praising the bill.  There were the obligatory counter-clips of GOP back-benchers grousing about the bill being Bad For America, but overall, the subtext was this:

Obama/Democrats Win Big.

Seriously?  No mention of the horrible price Lieberdouche exacted for his support?  No mention of the humiliation of the Senate leadership by the Conservadems?  No "Obama forced to accept crappy-ass compromise" storyline?  Nope.  Wow.  Sure, there was the obligatory mention of the "controversial" public option and its death, but in the context of "Obama Wins" this was relegated to no more than a brief aside.   Bear in mind that I'm talking network news, NPR and local news outlets mostly, not the WaPo or other "insider" publications.

It is, of course, not yet a sure thing that the whole bill will ultimately pass.  Byrd is only barely still legally alive, and the thing could fall apart in conference if the House refuses to sufficiently abase itself before the awesomeness and glory of the Senate.  If it does, however, this really is a win.  It's a win as it is judged by the most important arbiters: the voters who are outside of the beltway and not intimately interested in the details of policy.  Yes, I know that reform polls poorly right now; that's to be expected given the controversy and continuous attacks on the proposals.  Once there is a final bill enacted into law, the coverage shifts from "beleaguered reform" to "reform triumphs" and the proponents get to take a victory lap in the media touting the great things the reform does contain.  (And that's even before the goodies start to get handed out.)  I suspect that public opinion will swing back in favor of the reforms, and the majority of people who are not directly impacted will file it away under "Well, that's settled, then, isn't it?" and go back to watching So You Think You Can Dance.

This is not to dismiss the anger of the teabaggers -- I do not doubt that it is real.  I also do not doubt that the Democrats will lose seats in 2010.  It's a natural year of retrenchment.  However, it would have been pure suicide for the Democrats to have embarked on reform and failed to deliver.  That would have set the stage for 1994 redux.  If reform does pass, economic fundamentals being what they are, the Dems will lose seats in both chambers, though I doubt they'll lose control of either, but they'll lose far fewer than they would have if reform had failed

If health care reform, the linchpin of Obama's and the congressional Democrats' election campaigns, were to fail, it would send the following message: Democrats are incompetent and cannot be trusted to govern.  (Which may not be too far from the truth, politically.  Insert Will Rogers joke here.)  Voters can accept partisanship, but they are not tolerant of incompetence. (See 2006 and Katrina.)

Obama understands this.  He understands that the Public Option or any of the other liberal shibboleths could and must be discarded if that if the price to get the vehicle across the finish line.  Which is why he never threw his weight behind it or drew any lines in the sand.  He is prepared to sign anything Congress gives him, and it's a happy coincidence that the "final" reform bill is looking to be flawed but highly worthwhile.  It may not be the eleven-dimensional chess his supporters credited him with, but it is the hallmark of a relatively savvy political operator.  If and when he gets to have the big signing ceremony, he will reap the rewards of his pragmatism.


  1. Alas, the passage of this bill will:

    1) Ensure costs continue to rise unabated. Private care costs rise more slowly than public care costs today, and that has been true over just about any short or long term time horizon.

    2) Move coverage from 90% covered (or could be covered if they wanted to) to 95% covered.

    3) Result in FEWER choices.

    4) Results in a big tax increase on those making from $50K to $80K...aka the middle class

    In the end, this bill gives coverage to 5% of the population that wants and needs coverage but can't afford it. That's a good thing.

    But we could have covered them for less than $60B/year.

    I'm glad to see that we can't be denied coverage.

    I wish the administration would have just been upfront from the gitgo and said "This is going to cost a crapload, taxes on everyone, including the middle class, are going up substantially. Those that have great insurance today are going to see it turn into mediocre insurance. This will do nothing to change longevity. This will do nothing to control costs."

  2. Anon,

    Agreed that upfront honesty and frankness might have been nice, but the sad political realities is that in politics it doesn't work. When you concede at the outset that the final product is going to be a steaming turd wrapped in a bow, the process tends to bog down.

    As for costs, it's to be seen how effective the cost controls I outlined and summarized here will be over the long haul. But it's not exactly "unabated" cost escalation any more. Whether the cost problem is solved (doubtful) or the first steps in mitigation taken (more likely) is to be seen, but for the first time in 20 years, there are real cost controls being placed on the system.

    As for taxes, I'm unclear where your source is. The House bill taxes the very wealthy. The Senate bill taxes only insurance policies worth over $23,000 -- hardly middle class plans, I would think. Can you explain your contention?

    Thanks for the thoughtful response.

  3. Though I agree with much of that, there's another part to keep in mind: Obama isn't the radical leftist that the right-wing (and, oddly, part of the left-wing) presumes him to be. The moderate, compromise bill that will likely be passed is thus not solely a function of political tactics, but also a function of Obama's own personal moderate, compromising ideology. Folks I've talked to who knew him prior to politics thought him more a conservative than a liberal.

    For more, see, e.g., http://motherjones.com/kevin-drum/2009/12/no-drama-obama

  4. The tax on the middle class will be substantial. If you are below $50K, there are subsidies to help with costs.

    But some are estimating the $55K to $60K earner that previously had no insurance will be seeing a 15% "tax". And those that did have good insurance coverage will be seeing a 5% hike.

    NYT posts today


    The cost controls that are put into place are not unlike medicare, where the government suddenly decides that a procedure is worth X. And that worth is usually quite a bit below what private insurers pay for X.

    This works today becuase medicare is a small part of the overall system, and the private system can subsidize the public system.

    But how does it work when the controls are applied to the larger system? Who subsidizes things then?

    I had two "moderately dysplastic" spots removed on my back. Two 45 mins of sessions, 5 cm cuts, pre- and post op visits, the works. Cost without insurance was $7K. Aetna price was $2200. I asked what medicare would pay for the procedure, she looked it up and said $830.

    That is cost controls? Telling a doctor that his overhead + nurse & doctor for 120 mins is worth $830?

    It's a dangerous place we're going.


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