Monday, March 22, 2010

Health care reform: I wish I were elated ...

This fellow pushed at the limits of the possible.

So the House passed the "health care reform". I'd like to be elated; all I can manage is mild relief. As Paul Krugman says:

There is, as always, a tunnel at the end of the tunnel: we’ll spend years if not decades fixing this thing.

Some afterthoughts on both substance and process:

About the law itself:

Will the private insurance products that result be anything that ordinary people can afford to use? Or will they have to buy junk "insurance" so hedged with copays and other costs that they still won't dare go to doctors except in the direst emergencies?
Last week a friend of mine was filling out an application to rent an apartment when one of the stipulations on the form stopped her cold: "Applicants must show that the rental cost will not exceed 25 percent of income." Yeah, and the sky is pink. That statement is one of those economists' maxims about identifying a stable middle class person that may, a long time ago, had some reality in real life. But no one in San Francisco in decades has expected to pay less than one third of their income for housing and often much more. Are the assumptions in this new bill about "affordability" similarly unhinged from reality?

In theory "out-of-pocket expenses will be capped at $11,900 per year per family, or $5,900 per year for individuals." That out of pocket cost for a family is roughly a quarter of the income of the median household in this country. Since 90 percent of that income is almost certainly already committed to housing, food, transportation and health insurance (up to 9 percent of income under the law), where is that supposed to come from?

Oh, there are subsidies -- if you can find out where to apply, if you are not too ashamed to even consider asking for help, if you can understand the forms, if you can hold off the bill collectors while the bureaucracy that might help grinds through its paper work ... All this might "work," but the sunny protestations from policy wonks, economists and Congresscritters that it will be taken care of come from people who never had to work at being marginal or poor.

What we are getting is a punitive, means-tested program. "Fixing the tunnel" will, like fixing the tax code, become an endless struggle to simplify while the cheap and the greedy continue to lobby for ways to game the system.

The new law contains a gaping hole in coverage.
To dodge the political fight, the 12 million or so people in the United States without papers were simply left out. Though these folks are some of the healthiest people in the population (mostly young workers), that's a lot of emergency room visits and a lot of human misery ahead because as a country we are punishing these people rather than adopting reasonable immigration policies.

About the process of passing this bill:

From the point of view of democratic activists (small "d"), health care reform has been a clusterfuck.
The White House decided from the outset that it couldn't pass anything that aroused the whole-hearted opposition of any of the groups that profit from the existing system -- doctors, hospitals, drug companies, medical devices salespeople, or insurers. U.S. health care costs twice what as good or better care costs in other developed countries because all these people make huge profits on the desperation of sick people. But they were too powerful to take on, so the bill does nothing to significantly impede their continued blood-sucking.

This may have been a realistic political calculation. Maybe health profiteers would have sunk a bill that allowed a small public option to compete with insurers or modest drug importation from Canada to put price pressure on drug companies. I don't criticize the White House for weighing the odds of passage and threading the needle the best they could.

But I do criticize them for lying to their constituents. If this was what had to be done, the President needed to level with the people who put him in office -- to tell us the truth that, at this moment in time a slightly slimy accommodation with health profiteers was the best the actually existing, skittish Democratic Party can deliver. Instead, better possibilities like "Medicare for all" or "the public option" were continually dangled out there, then snatched away. This behavior simply pisses of their friends and kills enthusiasm.
  • Coming out of the 2008 campaign, the one thing that seemed certain about an Obama political operation was that it would be smart and subtle. On health care reform, it was ham-handed, tone deaf, and downright incompetent. Item number one: failing to understand until too late that Republican Scott Brown could win a Massachusetts Senate seat running against Washington.
  • Shying away from showing fight for reform in the hope of dragging in a few Republicans for this very conservative bill, the President reinforced the meme that Democrats are wimps. The people who worked their butts off to give the Party its huge majorities felt betrayed. The enthusiasm gap is very real: there are millions who who think something like this: "we elected you -- now fight for us and deliver." Time will tell whether passing the bill brings folks back. More were lost here than were necessary, I think.
  • OFA, the President's vaunted 13 million person email list and campaign apparatus, was neutered by the White House strategy. Making phone calls to thank Congress people who were already reliable votes is a waste of volunteer energy and volunteers aren't dopes. But the White House couldn't/wouldn't target Democrats who were the only votes in play until the very end. So OFA drowned and sank in busy work. It is an open question whether it can be resuscitated for November elections.
In the confused aftermath of the passage of something we won't really be able to evaluate for years, it will be easy to turn on the people who pushed for a better bill. Don't.
Yes, people got angry, shrill and even unreasonable, especially Jane Hamsher at FDL. Well good for them. I don't believe the powers that be would have done anything about this if they hadn't had the specter of furious constituents nipping at their heels. After all, they've got theirs. It takes people with a passion that goes well beyond reason to get anything difficult done, even if their presence complicates the accomplishment. Be grateful for the screamers.

And then get back to work to make this thing better. Not surprisingly, Jon Walker at FDL is out with a quick summary of six improvements it will take to make this "health care reform" more broadly meaningful.

It's never over.

UPDATE: This set of poll results among the very engaged, very informed, mostly progressive community at Daily Kos is interesting. I feel much in the mainstream here: I wanted this bill passed, but both content and process leave me less than joyous.


Nance said...

With a creature as complex and varied as the American populace, it clearly WILL take time to evaluate the effects of the passage of this bill. And it WILL require continuous reworkings and refinements, but that start had to be made somewhere. I have no doubt that the insurance companies will now do triple back flips to hold onto their profit margins, but the American patient/victim has gotten a taste empowering change.

Kay Dennison said...

Thank you for being the voice of reason in a sea of misplaced euphoria!!!! I just heard that there are Medicare cuts in that bill and how many elders can afford that? I haven't had a chance to go over the bill yet but I will.

Rob McB said...

I wish it could be fixed, but the jump in stock prices of health care companies following its passage makes me skeptical. I think we have to take seriously the comments of Physicians for a National Health Program:

As much as we would like to join the celebration of the House's passage of the health bill last night, in good conscience we cannot ... Millions of middle-income people will be pressured to buy commercial health insurance policies costing up to 9.5 percent of their income but covering an average of only 70 percent of their medical expenses, potentially leaving them vulnerable to financial ruin if they become seriously ill... Insurance firms will be handed at least $447 billion in taxpayer money to subsidize the purchase of their shoddy products. This money will enhance their financial and political power, and with it their ability to block future reform. More in their press release.

Neil said...

I can appreciate what's lacking about the bill, but let's face it, this is a major accomplishment. For the first time ever in U.S. history we can no longer say health care is just a privilege for citizens who can afford it. Some 32 million Americans will gain access to health insurance. The worst practices of the health insurance industry will end. It's a mistake to underestimate the sea change that the passage of this bill represents and the real change this bill will bring for millions of Americans.

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