Differing Views of Government

One of the reverberating themes on the right wing of the blogosphere these days is the notion that 'Liberals can't complain about Stupak-Pitts because they wanted the government in health care and that means giving the government the power to screw it up.'

In the words conservative feminist blogger Jenn Q Public:

Proponents of liberal health care reform deliberately lured a bloodthirsty vampire over their thresholds, and now they’re shocked – SHOCKED – to find they have fangs buried deep in their necks. I’m not one to blame the victim, but it sounds like they might be getting exactly what they were asking for.

This sums up the entire conservative response to liberal complaints about Stupak-Pitts in a nutshell. 'Stupid liberals wanted fascism and now they are complaining about it.'

This, of course, is not an argument at all. It's an ad hominem attack that allows the actual points of debate to be entirely ignored. I'm not entirely sure, however, whether this is premeditated or whether it is intended as a genuine argument.

The left and the right, after all, have fundamentally differing views of the proper definition of 'government.'

The conservative view of government is that it is an inherent entity of its own, with specific coercive and authoritarian traits that define it. Government cannot exist without those traits, goes the right wing argument, and is something else entirely without those traits. Hence the need for a small government with specific and strictly defined areas of authority.

The liberal view of government is that government is representative of the people who elect it and that it has an obligation to pursue, protect, and ensure their interests, opportunities, and rights. They believe that government should be able to do what needs doing, in the best interests of the people, as long as the rights of the people are protected.

The emphasis is important. Liberals do not believe in the 'unlimited' government that conservatives often claim they advocate nor in 'fascism' (not even the terribly misdefined 'fascism' of conservatives) or 'socialism.' Liberals believe in responsible, effective government as a necessary component of civil society.

There needs to be a balance between the power of the government to do what needs doing and the protections in place to prevent it from ignoring all responsibility and simply using coercive force to do its will. The irony is that it is conservatives who have continually advocated the use of coercive force by the government to do their own will both at home and overseas. Corporate conservatives want the US military to enforce their business interests. Neoconservatives want American empire. Religious conservatives wish their religious mores enforced as law. All of these require the expansion of government power, not its contraction, and all are far more dangerous to the rights of individual Americans than health care reform. Yet they crow over Stupak-Pitts as some sort of self-fulfilling prophecy of government run amok. They rarely acknowledge the far greater danger of irresponsible demagogues advocating for real fascism from several directions at once.

While not precisely a 'liberal' myself (if anything, I am well to the left of most American liberals), I certainly support health care reform. Like liberals, I believe in responsible government rather than the unfettered government alternately feared and worshiped by conservatives. I certainly don't care for Stupak-Pitts and think it a horrible mistake, both politically and morally.

From the quoted article:

'When you invite the government to become more deeply involved in health care, you’re also inviting greater government interference in personal choice. Medical decisions become political decisions. That’s how it works, and it’s why philosophical opposition to the growth of government isn’t the crazy-eyed wingnuttery progressives make it out to be.'

Once again, rather than discuss the real issues at hand, we see an evasion of the topic with a statement about those stupid liberals who keep inviting the monster into the closet. The automatic assumption that responsible decision making and rational thought go out the window once one decides to create health care policy means that liberals have no right to complain about the policies that result from reform.

I can't speak for 'liberals', but I don't consider 'philosophical opposition to the growth of government' to be all that terrible. The government is one of several potential threats to individual freedoms. There are real risks to government expansion that must always be weighed carefully. I am no statist, I am a philosophical anarcho-socialist. What I consider 'wild-eyed wing-nuttery' is the belief that the private sector can take care of all of society's needs if civil society abdicates its own responsibility for its own needs. To reference a favorite phrase of the Anonymous Liberal, one cannot rely on the underpants gnomes to take care of the poor, elderly, and sick if we do not do so as a society. When one puts 'philosophical objection to the growth of government' over the economic and physical well-being of Americans, one has crossed the 'wing-nut' line. When one's personal concern for having to wait longer in the office for service prevents one from wanting others to have that same access to medical care then one has crossed an even darker line: one is no longer merely a wing-nut.

This brings us to the ultimate issue regarding Stupak-Pitts and health care reform at large. The government works for us. As conservatives are so fond of saying, American tax-payers pay a great deal of money to the government every year. If an automobile mechanic you were paying to provide proper maintenance and upkeep on your car deliberately used substandard parts and you were injured in an auto accident as a result, the depraved indifference law means that the auto mechanic is guilty of a felony.

Stupak-Pitts is a deliberate act of depraved indifference on the part of a bipartisan conservative coalition.

Everyone should complain about that.

'What have here is a failure to communicate..." (Or: Why Moderates Are Stupid About Abortion)

When I wrote my first piece on abortion, I had intended for that to be the end of it... at least for the year. A great many people of all political stripes throw wood into that particular oven every day all over the internet and it's not my intention to simply talk about what everyone else is talking about. I try to stay on track with economic, social, and political philosophy and commentary and a heavy dose of social and political criticism. The abortion debate in America, as driven by the right wing (aided and abetted by the unthinking center), has very little to do with the facts or realities of abortion. I had meant to say so, communicate the facts, and be done for at least the foreseeable future. While I had mentioned abortion in a recent criticism of moderates and 'fiscal conservatives', it was in tandem with other personal rights issues.

Unfortunately, Michigan Congressman Bart Stupak (D) and Pennsylvania Congressman Joe Pitts (R) made it an issue again with an amendment that would bar even indirect federal funding of abortion by denying private insurers in the national insurance exchange the commercial freedom to offer abortion to their customers if those customers are receiving federal subsidies to help them purchase health insurance. It's worth nothing that this is an issue of commercial freedom as much it is an issue of abortion rights. Barring private health insurers from offering a legal medical service to paying customers is restraint of trade. This is also a medical issue, as it is precisely the sort of intervention by government in the patient-physician decision making process that Republicans claim to oppose. Dr. Ron Chusid makes precisely this point on the excellent Liberal Values. Southern Beale mentions this as well, and also offers the more traditional feminist criticism of the bill. I agree with both of them.

Now some of you who read me closely may accuse me of being inconsistent and waffling on this issue, because when I proposed my own health care plan I included elective abortion on a list of procedures not to be covered by a national health care plan. First, that was just that: a national health care plan, not a program of health insurance reform such as Congress is currently considering. Second, I specifically noted that only truly elective abortions should not be funded and that medically necessary abortions were not elective at all and should be covered. Period. If one is going to undertake a massive program to fund necessary healthcare costs (as I believe we inevitably must) then one is going to need to exclude a range of genuinely elective medicine in order to reasonably control costs. Several of the items I included on that list are male-specific medical services or procedures that currently are covered by most insurance. As a note, I think birth control medication should be covered by such a plan.

Private insurance is not a national health care plan, however. While I am no supporter of the lawless state of volia advocated by today's conservatives, I believe in the free market. If we are to keep health care, for the time being, primarily in the preserve of the market than we have no business restricting the supplier's right to sell the consumer what they want or the consumer's right to buy it. Even if the consumer is buying, partially, on the government's dime it is still the consumer and the supplier who must make the decision in question. The government's role is to ensure that supplier offers a quality product. Not to restrict the supplier from offering legal products to paying customers. As the public option is intended to compete in the free market with private health insurance, it must be empowered to offer its paying customers a full choice of legal products as well. Offering abortion coverage with the public option is not 'federal funding of abortion.' It is offering a paying customer a legal product.

I want to be clear that anyone saying otherwise is grossly in error or guilty of deliberate intellectual dishonesty.

I worry that it breaks the thread of my narrative and somewhat undermines my point, but most private insurance already does not cover abortion. Southern Beale has rather firmly and thoroughly described the real inequities in health insurance costs for men and women. One of the goals of health insurance reform, if we cannot yet get real health care reform, should be to establish a regulatory framework to eliminate such inequities rather than to legally reenforce them.

I am on record supporting insurance reform efforts in the short term because it would improve the current system and establish a precedent for future reform. In the most basic examination, any improvement over our broken system is radical improvement. However, it must be real improvement and the Stupak-Pitts amendment is reenforcement of much that is wrong with the current private health insurance picture. It is also a reenforcement of much of what is wrong with the current political debate on the issues of both abortion and health care.

The Health Care Reform Debate In Perspective

As everyone paying attention has seen, I've done a lot of writing about health care. A lot of it has been in much the same vein as every other liberal-to-socialist blogger on the blogosphere: criticism and polemic on the debate itself. As I've noted before, there's a lack of excellent writing on the substance of the debate. I've decided to try to address the substance again, partially because new readers who find me 'more liberal than radical' may not have seen my earlier commentary on the substance of the debate and partially because I'm still not terribly satisfied with the final form health care reform is taking despite my pleasure that it looks like some basic problems will be addressed.

First and foremost is the substance of the reform actually being discussed in Congress. The right-wing advocates of market reform and the left-wing advocates of national health care policy have both been excluded from the debate. As I (and others) have said before, what is being debated in Congress now is insurance reform. Insurance reform is better than no reform at all. It certainly addresses the real problems of health care in America better than market reform as advocated by the right.

Those problems, which I have also written about before, are basically three-fold:

1.) High consumer costs generated by the inefficient pooling of costs in multiple payment pools. This means multiple partially funded systems of payment and no single fully-funded pool of shared costs. This is entirely opposite to the principle of shared cost. Whereas other insurance can survive this way because it covers against the unexpected, everyone will need medical care at some point in their lives. Thus the inefficiency of the cost-sharing method has a mushroom effect on consumer costs. When one adds to this the cut the insurance companies must take from the consumer to make a profit it only gets higher. So while medical costs really do rise as technology changes, the consumer costs created by our insurance system are the biggest cost problem.

2.) Access to proper care is restricted in a variety of ways. The uninsured frequently forego all but the most urgent care (which is much more expensive) for financial reasons. Insurance companies frequently make their customers jump through hoops to make full use of their benefits, or deny payment entirely if it suits them to do so. Medicaid is difficult to receive (indeed, many of the people who need it are ineligible because of the family requirements) and offers inferior service. Medicare and the Veterans Administration only serve specialized portions of the economy. Thus many people cannot afford to see a doctor, believe they cannot afford to see a doctor, or choose not to see a doctor because they prioritize other financial needs before medical care. Even when one has coverage, there is no guarantee the insurance company will provide full access to necessary care under the current system.

3.) The current health care system puts a tremendous burden on American business. The majority of people with insurance who are not covered by Medicare or Medicaid receive health insurance benefits through their workplace. This infringes their economic freedoms (because their benefits tie them to their job) and it also shifts much of the cost of health care onto the business sector as a de facto tax burden. This latter aspect is worth taking into account among the many problems with American economic policy. I'm no friend of corporate culture, as anyone who reads my stuff knows, but forcing the corporate sector to underwrite what most of the world considers a national issue and a government responsibility is... of questionable capitalist virtue.

The current health care reform proposals in Congress primarily address problem #2. They would require insurance companies to open access to more care to their customers and restrict them from simply dropping their customers or refusing to pay for a variety of reasons. This is a huge improvement not to be ignored. However, it is key to remember that the first and third problems with our current system are only addressed tangentially if at all.

The focus on costs is on medical costs, not consumer costs. While medical costs are a real issue, they are secondary. A better system for paying consumer costs would lower them dramatically without the need to focus on medical costs that can probably not be cut to the degree believed by the advocates of insurance reform. The creation of a competitive, national insurance exchange will probably lower consumer costs somewhat... but it is difficult to say how much and it is possible it won't have a real impact because of the increased standards of quality may keep consumer costs higher than desired. A competitive, robust public option might help to drive costs down somewhat... but it is again very difficult to say how much this will help the guy who already can't afford to buy private insurance.

The economic problem is ignored entirely. First (and perhaps worst) it is assumed that everyone with employer-paid insurance is happy with their coverage and that there is no need for reform of this market. My partner's experiences following surgery have shown, to me, the facts are very different. Employer-paid insurance is in much the same state as private insurance, whether the premiums are lower or not. The public option, as it stands now, would not be available to anyone receiving employer-paid insurance.

In addition, liberals appear to believe that corporations can and should foot the bill instead of government. They advocate increasing employer's responsibility to provide insurance to their employees and punitively taxing those who do not. This may serve the needs of PayGo, but it is aggravating rather than solving problem #3.

None of this is intended to suggest that the insurance reform being discussed in Congress is not better than our current situation. It is. Nor is it meant to rally opposition to said insurance reform. If nothing else can pass, insurance reform needs to pass.

It is meant to put the problem in its proper context and to instill an understanding that this reform is not the 'end' of health care reform. It is a first, shaky step in the right direction. The issues of consumer costs and economic burden will remain to be addressed, and the left must not forget that. We must continue to raise and address these issues to affect future policy debate as much as possible.

To put it more simply, we need massive reform and even the 'liberals' in Congress are not approaching the problem from a sufficiently radical direction. We should support them, but we should keep pushing in the wake of their success.

Wall Street Journal Admits Support For Public Option Growing

Yes, that's right.

Citing their own poll, carried out jointly with NBC news, they note that support for a public health insurance plan is up to 48% from 43% during the astroturf attack on town-hall meetings.

I usually don't post a lot of polling data here, but I think this is illustrative. It suggests that conservative opposition to the public option (and health care reform in general) is starting to become counterproductive. While the Journal still claims that Americans are opposed to 'his health-care plan' (meaning President Obama's) 42%-38%, these numbers are far less important than the growing support for the public option.

Naturally, the Republicans don't think so. Per a spokesman for Senate Minority Leader Mitch McConnell (R-KY):

Don Stewart, spokesman for Senate Minority Leader Mitch McConnell (R., Ky.), said positive movement in favor of the public option is "meaningless" if Americans remain opposed to the broader legislation.

"They can talk about momentum all they want. The momentum is in the Senate Democratic cloakroom. It's not in Topeka, and it's not in Arcadia, Fla.," Mr. Stewart said, referring to the town Mr. Obama was visiting Tuesday.

While this is the kind of argument that is required from a political operative under the current circumstances, it is simply wrong. The reason for this is simple: 'his health-care plan' does not exist. There is no White House bill for those polled to approve or reject. Thus one must assume that opposition to 'his health-care plan' is really disapproval of the plans in Congress now. The plan receiving the most play in the media is the Senate Finance Committee bill. As quite a few writers have said, this is a bad bill. It falls well short of the 'liberal' goals of health care reform and its sops to conservatives are not sufficient to induce the right to support the very idea of health care reform. So it's only natural this bill would not have a very high approval rate the polls. Indeed, as the growth of support for the public plan shows, it is very likely the lack of a public plan in the Finance Committee bill is the reason for significant portion of public opposition to it.

Growing support for the public option means growing support for real health care reform of the kind not provided in the Finance Committee bill as currently written. Plenty of polls, from a plethora of sources, have shown strong support for robust health care reform. Those who do want robust reform will naturally be skeptical of too much moderation in the pursuit of virtue.

The Republican establishment has shot their wad on health care and they know it. While they have successfully created a climate of fear and uncertainty, which is something they do very well, this time it is not going to work to their benefit. It worked in 2004 because it was possible to portray President Bush as a folksy, comforting figure and as a tough guy who would protect the nation. Thus, despite his myriad flaws and incompetencies, they were able to offer fear in one hand and comfort in the other. The problem now is that the Republicans have no leaders to make Americans feel safe about the economy or health care. They can scare Americans about President Obama's reform efforts, but they have nothing to offer to comfort and reassure American voters in its place.

The fact is that, regardless of how the right attempts to portray polling data, Americans want to see the mess the health care industry has become cleaned up. They want to know they can see a doctor if they are hurt or fall ill, they want to know they can do it without going bankrupt, and the current situation is that they do not know either of those things. Republicans can talk about how great American health care is all they want. People who are being sued by their hospital know the real situation.

People do not think they understand HR 3200 or the Finance Committee bill and so they have a hard time supporting them. They understand, or think they understand, the public option and so they can get behind it. As support for the public option grows, it won't matter what Americans think of 'his health-care plan.' Support for the public option means support for robust health care reform and that means the Republicans have lost. Filibusters and bravado may stop legislation, but they won't help the Republican Party. As time goes on and the support for a public option continues to rise, even those who intend to vote against the bill will not want to be seen blocking it from reaching the floor.

Who was trying to gut Medicare, again?

The number one insurance industry scare tactic related to health care reform as always been the threat that the government will ration your health care access if any sort of federal health care reform passes. The most recent Republican rallying cry against health care reform has been the notion that Democrats are going to cut Medicare. This trope has been kicking around right wing circles for sometime despite the fact that the only plan that would actually cut or ration Medicare services is a Republican plan whose own sponsor has now abandoned it. Yet the trope has gained a lot of traction in a lot of circles because of the skill of the right wing spin machine in exploiting basic human fears.

All this propaganda aside, Democrats recently tried to pass a bill (originally co-sponsored Republican Senator John Kyl of Arizona) to fix the deeply flawed system which Medicare uses to determine payment to physicians. Congress has, for several years now, been ignoring the system of payment with a series of delaying actions to keep the full damage from being done to the Medicare system. This has allowed 'fiscal conservatives' to claim that money is being saved when, in actuality, the system designed to reduce costs is not being implemented in order to prevent turning Medicare into the same kind of health care ghetto as Medicaid. This is a financial shell game that the Democratic leadership and the White House attempted to bring to and end by simply making the system actually in use the legal system of compensation.

Republicans were having none of that. All but one Senate Republican (Rhode Island Senator Sheldon Whitehouse) voted against cloture, allowing the anti-reform crowd to filibuster the bill if they wish to do so. Eleven Democratic Senators , unfortunately, joined in them in blocking the bill. The fact that Virginia's two Democratic Senators Mark Warner and Jim Webb joined Tennessee's Republican clowns Lamar Alexander and Bob Corker in opposition to the bill was especially galling. I had thought much better of both men. Original co-sponsor John Kyl (see the Malkin link below) voted against cloture and even denied co-sponsoring the bill.

Michelle Malkin, always ready with something nasty to say in such situations, crowed at the failure of 'Obamacare's bribe to doctors.' I understand the GOP's commitment to the rhetoric of fiscal responsibility, but in this case true fiscal responsibility would be to tell the truth to one's selves and the American people about what one is going to spend on health care. A partisan propaganda machine so determined to convince Americans that health care reform is a threat to Medicare and to seniors should probably be supported by a policy machine willing to step up to the plate and do something to secure the stability of medical access for Medicare recipients. When it is not, it shows the truth: the Republican opponents of health care reform are liars who do not care about the cost of human life and economic drain our current system represents. When their actions prove their lies, it is time to stop taking anything they say seriously.

As a brief aside, I should note that there are those who believe the only possible reason the left might have to heap verbal abuse on Michelle Malkin is misogyny. I think it is far more accurate to say that she invites attack upon herself by proving herself to be a lying and unprincipled shill for a morally bankrupt political machine. When one crows about the defeat of a measure intended to clean up a dirty mess, one invites abuse.

Dr. Ron Chusid write a far more incisive analysis of the situation that those offended by Malkin's line of crap should take the time to read.

It should be noted that Republicans alone are not to blame. Democratic Senators Evan Bayh (IN), Robert Byrd (WV), Kent Conrad (ND), Byron Dorgan (NM), Russ Feingold (WI), Herb Kohl (WI), Claire McCaskill (MO), Bill Nelson (FL), Jon Tester (MT), Mark Warner and Jim Webb (VA), Ron Wyden (OR) were joined by Independent caucus-mate Joe Lieberman (CT) in backing the Republicans in this idiotic perpetuation of a corrupt lie. I can only speculate on their reasons. Nelson is the most surprising, as he represents a great many seniors in Florida and was said to be shaky on the Baucus bill because some of its features might look bad to Medicare recipients. So he is willing to vote against properly paying their doctors instead?

More surprising, perhaps, is that Republican-in-Democrat's-clothing Ben Nelson of Nebraska voted in favor of cloture.

Those of you happily polishing your Democratic Party tie tacks should keep this in mind. Not everyone you are voting for is on your side anymore than the Republicans you are voting against. Some of the people choosing to oppose this real fix to a broken payment system were people for whom I had a great deal of respect before seeing the list of votes. Those people have dropped several notches.

All of this goes to show just how deep the tendrils of the insurance companies are sunk into fighting health care reform at all costs. The people claiming to be defending seniors from health care reform stabbed those they claimed to be defending in the back and are crowing about their great accomplishments. Some of those who should have been committed to truly defending seniors from conservative daggers instead helped the right-wingers aim the knives.

What makes my teeth grind the most, however, is Robert Byrd voting against a Medicare fix. I realize he has the full benefits of the Congressional Health Plan at his own disposal, but you would think he'd have a little understanding and compassion for the elderly. All things considered.

Arlen Specter on Health Care

From Think Progess:

Sen. Arlen Specter (D-PA), who until late April of this year was a lifelong Republican, castigated his former party this morning on Fox News. Specter ripped the GOP for refusing to be a good-faith negotiator in the health care debate:

'On the Republican side, it’s no, no, no. A party of obstructionism. … You have responsible Republicans who had been in the Senate — like Howard Baker, Bob Dole, or Bill Frist — who say Republicans ought to cooperate. Well, they’re not cooperating.

Specter also indicated he would fight hard for the public option. “I’m not prepared to recede at all. I think the public option is gaining momentum,” he said. “I am not going to step back a bit. I am going to fight for the best public option."

The original story Think Progress blurb (linked above) includes a forty second video of Specter waxing querulous against the GOP. I was rather impressed in one sense. The quoted article included another link to this story. He sounds like an old line New Dealer promising Medicare For All in the Nixon administration when he gets on his ear. It's an amusing change of tenor. When Specter originally changed parties earlier this year he said, "I will not be an automatic 60th vote for cloture.'' Now he is promising to be a liberal lion on the health care issue.

Naturally there are political issues at stake. Specter represents a state where, by his own calculations when he himself changed parties, 200,000 of his constituents switched from the GOP to the Democratic Party on issues like labor and health care. He had been facing a challenge from a threatening primary challenger as a Republican and his core support base has gradually shifted parties. He is still facing a more liberal Democratic Party challenger this mid-term and so it certainly behooves him to be a strong liberal voice on health care in order to convince his new party that he would serve them better than a new face.

If it means a better health care bill, however, good for Arlen Specter. While I've never been certain I'd vote for him if I lived in Pennsylvania, I've always felt that he was a genuinely independent lawmaker who stood for his constituents over party ideology. Since the interests of many of his constituents are directly related to his new party's ideology on health care, he is likely much more comfortable as a Democrat.

Living in Tennessee, I'm not directly concerned in Specter's continuing political fortunes... but it is terribly difficult not to root for him just to spite the GOP.

Half Full or Half Empty?

The most difficult problem of political analysis is trying to determine just what the facts really mean. This means any political analysis is inherently guesswork. As an example (and proof that I am not perfect) I give you this: I believed that Avigdor Lieberman's political blood feud with the Ultraorthodox Jewish party Shas, his quasi-socialist domestic agenda, his hunger for personal political 'respectability', and his commitment to the concept of 'land for peace' would trump the fact that the fact of shared racism and lead him to tell Benjamin Netanyahu to go to hell in favor of the greater legitimacy of serving in a broader coalition government led by Kadimah. Obviously, I was pretty wrong. Was this wishful thinking on my part or merely a misunderstanding of what was really important to Lieberman? Was it a combination of both?

Naturally the most frequent reason for differences in political analyses is partisan. If one watched CNN at all during the election cycle last year then one could see the partisan bias dripping from every word the Democratic and Republican analysts said. The Republican analysts were particular egregious in their attempt represent the entire country as frightening right wing nuts and represent the views of people like Sarah Palin as mainstream. All the same, Democratic analysts were certainly equally partisan in their presentation of the facts of the election.

Of course partisanship is not the only reason for such differences.

Yesterday Robert Creamer wrote, on HuffPo, that momentum for the public option is growing. Citing the votes in the Senate Finance Committee, in which the public option received ten votes in the second go round:

This robust support for the public option -- in what most observers consider the most conservative committee in the Senate -- signals a sea change in Congressional opinion toward the public option. The odds are now very high that some form of public health insurance option will be included on the final bill when it emerges from a House-Senate Conference Committee later this fall and is ultimately passed by Congress.

Read more at: http://www.huffingtonpost.com/robert-creamer/growing-momentum-for-publ_b_303415.html

Great news isn't it?

Just about an hour and a half after Creamer wrote that the public option was gaining momentum, HuffPo staff writer Jason Linkins used the exact same facts to come to the exact opposite conclusions:

Today, the Senate Finance Committee rebuffed two amendments to include the public option in its health care reform bill. The first amendment, offered by Jay Rockefeller (D-W.Va.) went down 15-8. The second, put forward by Chuck Schumer (D-N.Y.), failed to pass by a 13-10 vote.

So, now what? Is the public option dead? Will the fight go on? Yesterday, Democratic consultant Peter Feld assayed today's committee machinations and warned: "Spoiler alert: the public option goes down in a ritual sacrifice of which this is step one." Want to bet he's wrong?

Being a columnist, Linkins answers his own question:

I'd advise against it...

For the record, after having read both articles, I see where both are coming from. Creamer is focusing his analysis on the fact that the public option picked up two votes the second time it was put to the question. Linkins is focusing his own argument on a general (and justified) skepticism of the Senate Democrats' willingness to overplay their hand. Speaking clearly from a critical perspective it is important to note that Creamer's logical reasoning the more sound of the two analyses. The problem is that Senate votes are not 'logical', they are human undertakings in which quite a few illogical decisions are made.

If this were about logic, after all, we'd have passed 'Medicare For All' when Nixon was president.

Linkins' analyses brings up something important that I cannot let pass. Six years of a Republican House under Bill Clinton and six more of a Republican House and Senate under George Bush have made many liberals extremely cynical. Furthermore the Democratic House and Senate of the first two years of the Clinton administration did not inspire anymore confidence than did the Democratic House and Senate of the last two years of the Bush administration. There is a certain justification for this cynicism.

That said, we cannot afford to be permanently cynical. Ongoing cynicism will merely weaken our resolve. We need to be optimistic of ultimate success even when short term success is unlikely. We need staying power. Right now we do not have it.

If we do not develop the optimism to see when the glass is half full and fight to fill it then the glass will always remain half empty. Over time, if the glass remains half-empty, eventually the right will drain it.

Food for thought.

Read more at: http://www.huffingtonpost.com/2009/09/29/the-beginning-of-the-end_n_303612.html

Read more at: http://www.huffingtonpost.com/2009/09/29/the-beginning-of-the-end_n_303612.html

On Truth

Note: This article originally appeared on Wednesday in different form. The original article contained factual errors that I was unwilling to leave in place. Responsibility for those errors is mine and I apologize to anyone who read the incorrect article. I offer this rewritten piece in its place, hopefully as some amount of compensation.

- Chris

The moral outrage of the immoral, the ethical standards of the unethical, the intellectual chauvinism of of the intellectually bankrupt, and the calls for truth of liars began to bore me in the 1990s. I am less dismayed now by the fact that the basic rhetoric and tactics of the right have not changed than I am that even people ON the right can still tolerate it.

I've been spending this week commenting on the most active of the two liberal blogs I follow (Dr. Ron Chusid's Liberal Values and The Anonymous Liberal... a doctor and a lawyer, which I find immensely poetic) and doing web research for a piece on poverty. In the course of both of these activities I was struck by two things. The first of these was the pure shamelessness in which 'thinkers' on the right present a specious argument with bald-faced purity even as they accuse the left of great evil and dishonesty. The second of these was the strange sense of innocence (or perhaps glee) with which these statements are made.

One of part of the process of researching an article on poverty was the attempt to find out what conservatives have to say about it. The answer was, 'not much.' Nearly every right wing blog reference to poverty online is connected in some way to an attack on policies perceived as 'liberal' by the writer. There is very little writing about actual poverty, whether or not it is a problem, or what should be done about it. The intellectual desert of conservative thoughts and writing on poverty surprised me a great deal, though in retrospect I should have expected it.

Christ, whom many on the right claim tells them what to do and when to do it on a personal basis, had a great deal to say about poverty. He spoke of charity, of caring for the poor, and of society's responsibility to its least members.

He also had interesting things to say about wealth, things which do not sit next to right wing policies very well.

'Now behold, one came and said to him, "Good Teacher, what good thing shall I do that I may have eternal life?
So He said to him, "Why do you call me good? No one is good but One, that is, God. But if you want to enter into life, keep the commandments."
He said to Him, "Which ones?"
Jesus said to him, "'You shall not murder'; 'You shall not commit adultery'; 'You shall not steal'; 'You shall not bear false witness'; 'Honor your father and your mother'; and 'You shall love your neighbor as yourself.'"
The young man said to him, "All these things I have kept from my youth. What do I still lack?"
Jesus said to him, "If you want to be prefect, go, sell what you have and give to the poor, and you will have treasure in heaven; and come, follow Me."
But when the young man heard that saying, he went away sorrowful, for he had great possessions.
Then Jesus said to his disciples, "Assuredly, I say to you that it is hard for a rich man to enter into the kingdom of heaven. And again I say to you, it is easier for a camel to go through the eye of a needle than for a rich man to enter the kingdom of God."

-- Matthew 19:16-24'

As you can see, the Jesus of the Gospels saw wealth and poverty very differently from the politicians who would marshal the forces of the religious right on their own behalf today. When a faction that claims Biblical and Godly authority for their every action ignores the words of scripture, just how trustworthy are they?

The Anonymous Liberal describes House Minority Whip Eric Cantor's response to a constituent at a health care town hall meeting. The following transcript of the exchange is from his site, but is originally from Alan Colmes.

"CONSTITUENT: I have a very close relative, a woman in her early forties, who did have a wonderful, high-paying job, owns her own home and is a real contributing member of society. She lost her job. Just a couple of weeks ago, she found out that she has tumors in her belly and that she needs an operation. Her doctors told her that they are growing and that she needs to get this operation quickly. She has no insurance.

[...]

CANTOR: First of all I guess I would ask what the situation is in terms of income eligibility and the existing programs that are out there. Because if we look at the uninsured that are out there right now, there is probably 23, 24% of the uninsured that is already eligible for an existing government program [...] Beyond that, I know that there are programs, there are charitable organizations, there are hospitals here who do provide charity care if there’s an instance of indigency and the individual is not eligible for existing programs that there can be some cooperative effort. No one in this country, given who we are, should be sitting without an option to be addressed."

As the Anonymous Liberal says aptly:

"Faced with this all too common scenario, Cantor has nothing to offer. The suggestions he eventually comes up with are profoundly unhelpful and deeply hypocritical. This outspoken opponent of government-run health care suggests, feebly, that perhaps the woman might qualify for an existing government program. This, of course, is highly unlikely given that she owns her home and just recently lost her job..."

The irony of this, of course, is that Cantor and other conservatives would cut existing government programs if their views of health care prevailed in House and Senate. I have written about this before.

The party that claims to be the guardian of American morality has abandoned basic moral values. There are no facts behind their 'truth.' There is no Jesus in their 'Christianity.' There is no logic in their 'common sense.' There is no patriotism in their worship of all things 'American.'

This is immensely dangerous. While, in recent years, this appears to have caused many sensible people of moderate and conservative views to step away from the Republican Party and movement conservatism it has also enflamed the passions of those who desperately want to believe they are better than their neighbors. The right has kindled a populist elitism that combines the worst features of both and sells authoritarian truth with anti-authoritarian lies of the worst kind while shamelessly pointing to the very facts that prove their intellectual bankruptcy.

Yet they have faith to move mountains.

Can you think of anything more dangerous than a lunatic with faith?

Yes, I'm Going to Pile On Max Baucus and Kent Conrad Too

Prior to day's piece, I've written six pieces about health care this year. More of them have been critical than not. I've attacked specific elements of reform bills. I've attacked whole reform bills as intellectually dishonest attempts to defund Medicare and exposing the Republicans as the only people actually advocating rationing. I've posted frank criticisms of many of the core 'religious' elements to arguments about free market health care. I've even proposed my own national health care bill. Clearly, I feel fairly strongly about the issue.

I've not been a fan of the Senate Finance Committee bill for some time. One of the early pieces I wrote critiquing the reform process was in reference to the original Senate bill as it left Teddy Kennedy's committee. I was already less than completely happy with it.

Well, Senators Max Baucus and Kent Conrad have gone and come up with something even worse. Dr. Ron Chusid of Liberal Values pointed out key problems with the Finance Committee bill back in early August and suggested it might actually be worse than no reform at all. As Bob Cesca and RJ Eskow both write on Huffington Post, the final Finance Committee bill is possibly even worse. Ryan Grim writes that the Baucus bill is already facing signficant resistance among Democratic senators and most of the Democrats in the House.

I'm going to pile on too. I'm not going to rehash every point that Cesca and Eskow make, except to say that I agree with their view of many aspects of the bill. It has the potential to do considerable economic damage to American business, seniors, and the working class. A provision to tax 'Caddillac' insurance benefits will double the burden already laid on older consumers by a fee scale that allows older customers to be charged as much as five times as much as younger consumers... a fee scale that completely wipes out the benefits provided by eliminating restrictions against and fees for consumers with pre-existing conditions. 'Health reform', if the Baucus bill passes, could actually end up making it more expensive for the average American to purchase insurance. At the same time, the individual mandate has not been dropped. The public option, of course, is gone.

The real damage done by the Baucus bill is in a provision that chop-blocks what would otherwise be the best provision in the bill before the bill even leaves Committee. Instead of a public option, the bill would empower health consumers to form their own co-ops to insure their own health care costs. I've more than once admitted to a strain of a certain kind of socialism, and that part of me certainly likes the idea of health insurance co-ops having the power to compete aggressively with the private insurance market. It would give many ordinary Americans an alternative to private insurance that could actually be superior to a government run plan. Conservatives have understood just how powerful co-ops could be in lowering health care costs and empowering health care consumers. That's why Ed Morrissey took the time to rail against them on Hot Air. Legitimately empowered health insurance cooperatives would be a very serious competitor for the insurance industry.

The trouble is that the Baucus bill kills co-ops before they get started. While allowing consumers to form cooperatives to cover their health care costs, it specifically denies those cooperatives collective bargaining power over fees. So the insurance companies would enjoy a huge advantage in competition, while the co-ops would be hampered in their ability to provide quality coverage at an affordable cost. When the single best part of the bill is so badly crippled by its own language, it becomes difficult to support the bill at all.

Baucus and Conrad become the real villains of this affair. Baucus has written a bill that gives the insurance companies everything they have asked for in order not to oppose reform. Yet the bill does not include enough comprehensive reform of the system to justify the concessions. If the bill contained a public option, a robust subsidy for those who cannot afford insruance but do not qualify for Medicaid, or a robust strengthening and widening of Medicaid to cover those unable to otherwise comply with the individual mandate then one could argue that the concessions might be worth it. Instead there is no public option, the subsidy is depressingly shallow, and the Medicaid benefits made available for those unable to otherwise comply with the mandate has been described as 'Medicaid lite.' When one considers how inferior Medicaid already is, this is simply unconscionable.

While Republicans have lied about the threat of any reform, Baucus has completely castrated reform in the hopes of winning Republican support. He has utterly failed to do so. Not one of the three Republicans in the 'Gang of Six' has signed on to the Baucus bill, not even Olympia Snowe... who is arguably more liberal than Baucus. Despite this, Baucus claims a belief that the bill will pick up support from Republicans on the Senate floor. I don't know what motivates this fount of optimism. Perhaps it is the same kind of 'we hope it is true therefore it must be true' thinking that impelled the Bush Administration to tell us all how easy the Iraq war would be.

Max Baucus needs to be run out of the Senate. He needs to be challenged by an aggressive liberal primary opponent who makes health care reform and the Baucus bill the central issue of the primary campaign. With this bill, with his lack of regard for the needs of the country, he has single-handedly stepped up to the plate for the role of scapegoat if this round of reform fails. If his excrable brand of 'reform' passes, he's clearly the man to blame.

Either way, we all need to make sure he becomes the face of Republican resistance to reform. It's what he has chosen to become in his quest for 'bi-partisanship.'

Some Thoughts On Health Care Debate and Policy --- Again

Everyone is writing about health care. I normally do not write about what everyone else is writing about, thought I do occasionally offer criticism of the things others write. However, as anyone who has read this blog knows, health care is one the issues foremost in my mind. I believe that American health care policy is in need of a near total overhaul and I've said so before. Then, I outlined many of the problems with our system that need to be fixed and attempted to attack those problems specifically in my ideas.

Much of the health care writing on the web and in print right now is centered on the health care debate itself rather than health care policy. This is somewhat dangerous. Indeed, much of this writing attacks or defends the process in Congress or the administration without advancing constructive ideas. There is also, of course, well measured and intellectual criticism of specific problems with the compromises being made in the Senate Finance Committee in the name of bipartisanship. This second quote piece is from Ron Chusid of Liberal Values, who is likely one of the most sensible and sober writers on the issue on the net. Not only is Ron a doctor, and thus possessed of a knowledge of the subject not always present with the rest of us in the blogosphere. He has a great deal to offer both on the debate itself, and in support of many of the reforms currently on the table, in addition to the aforementioned critique of the finance committee bill. He's not so far out on the left as I am, myself, but who really is?

I'm not going to write, this time, about the debate. I agree with the majority of Ron's comments about the debate (I believe passing the current reform agenda in the form most palatable to liberals and most likely to pass muster is extremely important, even if not the final word), though I do believe that those on the left criticizing current proposals have important views that should be heard as well. I believe the left has been shut out of the debate on a more meaningful level even than the right, and I think it's inappropriate that so much sound thinking on the left was merely dismissed.

Instead, I am going to offer something tangible: a new American health care policy. While it is unlikely anything on this scale will be included anytime soon, it is important that such ideas be presented and circulate for the future.

I am going to start by identifying what I think are the most serious problems with the current system, and offer specific solutions to those problems. I will then attempt to predict the problems such a system might create, and create ideas to attack those problems as well.

1.) The chief problem with our current system is financial. This is not the problem of 'health care costs' as described by the pro-reform voices in the debate, but rather the high consumer costs created by the utterly inefficiant means of paying those costs. Rather than pool all the available health care dollars into one pot to pay the total health care costs those dollars are divided between individuals (both those wealthy enough to pay for most health care out of pocket and those too poor to pay any other way, as well as the dollars paid to insurance companies... as well as Medicare taxes), corporations (both through employee benefits and workplace liability laws), insurance companies (who collect money from both individuals and corporations, take their cut, and then pay health care costs), and the government (through Medicare and Medicaid... and also into insurance companies for government employees.) So there are four different entities who pay into multiple pools. In the case of individuals, the government, and corporations those involved all pay into at least two pools and sometimes more. For example: the same person pays Medicare taxes and insurance premiums, while also paying co-payments out of pocket. That person is paying three times for the same amount of health care. Employers pay into insurance pools while paying corporate taxes that go into the budget to pay for Medicaid, and also pays any workplace liability claims. The government funds Medicare and Medicaid and private insurance costs for government employees. That's a horribly sloppy division of costs and is practically impossible for all of that money to be properly applied the way it is spent.

The solution to this is obvious. Eliminate all the pools but one. Every individual pays a dedicated tax, based on the Medicare tax, into one pool of health care dollars. The insurance companies are eliminated. They are only a drain on the system anyway. Their administration costs and their profit requirements merely serve to suck money that could be paying for health care out of the health care pools. The drain on resources to pay for health care that they create does far more damage than the benefits they provide. While there are some excellent companies that would provide a useful model for a single-payer system or national health service (Kaiser Permanente, despite real flaws, would be excellent for the latter), even the best companies drain money out of the health care pool by their business models. The goal is to eliminate co-payments and deductibles for medical care and confine costs to one dedicated payment that would replace health care premiums.

Medicare and Medicaid would also be discontinued and this system would replace Medicare and be extended to cover Medicaid recipients as well. Importantly, this would eliminate the additional expense of Medicaid eligibility testing. An entire bureaucracy would be shaved off, the money saved to supplement the new health care system as necessary.

2.) Access to health care is, by far, the second biggest problem with the current system. This takes two forms: access to actual care and access to care of sufficient quality. The first is actually a set of several subgroups: those who are refused coverage by insurance companies because of pre-existing conditions despite the ability to pay, those who cannot afford to pay for health insurance and thus do not seek medical care under most normal circumstances, and those who have health insurance but whose provider refuses to pay for care for a variety of excuses. The second group consists of members of all the subsets of the third group: those who generate sufficient debt due to the cost of health care that their physicians will no longer see them until they have paid off their bills.

This problem is solved by the previous solution. Everyone is paying directly into the same pool and so everyone has access to health care when they feel the need to exercise that access. This increased access and the increased ability of health care facilities to receive compensation that results from increased access should also have the benefit of including the quality of care to which many people in the second group have access. The reforming of the Medicaid ghetto into part of the mainstream health care system would give people now on Medicaid access to a better quality of care. This would cause those clinics currently providing services to Medicaid recipients on a nearly exclusive basis to improve or be replaced by better facilities. In this sense (and in that of many people on low quality private insurance) this increase in consumer choice would actually encourage a more 'free market' competition between medical facilities and practices. If patients can go where they please with fewer limitations, then facilities must compete for patients more aggressively with better services and care.

3.) One of the major weaknesses of our current system is one that few people on the left or center properly appreciate, one of the few areas where the right is generally correct in their assessment: the economic burden paying for employee health care costs places on business. Many small businesses cannot afford to pay for health care for their employees at all, while more and more corporations are ceasing to provide health benefits or dramatically shifting the burden of paying for those benefits onto employees. The lifting of this burden would do American business far more good than any corporate tax cut. Current health reform proposals seek to shift more of the burden of paying for health care onto American business and to make it more difficult for corporations to opt out of paying employee health care costs by requiring those that do not to pay punitive taxes. Not only is this punitive taxation potentially a bill of attainder and thus legally questionable, but it aggravates what is already a major economic problem.

The system outlined eliminates this problem entirely. There's no need to add much more than that, and this one of the strongest arguments in favor of single-payer or a national health care system. It lifts a huge de facto tax burden on American business.

4.) Insurance companies and medical facilities currently compensate many medical specialists at a rate far beyond what Classical economists would consider 'market value.' Classical theories of labor, based on utility, would argue that the most important medical practitioners would be primary care physicians. However, because of the inordinately high compensation offered to specific specialists (cardiologists, endocrinologists, neurologists, oncologists, psychiatrists, and specialty surgeons all come to mind), the most necessary facet of medical practice is grossly underrepresented while specialty practice is overrepresented. Specialties like geriatrics and internal medicine are also frequently underrepresented, despite the incredible need for doctors in those fields.

The new, single pool for which to pay for medical costs would allow medical study of the need for specialists in various fields to be done to restructure more reality-based compensation for both general practitioners and specialists. Increased compensation for primary care physicians and underrepresented specialties would draw more doctors to those fields. More reasonable compensation for less necessary, but overrepresented specialties, would help to impose some small degree of basic cost control on the system.

There are at least two problems that such a thorough-going reform could create, which must be anticipated and addressed.

1.) Successful medical programs grow in cost precisely because they are successful. This has been witnessed most specifically with Medicare. The huge change it has wrought in the lives of American seniors has steadily increased the cost of the program because of the increased availability of medical care for seniors and the fact that seniors living longer because of increased access to better medical care means that there are more seniors needing medical care. It is only natural and logical to make a baseline assumption that improved access to medical care for all Americans would have a similar effect on the budget of such a system.

There are several things, however, that can be done about this. The most obvious is that purely elective procedures and medications (plastic surgery not directly necessary for reconstructive purposes, Lasik surgery, abortion in any case where the termination of a pregnancy is not necessary to protect the health or life of the mother, elective hysterectomies and vasectomies, ED treatments, etc) would need to still be based on the ability to pay. If this sounds unfair, then perhaps it is, but there is such a thing as economic necessity and that the more efficient allocation of health care dollars should allow the health care industry to lower the costs of elective procedures to a level where more people can afford to pay those costs.

Second, and perhaps most importantly, is this: the current SS/Medicare tax is capped and income over a maximum level is not taxed. A dedicated tax to pay for national health care costs should not have this cap. All income earned above the current cap should be taxed to pay for health care. Such a tax would still be lower, in all likelihood, than the insurance premiums/deductibles the highest paid Americans are already paying for their insurance, simply because of the need for insurance companies to funnel a percentage of their inflow into profits.

2.) Increased access to health care presents the problem of demand outgrowing supply. This used to be the right wing nightmare scenario, before they decided 'death panels' were even scarier. The image of flooded emergency rooms full of the miserably ill waiting their turn was flaunted by the GOP during the 1994 health care debate.

While there are definitely areas where this will be a problem, some of it is actually highly exaggerated. Emergency rooms are already flooded because of the inability of those without health care coverage to simply make an appointment and go to a doctor's office when they have non-emergency health care concerns requiring attention. The increased ability to see a doctor would reduce the strain on emergency rooms rather than increase it, particularly now that 'urgent-care clinics' have become the ongoing medical fad. The recent profusion of urgent-care clinics would relieve much of the current strain on emergency rooms without overcrowding the new clinics. Emergency rooms, more and more, would only be patronized in the case of actual emergencies. That would relieve the system of a tremendous burden.

The area where demand is likely to outstrip supply is primary care. The shortage of primary care practices could mean longer waits until new doctors enter the field. However, demand creates supply. An increased demand for primary care physicians would naturally generate more primary care physicians to meet that demand. The restructuring of medical compensation to pay primary care physicians more equitably would speed this process. There would be a short-term period in which appointments would need to be scheduled further in advance and waits at doctors' offices would be longer, but this would gradually normalize as new doctors entered the primary care field. PAs and nurse practitioners currently fulfill many responsibilities in this area and the expansion of both fields should be encouraged as well.

Besides, in the simplest possible terms, a medical system in which the biggest problem was the office wait for routine care would be a massive improvement over the current mess.

Let's All Take a Moment to be Frank About Health Care...

There are a lot of misconceptions about health care on the right and the left. On the left, too many are in love with the idea of 'reducing costs' in some way that will miraculously solve the system's problems. The liberal idea that more access to primary care doctors will lower fundamental health care costs is akin to the conservative idea that cutting taxes leads to increased tax revenue. It's so counter-intuitive as to be ridiculous. Better health access to better health care will always raise health care costs, and as I go on I will explain in more detail and give a tremendously cogent example.

On the right, there is a failure to understand that one is frequently advocating what one is professing to hate and fear. Namely: rationing, the writing off of human life for utilitarian benefits conveyed to society by so doing, and ultimately a far greater number of otherwise preventable deaths. This is the horror scenario presented by the right to frighten us all out of supporting what is, essentially, far from 'comprehensive health care reform' but rather a health industry bailout following on the heels of the bailouts of the automotive manufacturing and financial industries. There are lots of reasons for finding fault with the House health care bill, and even more to find fault with the Senate Finance Committee bill. None of those reasons are vaguely related, however, to socialism, government takeover of health care, or rationed care. The current system, as it exists now, is a system of rationing: economic rationing. The ability to pay guarantees access to care and those unable to pay face significant health risks and even greater economic burdens. 'Free market based' reform of health care will simply be a crystallized, finalized statement that economic rationing is the correct social decision.

Jenn Q Public quotes an Atlantic article by David Goldhill on her blog, an article highly critical of current health care reform efforts that Jenn rightly (in my view) refers to as 'mommy kisses and a Dora the Explorer band-aid.' Mr. Goldhill is a business man and registered Democrat who begins his piece with a very moving personal testimonial about his father's death and how a hospital hand-washing procedure rejected by doctors as 'unnecessary' could have prevented it. He then moves on to discuss how the experience drove him to research health care problems and solutions. Clearly, he put some work in.

Goldhill is correct in his fundamental analysis of the fact that the current reform package will affect the problem of fundamental health care costs: it won't. He is also correct in his characterization of the reform bills currently under consideration as merely fundamentally re-cementing the foundations of the current system. As I said above, what is being discussesd now in Congress is not so much 'comprehensive reform' of the health care industrty, but a comprehensive health care industry bailout. Goldhill certainly recognizes that and is not afraid to say so, to his credit:

"But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform."

I can't disagree with that assessment at all. Nor with:

"Health care simply keeps gobbling up national resources, seemingly without regard to other societal needs; it’s treated as an island that doesn’t touch or affect the rest of the economy."

The problem, however, lies in how Goldhill sees health care reform and how he defines failure. It is important graps this definition of 'failure' and the full consequences of such thinking in the long run. I don't know if Goldhill grasps them or not. It's very reflective of much of libertarian and conservative thought about health care reform and it reflects the blind spots and rationalizations inherent in many of their arguments and solutions.

"But even leaving aside the effects of price controls on innovation and customer service, today’s Medicare system should leave us skeptical about the long-term viability of that approach. From 2000 to 2007, despite its market power, Medicare’s hospital and physician reimbursements per enrollee rose by 5.4 percent and 8.5 percent, respectively, per year. As currently structured, Medicare is a Ponzi scheme. The Medicare tax rate has been raised seven times since its enactment, and almost certainly will need to be raised again in the next decade. The Medicare tax contributions and premiums that today’s beneficiaries have paid into the system don’t come close to fully funding their care, which today’s workers subsidize. The subsidy is getting larger even as it becomes more difficult to maintain: next year there will be 3.7 working people for each Medicare beneficiary; if you’re in your mid-40s today, there will be only 2.4 workers to subsidize your care when you hit retirement age. The experience of other rich nations should also make us skeptical. Whatever their histories, nearly all developed countries are now struggling with rapidly rising health-care costs, including those with single-payer systems. From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. Cost control by way of bureaucratic price controls has its limits."

The indictment of Medicare as a Ponzi scheme is extremely harsh and is reminiscent of neoconservative indictments of Social Security. In a Ponzi scheme, the sucker gets nothing for his money. The swindler pockets or spends it all and walks away with it. Moreover, a Ponzi scheme is a deliberately orchestrated fraud for profit. One pays off early investors with later investors money, pocket the remainders, and skips town. It's worth noting that the only people actually discussing so treating Medicare (or Social Security) are the Republicans who want to slash it entirely. I have not heard their plans to reimburse all of us paying Medicare taxes. So who are they really fooling? Goldhill's solution to 'the Ponzi scheme' of Medicare is the same as theirs... pocket the money and walk away rather than fulfilling the program's obligations. This is a fundamental flaw in the indictment of the program.

The description of growing health care costs is accurate, but more central than the weakness of the 'Ponzi scheme' analogy is the failure to recognize why Medicare costs (and the costs of health care in nations with thorough health care policy) grow so steadily. It is because Medicare works. If Medicare did not work, it would be the cheapest government program ever.

Consider this: before Medicare, senior citizens frequently lived in circumstances of crushing, absolute poverty or entirely off the support of their younger relatives. The reason that the age of 65 was chosen as the date of entry for Social Security was that the average American life span before WWII was 63. To put it bluntly: old people died more. No one spent anything on their health care... because they were dead. Medicare came along, and old people started living longer. Not only because they got better medical care at far less cost, which they did, but also because the financial burden their health care costs imposed on them had been affecting their entire standard of living. Not only were they able to get medical treatment for their medical problems, the increased ability to provide for their material needs meant that they were far less likely to die (or suffer medical problems) because of the influence of economic factors on their health. Their younger relatives also had more money as a result of the program, contributing more fully and vibrantly to the economy. So their standards of living were beneficially affected as well. Medicare was good for everyone and the country and still is.

So, by pure analysis of what many consider to be the core test of success (whether or not it meets its explicit goals), Medicare is the single most successful government program ever. So much for right wings paens to the United States Postal Service as the only thing the government ever did right. Medicare has done everything it promised, and even exceeded expectations for its success.

Of course, people living longer means more old people visting their doctor twice a month. Which means more medical costs. This is an inherent problem in the system, certainly, but I prefer paying those costs to adopting the Malthusian attitude toward human suffering necessary to lower them.

Here's where it's time to be really frank: when the right talks about how 'the free market' will lower health care costs they mean that only those who can afford health care will have access and everyone else will do without. This certainly eliminates the 'free rider problem', so the people paying for their health care experience cost reductions and the government certainly saves a lot of money on the budget. On the flip side, we're talking about Victorian Era living conditions reimposed on a significant portion of civilized society. Do any of us want that, even if it means lower taxes?

Goldhill's solution to the problem of health care costs is much like right wing solutions. His description of the ideal health care reform package sounds very much like the perfect Republican utopia:

"The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result."

Now, it's true, that the right doesn't want to see any direct subsidy of those unable to afford health care. In that sense, Goldhill's proposal is superior. However, the reason that the system of comprehensive health insurance that exists today came into being is because it was already, during the 1940s and 1950s, becoming incredibly difficult for individuals to pay for their own health care. Fundamental costs have risen since then, every bit as rapidly as administrative costs, and eliminating the administrative costs of the insurance agency and government bureaucracy will not reduce the fundamental costs one iota. Real wages are lower than they were in 1950, real health care costs higher. If the working man could not afford to pay for his family's medical care without comprehensive insurance in 1950, how could he possibly hope to do so today? Ignoring these economic realities is very dangerous.

Catastrophic health care insurance is a key portion of Goldhill's program:

"First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance. All Americans would be insured against catastrophic illness, throughout their lives.

Proposals for true catastrophic insurance usually founder on the definition of catastrophe. So much of the amount we now spend is dedicated to problems that are considered catastrophic, the argument goes, that a separate catastrophic system is pointless. A typical catastrophic insurance policy today might cover any expenses above, say, $2,000. That threshold is far too low; ultimately, a threshold of $50,000 or more would be better. (Chronic conditions with expected annual costs above some lower threshold would also be covered.) We might consider other mechanisms to keep total costs down: the plan could be required to pay out no more in any year than its available premiums, for instance, with premium increases limited to the general rate of inflation. But the real key would be to restrict the coverage to true catastrophes—if this approach is to work, only a minority of us should ever be beneficiaries."

Great... except that unless he is advocating the government completely subsidize medical costs below $50,000 for everyone who doesn't have fifty grand lying around in case they need life-saving surgery, I don't see how this system of insurance would help most Americans. Despite Goldhill's blithe assurance that competition will naturally lower those costs, I'm highly skeptical. My partner had life saving surgery and the bill (most of which was paid by her workplace insurance) was $56,000. Under Goldhill's system, we would have been responsible to pay for all but six grand. We are facing a certain financial burden from our health care costs as it is, but $50,000? That's an awful lot of debt for the average working American to rack up from one trip to the OR. And my partner is a fairly well-paid employee of a major corporation... but she $50,000 is a lot more than a year's wages for her. It's probably more than the sum of both our yearly incomes. I'm all in favor of the government subsidizing health care in such circumstances, but I'm not sure most of the people who might like Goldhill's plan would be.

Goldhill's solution also relies greatly on personal health care savings accounts, another favorite Republican idea. In his world, like theirs, everyone pays their health care costs out of pocket at point of service. HSAs would increasingly pay people's health care costs as they aged. Except people have a great deal of difficulty saving under current economic realities as it is. What is to make it suddently easier for them to save to pay for their health care? Goldhill is speculating that all that money spent on insurance premiums will be available to go into the bank and he is also speculating that companies, no longer paying for health insurance for their employees, will pay more money. Great... except there is no actual way to guarantee it will actually happen that way. Indeed, in today's corporate culture, the predictable outcome is that corporate employers will simply pocket the savings and reinvest them in increased corporate management costs.

Ultimately, Goldhill's final answer to 'what about those who can't pay' is that the government needs to pick up their tab. For someone who is arguing that health care should be simplified, because the system is too complex, his solution is awfully complicated. HSAs, catastrophic insurance, sliding-scale health care deductibles based on age...

If, in the end, you want everyone with money to be able to buy their own health care and the government to pay for it for everyone else then I'd have to say that single-payer, a national health care service, or the kind of everything-at-once hybrid system used in countries like Sweden makes a lot more sense. Goldhill's agruments for a free market based solution are going to be most attractive to conservatives who will see many of his arguments as echoing theirs... and who will entirely oppose the idea of the government paying any of the costs.

The Poison Pill: Just how toxic is the litmus test for abortion?

I rarely write at length about abortion. It is not that I don't have opinions on the subject, as I do, nor that I do not think the issue is of real importance, I do. Clearly, the debate regarding the right to life of the unborn vs a woman's right to make her own life and medical choices is of real import. The reason I don't write on the topic is because my views have very little to do with the highly polarized consensus reality existing on the topic and I feel that the political debate regarding abortion has very little to do with the genuine issues at the root of the argument. Regardless of their outrage over the possible loss of life of the unborn, the anti-abortion side of the argument is clearly less than sincere in their 'pro-life' agenda. While certain religious groups communicate that agenda quite ably, consistently, and forcefully (as the Catholic Church has done), most political debates on the issue do not.

The Catholic Church's Pro-Life position (and it is the label communicated by the Catholic Church under Pope John Paul II that has been expropriated by American anti-abortion activists) is anti-abortion, certainly... but it is also anti-death-penalty, anti-euthanasia, and anti-war. The American political anti-abortion position (though usually accompanied by anti-euthanasia sentiments as well) is most often communicated by conservatives who advocate an aggressive, militant foreign policy and a law and order position that puts great value of the deterrent value of capital punishment. A truly 'pro-life' stance on issues of human life and dignity is rarely offered in US politics and the defense of individual choice advocated by those who do believe in abortion rights is generally presented (dishonestly) as a support for abortion itself. Furthermore, American 'pro-life' groups frequently dismiss the value of life after birth nearly entirely. They frequently oppose welfare, medical programs for children, education spending, health care, or any other programs that effect the quality of life of the human beings in question after they are born. Worse, by opposing medical exceptions, they advocate a 'pro-life' position so stark that a high risk childbirth in which a critically damaged fetus becomes a stillbirth and the mother is left comatose for life as an outcome of the birthing process is preferable to an abortion allowing the mother to live a healthy life.

Despite the 'personal responsibility' mantra of conservatives, they also generally oppose exceptions for rape, incest, and child abuse. 'Personal responsibility' is a poor excuse to force a victim of sexual violence to carry the living reminder of that violence to term just to give the child up for adoption, as valid an alternative as adoption may be. A rape victim did not ask to be pregnant, 'personal responsibility' does not apply. The argument that the unborn is innocent does have some merit, but claiming that society has the right to force the victim of sexual violence to carry a child to term undermines many core conservative principles. Many opponents of abortion, when pressed, admit that they would give their own child a choice were they the victim of violent crime or pregnant with a seriously damaged fetus. There is a dishonesty in this approach. They believe abortion is wrong, but they are less opposed to abortion than they are opposed to sanction its removal from the unpleasant closet of family life in which it has always belonged throughout history.

On the flip-side of the issue, however, many advocates of abortion rights do not give proper weight to the view that life really might begin at conception and certainly does begin at some point in the womb. In their desire to bring it out of the closet and protect the lives, health, and respectability of women and their exercise of the same freedom of life choices as men, they deny the possible humanity of the fetus entirely. While this attitude has lessened over time, and more and more focus has turned to the medical and individualist reasons behind legalized abortion, it is not entirely gone.

Now, this is a biological fact: in order to enjoy the same freedom of life choice as men, women must have access to birth control and this ultimately includes legal abortion. Men do not have to deal with the consequences of their sexual actions in the way that women do, and this affects their sexual choices. Nor has male promiscuity ever been stigmatized in the way female promiscuity has been throughout history. A successful lecher is often admired in his male social circle, and is certainly forgiven minor peccadilloes, while the sexually active woman is branded a 'slut.' This is a clear case of culture prejudice, regardless of what pretty paper one chooses to wrap it in. We can debate the ins and outs of sexual morality for eternity, but the fact that birth control and abortion are necessary for a woman to enjoy the personal, professional, and social freedom enjoyed by men is not really open to argument. One can argue that sex is not treated with its proper seriousness in modern culture, one can argue that women should not have the same personal, political, professional, and social prerogatives as men, or one can stand on a picket line and throw blood on pregnant women trying to make a difficult choice... but one can't deny the biological necessity of birth control or abortion in an egalitarian world. The only possible response is to argue against the value of an egalitarian world.

No one on the mainstream of either side of the abortion debate is willing to face this core fact, though there are extremists on the right who do argue against the position that a society practicing gender-equality is desirable. On the left, however, the extreme response (publicly at least) is not to bear the burden of egalitarian society but to deny that a fetus is life. This is another way of avoiding the issue.

Naturally (to anyone who reads my stuff, at least), I support an egalitarian society in which women enjoy full private and public social and civil rights. This means that I am a strong advocate of birth control and recognize the necessity, for reasons of public health and freedom of individual choice, of abortion.

This brings us to a second important argument. There are those who recognize the necessity of legal abortion, for reasons of public health and individual choice, but do not want the federal government to pay for it in any way. Many pro-choice Republicans (those left, at any rate) advocate such positions. This was John McCain's argument in the past, as well as that of George H.W. Bush. It is, to them, an individual right in which the government has no right to interfere but also an issue of personal responsibility which the government should not support. Of course, McCain has since backed down on his advocacy of this position and achieved a more common Republican anti-abortion position. George H.W. Bush did the same in his bid for re-election.

The problem with this position is that it is based, as many conservative positions are, in the theory that other rights derive from property rights. One has the right to own and acquire property and to do with it what one pleases, but one's freedoms are dependent on one's means... in other words, one's freedoms are incumbent on one's wealth. The rich have more freedoms, the poor have fewer freedoms, and this legal inequity is not antithetical to conservative views of natural rights.

Which brings us to the question of just how the abortion debate and various positions taken by the participants poison nearly every other issue in American politics. No one has forgotten how the question of abortion and birth control invited right wing criticism of the health care programs in President Obama's economic bill. Now the question of abortion is proving equally toxic to the question of health care reform.

This is serious for a couple of reasons. First and most obvious, of course, is the barrier it poses to the passing of comprehensive health care reform legislation. Democrats opposed to abortion rights are threatening not to support the reform bill unless it explicitly forbids providers participating in the national exchange proposed by the administration from providing abortions. Should self-styled 'progressive' Democrats refuse to compromise on this issue, then the health care reform bill would implode as 'pro-life' Democrats defected to vote with the Republicans in opposition to the bill. In the House, this might not make a significant difference. In the Senate, it could.

Second and more importantly, we all know that there will be compromise on this issue. Senate Democrats, wishing to find a consensus policy and seeing themselves as the last line of defense against the 'radicalism' of House liberals, will find a compromise position that will make the anti-abortion Democrats happy with the Senate bill. Even liberals in the House (such as the genuinely admirable Henry Waxman) are talking compromise in the interest of preserving party unity to save health care. The current compromise being thrown back and forth (which I am sure will be accepted in some form) is allowing the participants in the national exchange from providing abortion... but forbidding them from spending federal funds on same.

This is almost certainly going to happen, and one can make a pragmatic argument that it is necessary to save health care. House leadership will need at least some conservative Democratic support to pass a bill. Democratic conservatives in the Senate will have the power to champion the interests of House conservatives and force a compromise that makes them happy. Based on the priniciple (the very true principle) that health care reform is desperately needed and the abortion debate is of less political import (which it is, as a debate solely about abortion in the manner it is seen in Washington) there will be compromise. We will get some kind of health care reform bill and it will improve the situation.

The problem is that the Democratic Party will be validating a key Republican argument... that all other rights are inherently based on one's ability to make use of them as determined by one's property. The wealthy will enjoy access to the exercise of natural rights that those less affluent will enjoy under the law but cannot afford to use. We will go from one health care system in which one's choices are determined by one's ability to pay to another, and we will have reaffirmed the principle that it is legitimate to limit the complete exercise of one's natural rights based on questions of property.

The real problem, of course, is that the Democratic Party does not really question this either. Rather than adopt a bold position of opposition to the conservative position that property rights determine the share of all other rights an individual possesses, liberals waffle on it and centrists unequivocally share it. 'Equality before the law' becomes a patriotic phrase much as 'freedom of choice' and loses its heft as a real idea.

There will always be economic divisions. They are not going to go away. Economic principles of scarcity mean that there will always be more and less affluent and that those more affluent will have priveleges the less affluent do not. This is why the social safety net is so important, and why health care reform is so desperately necessary.

The problem is, you can bet your bottom dollar that Blue Dogs in the House will refuse to consider a 'medical exception.' Which will put the decision squarely in the court of the administration and conservatives in the Senate.

Do you trust Ben Nelson with the life of your aunt, daughter, girlfriend, grandaughter, mother, niece, or wife?

That's what Blue Dogs in the House are asking you to do.

Conservative Republican Health Care Reform: These are the people telling us they want to protect us from rationing?

I've already written that the health care plan championed by Senator Teddy Kennedy (D - Massachusetts) leaves a lot to be desired at best. It seeks to rely on the dangerous crutch of corporate subsidization of employee health care while failing to address the major problems presented by our existing system. I likened it to the state health plan adopted by Massachusetts during the Mitt Romney administration, calling it 'Romneycare Plus.' Naturally, I stand by this attack. If the Kennedy plan is the best that the Democratic Party can produce, then the Democratic Party deserves a great deal of criticism on this issue.

The sad and tragic fact, however, is that the Republican plan being championed by conservative Senator Judd Gregg (R - New Hampshire) is far, far worse. Some of you may remember Senator Gregg, whom President Obama had nominated for Secretary of Commerce (and who first accepted and then repudiated that nomination in a manner that could not have looked more like a deliberate attempt to deceive and discredit the administration if the senator had been studying at the Actor's Studio in preparation for the performance) back when cabinet appointments were still the News Du Jour every day. Yes, that was a bit of an ad hominem attack. It doesn't prove the following argument in any way. It is, however, worth remembering.

Senator Gregg advocates a program called 'Coverage, Prevention, Reform' or 'CPR.' This program seeks to solve America's health care ills by penalizing working people and senior citizens in an attempt to force them to pay full price for private health insurance for which they would already be paying if it were within their means and met their health care needs; not to mention ignoring Medicare's highly successful competition with private health plans among those seniors who can afford them. They are not 'on the dole' because Medicare is cheap, if it were the failed and broken program described in the linked plug for CPR then very few of the people Senator Gregg wishes to force off of it would be on it in the first place . For those of you who doubt me in my description of CPR, please read the link. It is not a liberal analysis of the plan by left-wing advocates, but rather is an advocation of the plan as written by its conservative authors.

Take the following statement into account:

"Ultimately, this information would be used to tier Medicare copayments and deductibles to encourage beneficiaries to utilize 'higher quality more efficient providers.'" The single quotes within the larger quotation are mine, I want you to read the whole sentence and consider its meaning.

It is very difficult to come to any conclusion other than this: a primary focus of CPR is raising the price of Medicare for senior citizens to make them leave the program and purchase private insurance instead. Hardly the kind of health care reform desired in a system where the number one problem is economic access to health care due to consumer costs and the number two problem is rationing of service by for-profit providers in service to their bottom line. It should also be noted that there is in this sentence a tacit admission that private insurance cannot compete with Medicare on purely 'market' terms but must instead rely on government sabotage of Medicare.

There is a lot of repetition of the phrases 'preventative benefits' and 'disease management' in the text. They appear in bold print. Certainly these are necessary medical tasks that should be paid for, but they are not the sum total of American medical expenses and the simple fact is likely that preventative care is not the magic cure for health care costs that both liberals and conservatives claim to believe it will prove. I am certainly not dismissing the need for preventative care, but I am against siezing it as the sole great mantra of health care reform as is so popular. The reason the repetition of these phrases is so important, however, is because something is very clear about the thinking behind this plan: reading it suggests, to me, that its authors believe that the greatest victims of the American health care system are the private providers of health insurance and that the system must be reformed in their favor.

Why do I say this? For the bulk of Americans, this package amounts to an unfunded mandate to buy private health insurance. Despite repeatedly using the word 'quality' before the phrase 'health coverage', quality is never entirely or clearly defined. Indeed, the bullet point summary specifically reads:

"Designs a cost structure (not a benefit structure) in order to allow for flexible plan design." The emphasis is mine.

CPR contains no mechanism whatsoever to ensure 'quality health coverage' beyond the very subjective and limited areas of 'preventative benefits' and 'disease management.' In fact, despite the focus on preventative benefits, the Medicare portion suggests a belief that seniors are getting too much preventative care. Senator Gregg appears to think so. I quote:

"And physicians are paid more when they order more tests, procedures and office visits, whether you need them or not."

Many medications require frequent blood tests to monitor levels of medication in the patient's bloodstream. As an epileptic under medication for grand mal siezures, I can attest to this personally. Any visit to a doctor's office that I make inevitably entails a blood test. As a man on the wrong side of thirty, sugar and cholesterol tests are becoming more necessary as well. The preventative care requirements for such testing for seniors is greater than in my case as a thirty-two year old male. Not lesser. A certain number of office visits for check ups and progress reports are a necessary part of preventative health care for anyone, as well, moreso for seniors.

It should also be noted that someone is always paid more when physicians order more tests, procedures, and office visits... whether the physician is paid or not. Private insurance does not change this fact anymore than Medicare does. Either way, you pay a co-payment for every test, procedure, and office visit. Proper preventative care will mean more of these for most people (who do not see the doctor enough) rather than less. To be fair, Senator Gregg's specific indictment of Medicare's overuse of preventative care is not in the subject of the proposal as linked. However, it is a fair assumption that the attitude of a great advocate is based on belief in the substance of the object of his advocacy.

The most insidious part of CPR, however, is the secret tax hike. CPR makes health insurance premiums and care costs totalling over $11,500 a year per family or $5,000 a year per individual taxable income if you receive coverage through an employer-funded program and places the same ceiling on its proposed tax exemptions for health insurance premiums. Anyone who has any experience with health care costs realizes how low these numbers really are. Assuming an individual paid a premium of $100 per month (my share of the premiums paid when I had employer-paid care came to more, I am guessing most people's expenses do), then that means there is still $7,000 a year of premiums not at all covered by the tax exemption. Worse, some people require actual medical care beyond their premiums. Since the cap has already been eaten up by less than half the cost of premiums, none of this is covered. So the tax incentive for private insurance is essentially meaningless and the tax exemption for medical premiums on your payroll taxes is mostly history.

The result of all this is to make health care more expensive for most people, harder to get for most people, and to force the working class and senior citizens out of employer-paid care and Medicare and into the private market despite the fact that most of us can't afford private coverage in the first place and many of us can barely afford employer-paid coverage as corporations slough off more and more of the costs on their employees.

So where is the reform? And why are they talking about rationing care for seniors? Isn't that the horror story they use to scare people away from 'socialized medicine'? The notion of 'rationed care'? It looks like the biggest purpose would be to institute a system of care rationing to scare people away from 'socialized medicine' with which the oh-so-effective 'free market' cannot compete.

Something smells bad.