Morning Fog

Pawlenty Offers GOP Health Care Ideas

I noticed that Gov. Tim Pawlenty, one of at least 20 Republican Presidential hopefuls for 2012, recently allowed a five-point list of Republican health care proposals to be published under his name.   It didn't attract a lot of attention, although it's intended as a presentation of ideas for the February 25 health care summit.  It's nice to see any Republican attempting to be constructive, but it's starting to happen as candidates for office realize they've got to have some kind of platform.

Pawlenty's list isn't all bad.  What he calls "incentivizing" health care consumers (No. 1 on the list), and "pay for performance" (No. 2) are both small steps toward the broader idea of consumer-driven care.  Small, because real change in this direction would challenge the profit margins of GOP-client big businesses, hospitals, and medical groups.  Is Pawlenty willing to tackle that?  Still, as he says, Minnesota has a system aimed at making changes in this direction, and we should look at it.

Hardly anyone will be against "modernizing health insurance," (No. 5), by which he means portability, no discrimination against preexisting conditions, and health savings accounts.  But it's  not much of a contribution to the dialogue, since all this already exists in the Administration bill that Pawlenty's Elephantine Party members insist on jettisoning.

Liability reform (No. 3) is another idea that most health reformers agree could make a small contribution to reducing costs of health care.  Obama has supported it though many Democrats in Congress have not.  Question for Pawlenty and his party:  If you want to argue that it's unconstitutional for the federal government to require people to buy health insurance, isn't it also unconstitutional to impose limits on settlements that can be imposed in malpractice suits?  I personally don't think either of these things is unconstitutional, but...

Finally, Item 4: "Interstate health care insurance."  Here, I think, is the wolf in sheep's clothing.  It sounds reasonable, as Pawlenty says, that there's no reason a Minnesotan shouldn't be able to buy insurance in another state.  Well, except that insurance in the U.S. is regulated (if at all) by states.  Some states have stronger consumer protections and higher requirements than others.  Insurance companies often tend to avoid issuing policies in states where they can't meet the standard, meaning that "out-of-state" insurance usually means substandard quality.  If Pawlenty means only that a Minnesotan should be able to buy insurance from any insurance company registered and approved by the Minnesota state insurance authorities, I suspect that's already the case (it is in most states).  If he means they should go buy it anywhere, that's a problem, as Ezra Klein explains in detail here.  It's kind of like going to have your car's brakes fixed in Mexico; it's likely to be a chance you don't want to take.

Overall, Pawlenty deserves credit for at least putting some ideas on the table.  He's shown some political courage in proposing two ideas that could lead to real innovation but which are opposed by most Republicans.  Two other proposals are already a part of the Obama plan, leaving only one that's a terrible idea.  So the question arises, as the old lady used to say, "Where's the beef?"  Why couldn't we have heard these ideas earlier from Republicans; was it really worth the wait for such thin gruel; and by the way, where in Pawlenty's proposals are the Republican ideas for reducing costs NOW of existing care (especially Medicare)?  Liability reform won't cut it.

  

Quirks of History

Recently I saw a play called "The Rivalry," written by Norman Corwin in 1959 to mark the centennial of the Lincoln-Douglas debates and more broadly, the 1858 contest between those two politicans to win a Senate seat in Illinois.  Though the play apparently didn't top the charts on Broadway in the late 1950's, some of its themes resonate today.

It was fascinating to see how time can wreak complete role reversals.  In the debates, it was Douglas, the Democrat, who argued what we now would identify as the racist point of view.  One of the key issues at the time was whether the people of the Nebraska Territory should be allowed to choose, after achieving statehood, whether to legalize slavery.  Douglas argued that they should.  Lincoln, a Whig at the time but only two years later, the first Presidential candidate of the new Republican Party, argued that preventing the spread of slavery to new states was a moral imperative not susceptible to decision by vote.  (Lincoln lost that election, by the way, though he won a more important one in 1860.)

In contrast, many of today's Republican politicans have assumed the racist cloak.  I say this not because they are necessarily committed racists themselves, nor because they oppose Obama (that's their job) -- but because since the mid-1960s, it has been politically convenient to pick up the votes of the old Democratic-segregationist South.  In a multitude of subtle ways, they curry favor with the racist element of our society, finding it prudent not to close the door on them. 

That's pretty much the GOP approach to the "tea party" (i.e., don't close the door, or as Reagan called it, "the big tent").  This Courtland Milloy commentary on a gent named Tom Tancredo, a former politician who is not surprisingly no longer in office, provides food for thought in this context.

Recently I saw a play called "The Rivalry," written by Norman Corwin in 1959 to mark the centennial of the Lincoln-Douglas debates and more broadly, the 1858 contest between those two politicans to win a Senate seat in Illinois.  Though the play apparently didn't top the charts on Broadway in the late 1950's, some of its themes resonate today.

It was fascinating to see how time can wreak complete role reversals.  In the debates, it was Douglas, the Democrat, who argued what we now would identify as the racist point of view.  One of the key issues at the time was whether the people of the Nebraska Territory should be allowed to choose, after achieving statehood, whether to legalize slavery.  Douglas argued that they should.  Lincoln, a Whig at the time but only two years later, the first Presidential candidate of the new Republican Party, argued that preventing the spread of slavery to new states was a moral imperative not susceptible to decision by vote.  (Lincoln lost that election, by the way, though he won a more important one in 1860.)

In contrast, many of today's Republican politicans have assumed the racist cloak.  I say this not because they are necessarily committed racists themselves, nor because they oppose Obama (that's their job) -- but because since the mid-1960s, it has been politically convenient to pick up the votes of the old Democratic-segregationist South.  In a multitude of subtle ways, they curry favor with the racist element of our society, finding it prudent not to close the door on them. 

That's pretty much the GOP approach to the "tea party" (i.e., don't close the door, or as Reagan called it, "the big tent").  This Courtland Milloy commentary on a gent named Tom Tancredo, a former politician who is not surprisingly no longer in office, provides food for thought in this context.

Health Care: Reform Or Rebirth?

I've said that I support whatever changes ongoing Democratic Party efforts to craft a "health care reform" bill can produce.  The Republican Party has mainly chosen to sit the effort out (will the upcoming open meeting with the President change that?) but even many GOP stalwarts agree that certain excesses of our current system, mainly shameful disparities in health insurance, need to be addressed. 

I've also said - like many critics from both right and left - that what's on the table currently fails to address significantly the issue of costs.  Even if a little smoke-and-mirrors and one or two hazy assumptions could deliver (say) coverage for everyone now uninsured, the question of the ever-rising price of health care for the rest of us remains undealt with. 

Finally, I've said, as most reformers shy away from saying, that it seems to me the only answer in the long term is to completely revamp our existing unfettered for-profit system.  My own assumption has been that we'd have to move toward a system similar to what most other developed countries now practice -- in which the government plays a role in setting, or limiting, prices.  Yet that, too, is imperfect, since many of those other countries, though doing far better than we are, still face continuously rising costs.

There is another school of thought.  Recently my attention was drawn to an essay by David Goldhill in last September's The Atlantic, entitled "How American Health Care Killed My Father."  It's long, but worth a read.  As the title suggests Goldhill focuses largely on the shocking shortcomings of our current system, which include not just high costs but a seeming indifference to basic changes that could save lives.  Ultimately, he focuses on what's known as "consumer-driven" care -- the essence of which is to allow individuals to pay for more of their own care directly, rather than through insurance, so that they have a stake in controlling cost.   It's not a new idea, but the author makes his case persuasively.

Goldhill, a businessman, confesses he is not a medical professional; he should also have noted that he's not a political scientist, either.  The changes proposed by advocates of consumer-driven care (Regina Herzlinger, of Harvard Business, is identified here as one such) would be far-reaching, totally restructuring our health care system, threatening the profits of insurance companies, hospitals, drug companies, and the whole "health care industry" as well as their representatives in the halls of Congress.  

The author admits a changeover would have to be gradual, and would take a generation to be accomplished fully (as younger people just entering the workforce begin saving for their future health care rather than paying into health insurance.)  The approach makes a lot of sense but it's difficult to imagine, in our current hyperpartisan political climate, or even in a more mellow one, how the country could make this gigantic shift.  Our current President has demonstrated a surprising willingness to push for radical but politically unpopular changes; our current Congress has shown an indomitable preference for petty party politics over the national interest.  

Thus in the kingdom of the shortsighted, we'll still need a political catalyst -- the total failure of our health care system, in some way now unanticipated --  before even the most farsighted leadership will be able to push us down the path to changing what needs to be changed.  

The Margins Of Charitable Giving

When Republican Scott Brown won election to the U.S. Senate in Massachusetts a couple of weeks ago, the political machinery of Washington almost ground to a halt as both parties reevaluated their plans and prospects.   While the Obama White House, in particular, is retailoring its message and shaping a new strategy, pundits are offering a lot of opinion as to how to proceed, but no one is really certain now how things will shake out.

Perhaps that's why many opinion-makers are focusing on marginal issues, as Michael Gerson does in an opinion piece today devoted to the enduring question of tax deductions for charitable giving.  He takes the Obama administration to task for proposing to limit the charitable deduction that people in the higher tax brackets may take.  

I've always thought this is a non-issue because I believe that for the most part people (and even corporations) give for reasons other than taxes.  In fact, most good investment advisors counsel never to make any financial decisions based on tax considerations alone.  Experts disagree on how a reduced deduction would affect charitable giving;  some say it would make no difference at all; Gerson, undoubtedly quoting the most favorable source he can find, admits that even the Tax Policy Center estimates the proposed change in rules would skim only about $10 billion off a total 300 billion in donations.

The side of the coin nobody every looks at in considering charitable giving is the extent to which we in the U.S. rely on voluntary contributions and nongovernmental organizations to perform functions that would otherwise be (and I would say should be) done by government.   Be it hunger, poverty, health, or even such post-caveman niceties as support for the arts, we rely far too much on volunteers and donations to accomplish basic services to our citizens that are really the province of government.  So, from my perspective, shifting funds away from NGOs and toward the government is not necessarily a bad thing. 

Gerson also complains that the government is not seeking "fairness" (in which case it would let everyone take the high 35% deduction on their donations, regardless of their tax bracket) - no, not fairness but revenue.  O anathema!  This is the standard Republican blind spot, the laughable notion that government doesn't need to be paid for.  Yes, Mr. Gerson, of course it's about revenue; otherwise there would be no need for a change. 

Things Falling Off Cliffs

There's a lot of ferment right now about what the President will say in his State of the Union address tonight, and at least some indications are available, but I would rather comment after it's given.

Meantime, it seems the country has come to a near-halt, though not near enough to force us to deal seriously with some of the problems we face.  Steven Pearlstein today has taken a look ahead to describe what the President should (but will not) say.  He captures the feeling I've had also, that our government is deadlocked in extreme partisanship that prevents it from accomplishing even its most basic tasks.  He also offers an idea for fixing that -- he professes to think that real change could be achieved by Obama's being rigid about requirements (i.e., any initiatives have to be paid for, no legislative special deals and earmarks, etc.).   Pearlstein, I think, has analyzed the problem correctly but his solution could not be effective even if Obama were to adopt it.

One reason nothing is working right now to restore momentum is the nihilism discovered in a recent survey.  People are confused, disillusioned, and most important, feeling the pinch - so they're basically critical of everything.  As writer Achenbach says, they don't like the status quo, and they don't like efforts to change it.  Go figure.  As I've noticed myself, people have resisted beneficial changes in their health care because they prefer to believe untruths than truths; they complain that the government is more interested in rescuing banks than rescuing them without realizing that they were rescued -- from a far worse fate -- by the taxpayers' support of key financial institutions.

Effective government isn't the only thing falling off a cliff.  We now have houses and other buildings on both coasts falling off cliffs too.  In California, recent storms threaten apartment buildings; in Maryland, cliffside homes are under threat for several reasons: damage done by storms earlier this year, plus the cumulative effects of natural coastal erosion; oh, and some insects, too -- the cliffs are home to the endangered Puritan tiger beetle, and local politicians are blaming the Endangered Species Act for preventing action to shore up the cliffs.  In both cases, there seems to be an expectation on the part of residents and local governments that it is (federal) government's job to try to rebuild the cliffs. 

Wrong on both counts, I think. People who build or buy homes need to realize that no cliff is forever; a cliff by definition implies ground falling away, collapsing, eroding.  If you buy such a place, you should buy a damned good - and expensive - insurance policy right along with it.  Governments might provide some disaster assistance but if they do, the principle should be that aid is conditioned on relocating, and abandoning the endangered property.  (This works for flood areas too.) 

So we have a pretty typical picture, I think, of what people expect from government:  Do nothing for the common good like rescuing banks or extending health care (that might cost me money) but help me out of a jam of my own making by saving my house (when somebody else pays me).   

The Country Without A Net

A friend e-mailed me a link yesterday to a New York Times article.  The incoming message showed only the title of the piece -- Country Without A Net.  As I opened it, I was expecting an item about our failure in the United States to provide the fundamental elements of a social safety net (like universal health care). 

I was very surprised when it turned out to be about Haiti!  It's a well-written piece by Tracy Kidder, which makes some very valid points about weaknesses in the global network of international disaster relief, so I recommend that you read it.

Back to my mistake, though: It was a natural one to make.

Haiti is very much a country without a net; even before this week's disastrous earthquake, it was a country that had suffered too much from a whole host of problems ranging from poverty to bad governance.  And yes, as social safety nets go, Americans are far better off than Haitians.  For some Americans, evidently -- those who seek to block efforts to make health insurance and affordable care available to all -- that's sufficient.  Those are the same people who take it on faith that U.S. health care is "the best in the world" despite much evidence to the contrary. 

But it's those same people who should let the scales fall from their eyes.  Haiti should not be our standard of comparison.  Among the developed nations with which we more commonly compare ourselves on various measures, we are Haiti. 

Health Reform - A Synopsis

It's not for nothing that I put a link over there in the right-hand column to The  New Yorker columnist James Surowiecki's blog "The Balance Sheet."  Surowiecki far more often than not gets it right (meaning, of course, that he agrees with me, or I with him) but equally often, he manages to offer a new perspective as well.

His January 4 opinion piece "Fifth Wheel"  pretty well nails the key realities of health care reform as I see them: 

First, that whatever emerges from Congress in the next few weeks or months will not be either pretty or perfect, but it will, despite its imperfections, be a significant step forward in achieving what most of the world's developed countries already have.   

Second, that the main issue remaining outside the scope of present proposed legislation is reduced cost, but that won't be dealt with now, nor probably in the next decade.  I have argued here in Morning Fog that we can't break the upward spiral of cost until we admit that the only realistic way to do so is to abandon our reliance on a for-profit insurance system. 

Surowiecki seems to agree, but the valuable new perspective he brings is encapsulated in one sentence:  "Congress is effectively making private insurers unnecessary, yet continuing to insist that we can't do without them."  How so?  Well, most members of Congress (including those who've opposed many elements of current legislative proposals) support universal access and the concept that those who have medical problems should not pay more.  Yet private insurance is based precisely on that kind of calculation of risk-to-price; when companies can no longer base rates on such variables, they must tend to atrophy. 

Congressmen by and large just haven't recognized yet the contradictions of what they are pushing for -- or perhaps just don't want to admit they do.  On the other hand, I believe most insurers have seen the handwriting on the wall and have begun to factor it into their business plans. 

 If not, they need to think about it now.   Reform need not be a zero-sum game between insurers and the public, but it can't remain a wealth-transfer from the latter to the former, with up to 50 cents of every premium dollar going to administrative costs and profits.  Successful insurance systems in several other countries (e.g., Germany and Switzerland) retain private insurers as the core, but they operate more like utilities for essential care, while continuing to derive greater margins by offering special coverages to those who want and can pay for them.  

More Planets

It's always kind of exhilarating to me to see some of the science reporting that manages to squeeze its way into the news amid the stories of corporate corruption, political pandering, and celebrity salaciousness.  How amazing that there is still so much being discovered, and yet to be discovered, about our world and our universe.

A case in point is the search for new planets now made possible by the Kepler telescope.  New planets with a variety of characteristics have been identified, but none yet with the right combination of conditions to support life as we know it.  Can Earth be unique?  I doubt it - something like us must be out there, and we can suppose it will be found (though I doubt strongly that I'll ever live on it).

Sometimes, though, I wonder why we bother to expand our understanding, to increase our knowledge, to seek out facts -- when the trend on our own planet (well, in the U.S. anyway) seems to be toward an ever-more-common denominator of ignorance, an unwitting shamble into a new Dark Age.  Here are a few of the things I have heard in conversation recently, from people with university education:

70% of all IRS employees don't pay their taxes (well OK, they may pay withholding, but if they owe more, they never pay it).
A British scientist who argues against climate change was beaten up by UN police because of his beliefs.
Interpol has carte blanche to operate "above the law" in the U.S.
You should not even think about answering all the questions that will be posed by the U.S. census this year - "just say no."

Sometimes, it seems as if the planets must be whirling around in people's heads rather than out there in space.  We're used to the exaggerated lie from politicians seeking to sway voters by any means (witness Sarah Palin and her death panels).  But now, we're seeing more frequent and even less factually-based claims from all manner of "ordinary" people.  

Of course, it's evident that these sorts of assertions, believed wildly and blindly by those who express them, come from that modern-day font of all knowledge, the internet, or its close cousin, talk radio.  They're picked up, believed, and repeated by many who ought to know better.  I have no doubt that the stories about new planets will give new vigor to all sorts of paranoiac theories about our being spied on by aliens.  Here is my own humble contribution:  A guy from the gas company came today to replace a battery in the gas meter (which reports usage without requiring someone to come into the house).  Naturally, I am absolutely certain this means that the gas company (and maybe others) can now listen to every conversation my wife and I have. (NOT!)

Maybe we'd better put aside our telescopes and focus a bit more on educating ourselves right here on Earth.  I have no doubt that the freshly announced initiative for science and math education is needed and useful, but it looks as if we need to focus more on some of the humanities:  civics, history, logic, evaluating and using sources of information.  Or, should we believe that the cause is lost, and accelerate that search for another planet that sane people might move to? 

Solstice Day - A Christmas For Everybody

Is Christmas obsolete?  No, but it's certainly changing.  Even the staid old Washington Post recognized, in an editorial a couple of days ago, that "Christmas" has increasingly become an ecumenical, even secular, holiday, one that's observed in some fashion or other by far more Americans than are card-carrying, practicing Christians.  According to the Post, we might want to blame or praise Irving Berlin for this trend.  His song White Christmas, appearing in 1942, got us all thinking about the holiday in a different way. 

More accurately, of course, Berlin simply put into music and feeling that was already a part of our collective consciouslness.  At its best, Christmas these days is a spirit of goodwill and giving in which many non-Christians, and even the areligious, get caught up.   Christian religions should be pleased to take credit for this aspect.  At its worst, the holiday is an exercise in mass-crass commercialism, and orgy of buying each other stuff we often don't need.  People of all beliefs get caught up in that, too; and our fundamentally commerce-oriented culture can (and does) take credit for that aspect. 

Some time ago, a not-so-famous blogger suggested that we need to redefine and re-calendar some of our official holidays to better adapt them to our changing multicultural society.  Specifically on Christmas, he wrote this:

....Christmas.  Although it's a Christian holiday, it is commonly observed in various ways by people of many faiths and persuasions.  I have known Hindus and Muslims in this country who put up a tree and exchange gifts as a secular tradition of the season.  To non-Christians and even many Christians, it has become more about gift-giving than anything else, and of course for retailers, it's lifeblood.  The date is arbitrary -- we celebrate Christ's birth at this time of year because it roughly coincided with pagan rites accompanying the winter solstice.  My suggestion:  December 22, Solstice Day, a time of rejoicing, a festival of cheer and light that chases away winter doldrums; a time, too, of gift-giving and of the all-important end-of-year extravanganza of buying that drives our economy. Maybe the change would also help move some of the commercialism away from the "real" Christmas on December 25.

It's still a great suggestion.  The time is nigh.

The Senate's Milestone On Health Care

The Senate reached an important milestone by passing its version of health care reform this morning before its members went home for Christmas.  It's not the "real deal" yet, since the different features of the House and Senate versions remain to be reconciled, but the broad outlines of what might result are now pretty clear. 

Could "reform" still unravel?  Might Republican efforts to strangle the baby in its crib yet succeed, or could it prove impossible for committees to reconcile the two versions of the bill into something enough Democrats can accept? 

I'm optimistic that Congress will pass a joint bill in the new year.  It will be a typical product of reconciliation, certainly.  Neither beautiful nor elegant, it won't provide every feature that its most extreme advocates would like, nor by definition will it give the opposition what they want (which is no bill at all).  It will have unintended consequences that might need patching in future years.  It won't control costs sufficiently, but it may offer enough room for experimentation in different cost-control approaches (by different states and local networks) that would point the way to the most practical, workable models. 

Meanwhile, it will provide significant improvements in the basic fairness of our health care system, and that, for now, is good and sufficient cause for holiday rejoicing.