I want to post again the full Q and A yesterday between Obama and the Republican leadership. It felt so good to watch and listen because it finally brought us a conversation - rather than a shouting match over a canyon. So much of American politics is debate conducted at a distance, through ads or soundbites or various talking points that never actually engage one another in debate. Reared in the British debate tradition - I debated through high-school and college, becoming President of the Oxford Union in 1983 - this has always felt to me like the biggest drawback of the American system.
The point of debate is to clarify things, to find where the real points of disagreement are, and to assess them in that context of actual alternatives. All last year we had a rather wonkish debate going on about the details of health insurance reform - how to insure 40 million people without breaking the bank, how to expand insurance with the cooperation of insurance and drug companies, how to curtail costs, how to pay for it, etc. I don't blame people for finding their eyes glazing over. Mine tend to as well. And I don't blame people for watching the sausage-making in Washington and feeling nauseated.
But the Dish forced me to grapple with these arguments and to subject my knee-jerk resistance to this topic to yield to a deeper understanding of how crucial it is for our fiscal future - and our moral present. Your emails brought home to me the desperation out there - not of the idle or irresponsible, but of those who had done all they could to take care of themselves and were rendered indigent or sick or terrified for no fault of their own. Finding a way to get insurance against the exigencies of human life, of which illness is a prime example, is not socialism. It's insurance. it also helps labor mobility, reduces crippling anxiety, and is fundamentally humane. Hayek again:
Nor is there any reason why the state should not assist the individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision.
Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance - where, in short, we deal with genuinely insurable risks - the case for the state's helping to organize a comprehensive system of social insurance is very strong... Wherever communal action can mitigate disasters against which the individual can neither attempt to guard himself nor make the provision for the consequences, such communal action should undoubtedly be taken," - The Road To Serfdom (Chapter 9).
This argument seems to have been lost on many of my more rigid libertarian friends out there.
But outside this reasoned debate, we had people and politicians and charlatans like Beck and Levin and Limbaugh turning understandable anxieties about this process into hysteria and hyperbole and panic. The reaction was so severe on the tea-party right that it seemed simply impossible to counter. You can't reason people out of total hysteria or utter contradiction: "Get the government out of Medicare!"
But here are the obvious facts. The president wants to find a way to get private insurance to 40 million people who don't have it, but can turn up in emergency rooms in desperation, cost far more than if they'd had preventive care, and keep pushing up costs for everyone else. The Republicans have no such plans. From the NYT's fact-check today:
The nonpartisan Congressional Budget Office found that the Republican bill would extend insurance coverage to about 3 million people by 2019, while leaving about 52 million uninsured (PDF). (Find the original Prescriptions blog post on the cost analysis of the House Republicans’ bill here.)
The House Democrats’ bill, by contrast, would extend health benefits to roughly 36 million people over the same time period, leaving about 18 million uninsured (PDF), according to the budget office. The cost of the insurance coverage provisions in the House Democrats’ bill was about $1.05 trillion over 10 years, according to the budget office, while the cost of coverage provisions in the Republicans’ bill would be just $61 billion.
Republican leaders had said all along that expanding health insurance coverage was not a main goal of their bill, because they viewed it as unaffordable. Instead, they had focused on narrowly tailoring their bill to reduce health care costs.
So if you want to insure 40 million people, back the president. If you want to continue the current system's failure to do so, back the GOP. I like the idea of the GOP's HSAs, but when you look at the details, you see that they cannot even come close to helping the actual uninsured to get insurance. As for the notion of just ending the obvious cruelties and anxieties of the current system, the only way to do that without insurance companies drastically increasing premiums, and forcing more people to lose insurance, is a mandate to bring as many people into the system as possible, to ensure that the most vulnerable are helped out by many more.
As for cost controls, the Senate bill has as many pilot schemes and considered options to make a serious start on that. Nothing is assured. Which is why this is the beginning of a process not the end. If we stop examining these cost controls and ensuring they are maintained, if we do not monitor the Congress to ensure that Medicare cuts are real, then the GOP skepticism is warranted. But to say that none of this could ever work is not conservative or empirical, it's nihilist and ideological.
I really do beg my conservative and libertarian friends to look at this problem pragmatically and not ideologically. We have a very serious public policy problem. No one doubts that. We have a new president with an historic opportunity to enact a bill that is right in the center of serious policy debates. And yet the GOP response has been to try and make it his "Waterloo" for primarily partisan political reasons.
I also beg my liberal and independent readers to think about this some more and increase pressure on their congressmen and Senators to get this done. Now, while we still can.