The Utter Fraudulance of David Brooks

I know it may seem like I (and many others in the lefty blogosphere) spend a lot of time slamming David Brooks -- after all, he's just a guy paid (a whole lot of money) to sling bullshit a couple of days a week at the nation's paper of record and on various public television and radio outlets.  But it is for precisely that reason -- he's the thinking man's conservative, the reasonable one, the guy the Obama Administration wants to appeal to -- that makes him far more consequential than he ought to be, and hence, a suitable target for all of the derision heaped upon him.

Today he has a column that demonstrates once again how little substantive knowledge he brings to the table and the degree to which he is simply a sly right wing propagandist.  (Contrast Brooks with someone like Ezra Klein, who has actually done the hard work of studying and mastering arcane detail about the day to day workings of our health care delivery system and those of other countries.)  Brooks, in his encomium to Chief Justice Roberts' sense of restraint, proclaims that we are now ready to proceed with the real nuts and bolts debate of how to furnish health care coverage to people.  He proclaims:

Liberals tend to argue that major structural changes can be made within the framework of Obamacare. Republicans tend to believe that the perverse incentives can only be corrected if we repeal Obamacare and move to a defined-benefit plan — if we get rid of the employer tax credit and give people subsidies to select their own plans within regulated markets.

He then goes on to state in the very next paragraph:

Personally, I think the Republicans’ defined-contribution approach is compelling. It’s a potentially effective way to expand coverage while aligning incentives so that people make cost-conscious, responsible decisions. But the truth is neither I nor anybody else really knows what works. We’re going to have to go through a process of discovery. We’re going to have to ride the period of rapid innovation that is now under way.

The truth is David Brooks doesn't know what the fuck he is talking about as "defined benefit plans" and "defined contribution plans" are opposite approaches to funding something -- and neither are traditionally thought of as approaches to financing health care.   

Defined Benefit Plan is a pension term of art describing a traditional retirement program where a participant is assured a guaranteed monthly income for life (and often the life of his/her spouse), with the monthly benefit based on some defined formula attributable to years of service.  I have never seen it used in the context of a health plan and I've been doing work for union health plans for 27 years.  

Defined Contribution Plan is also a pension term of art describing an individual account retirement arrangement, like a 401(k) plan, where one gets at the end of one's career a payout of the amounts that you or your company contributed, plus any investment earnings thereon.  There are no guarantees of what that amount will be and no assurance that the amount saved will be adequate to last until one's death.  Again, this is not a term that I have seen associated with health plans as a general rule.  

A defined contribution approach to health care would be, I suppose, one in which an individual sets aside a certain amount of money to cover actual health care costs incurred over time.  This is a spectacularly bad idea and one at odds with the entire historical concept of insurance, which is all about socializing risk. Anyone who has worked with health plans knows that roughly 20% of the covered population will incur about 80% of the costs.  (And you should thank whatever deity you thank if you are not among that 20%.)  Catastrophic health occurrences are not evenly distributed and they are very often simply random events that victimize people for no particular reason.  (I know any number of people who at young ages have suffered from cancers or other genetic diseases that were immensely expensive to treat and that were in no way related to unhealthy behaviors -- not that I think the latter should matter.)  If this is what Brooks and the Republicans are advocating, it is a terrible idea.

Finally, the notion that we don't know what works in this realm or that there is some great mystery about controlling costs is simply nonsense.  There are any number of models out there of how to run a health care system more cheaply than we do in the U.S. and with universal care provided.  Brooks can choose to ignore this as they are all in some form or fashion examples of national health care, but the notion that this is all shrouded in mystery is just more bullshit from the master.  The issue addressed by the ACA is trying to cobble together a system that approaches universality and bends the cost curve down without arousing too much opposition from insurers, hospitals, providers, and the pharmaceutical industry.  It is complex out of political necessity, not because health care delivery needs to be complex.  Brooks' fellow Republicans have made cost containment more difficult by their demagogic campaigns against "death panels" and the "$500 billion cut from Medicare by Obama," i.e. cuts to Medicare Advantage providers, all the while plotting to impose significantly larger obligations on individuals to pay for health care as necessary "skin in the game."  

The bottom line is that this latter approach will only serve to further deny needed care to people, while doing nothing to promote universality or contain costs.  In this policy debate, the right (and Brooks) literally have nothing to offer.

Lastly, I note that Brooks has the old "tort reform" canard in his column.  This ignores consistent findings that malpractice suits do not add significantly to the cost of medicine as well as the fact that many states, like Texas and Florida, have already enacted tort reform -- seemingly without any boost to getting people insured.  My question is how can all of these principled federalist take the position that Congress has the power to legislate on tort law, an area that has traditionally been the province of the states, when it cannot dictate terms to states under Medicaid?  

 

Comments

[Bill H]

"The issue addressed by the ACA is trying to cobble together a system that approaches universality and bends the cost curve down without arousing too much opposition from insurers, hospitals, providers, and the pharmaceutical industry."

Seriously? That will keep me laughing for the rest of the day. Screw the people blind, just don't arouse, "too much opposition from insurers, hospitals, providers, and the pharmaceutical industry."

[Sir Charles]

Bill,

As we have discussed ad nauseum, there would be no bill in the wake of concerted opposition by these groups.

You can try and wish it away and indulge your rich fantasy life while 50 million people remain uninsured or you can try and put something together that will hopefully make life better for at least tens of millions.

There is no politically realistic scenario for a single payer system to emerge anytime in the future because your friends in the Republican Party will fight it until the death.

You can't pretend that both parties are functionally the same and then decry the compromises that have to be made to actually achieve something in the real world necessitated by the bloody-mindedness on one side of the debate.

[Paula B]

Thanks,SC, this had to be said:

Finally, the notion that we don't know what works in this realm or that there is some great mystery about controlling costs is simply nonsense. There are any number of models out there of how to run a health care system more cheaply than we do in the U.S. and with universal care provided. Brooks can choose to ignore this as they are all in some form or fashion examples of national health care, but the notion that this is all shrouded in mystery is just more bullshit from the master. The issue addressed by the ACA is trying to cobble together a system that approaches universality and bends the cost curve down without arousing too much opposition from insurers, hospitals, providers, and the pharmaceutical industry. It is complex out of political necessity, not because health care delivery needs to be complex.
-------------
What do you think doctoral students do at some of our stellar schools of public health and probably business and law schools, such as Harvard, Columbia, Stanford, Dartmouth, Georgetown? Researchers here, at the WHO and at every major university and medical school have been working on these models for decades, using data from every setting and culture you can name. You could fill a Barnes and Noble with the what's been written on aspects of health care systems. If Brooks demands big bucks for opining on health care reform, you would think he would go to the source(s) that put forward the concepts used to develop the ACA, and not attempt to invent his own plan. Based on what? Air?

And thanks for pointing out that the politics are as complicated -- if not more so -- as any system designed to successfully deliver health care services to several hundred million people of varying levels of health and wealth.

[Davis X. Machina]

Does this mean we want to Kill the Bill?

I'm so confused.

I'm pretty sure we wanted to Kill the Bill.

And now we don't.

Just trying to be a good liberal progressive here

[Sir Charles]

DXM,

Ha! You're fucking with me, aren't you?

Jesus, it's 4:00 Pm and it's 103 here right now. I blame John Roberts.

[Joe S]

DXM, you have to get better at double think. I actually think the Conservatives have this down better than we do. The mandate was a paean to conservative values. Good hardworking Americans insuring that all those freeloaders paid their fair share for health insurance. Now, it's pure creeping fascist-socialism. A giant fop to the looters and moochers.

[beckya57]

Joe, there's no question that the right is better at double-think than we are. More importantly, they're also better at appealing to people's emotions. The limbic system will trump the frontal lobes every time. The Dems need to be telling heart-wrenching stories about people with hideous health problems through no fault of their own (I'm with you, Sir C, but most people have far more empathy with "innocent" victims), who will now be saved from bankruptcy and/or terrible disability and/or death by the ACA. They need to be going for the heartstrings over and over and over again. (They're actually off to a decent start with the anti-Bain ads, which are designed to make people angry--as the right has demonstrated, that works very well too.)

[beckya57]

By the way, I want David Brooks' job. I spend every working day expending massive energy trying to make sure the meds I prescribe are helpful and aren't going to poison anyone. I'm sure he gets paid a lot more than I do for pulling right-wing cant out of his ass. Moral Hazard, will you please bite him on the leg already?

[nancy]

I suppose this is mean, but...

We have David Brooks' fraudulence. Then there's Peggy Noonan's 'feeliness'.
She's worth one last pause for derision I'd suggest. She's the appeal-to-the-limbic system, late twentieth-century exemplar. She and Ronnie. Her confectionary voice and delivery won't be duplicated anytime soon I suspect. Matalin tried, a bit, but couldn't pull it off. Riddance all.

Mitt sends the limbic system into retreat, luckily. Think that's what his fellow party members recognize. He can't do the dance.

[Sir Charles]

Massive storm here tonight. The power got knocked out a couple of hours ago. I've been reading Bring Up the Bodies by flashlight for a couple of hours. I am hoping that it will cool off enough to sleep. Writing substantive comments by iPhone is beyond me so I will bid you good evening until the morrow.

[Bill H]

"there would be no bill in the wake of concerted opposition by these groups."

Which is exactly my point. We have been beaten down so badly that we not only accept mediocre policy, we cheer wildly and laud it as "a massive victory," that which our corporate overlords deign to give us. Programs which serve the public are not determined by the needs of the people served by the programs, but are crafted by Congress to "not arouse too much opposition" from our corporate masters.

I'm not usually given to that sort of colorful rhetoric, but...

"You can try and wish it away and indulge your rich fantasy life..."

I don't have any fantasy life. If supporters of this dog were saying, "Well, it's not wonderful, but at least we did something," I would agree in a heartbeat, issue a cheerful "well done and move on to the next topic. It's all of this nonsense about "the new FDR" and "the greatest piece of legislation in generations" and such that drives me nuts. It isn't even centrally about health care at all, it's about health insurance.

Even if it did massively "bend the cost curve" of health care down to what other civilized nations paid, which is laughable, we would still be stuck with an insurance system that slapped a 25% markup on top of that health care cost, because all we're doing is make sure everyone has, that is buys, insurance. Gack.

[Prup (aka Jim Benton)]

Bill, before I discuss -- maybe tomorrow morning -- whether any of us have indulged in "It's all of this nonsense about "the new FDR" and "the greatest piece of legislation in generations" and such that drives me nuts." let me quote most of a long post by Desert Beacon who -- you may have been to new to have seen much of this -- I consider the best blogger, period, on economic matters. Better than Krugman -- who takes too much for granted in his audience -- or Ezra:

So, on the occasion of this 4th of July perhaps it’s time for a reminder about the freedoms now available to all Americans as a result of the passage of the Affordable Care Act.

Freedom from being denied coverage because of a pre-existing medical condition. Under the terms of the ACA you cannot be denied coverage because you have a medical condition, or have had a medical condition, which an insurance corporation doesn’t want to cover.

Freedom from being denied treatment because you have used up the “life time” limits of a health insurance policy. These “junk policies” have been sold across the nation, and the unfortunate result is that a person may be receiving treatment for a catastrophic condition like cancer only to discover that the treatment may be stopped because the “limit” has been reached. You are also free from policies that have annual limits.

Freedom from having to rely on expensive emergency room treatment. No longer will uninsured Americans and their children have to wait for medical treatment in an emergency situation for a condition that could have been treated earlier and much less expensively in a doctor’s office.

Freedom from worrying that our children will be denied coverage because of pre-existing conditions like asthma, or other chronic conditions. The ACA also allows parents to keep their children on their own health insurance plans until they are old enough to be able to purchase their own insurance.

Freedom for senior citizens to purchase their prescriptions without the infamous do-nut hole swallowing their income.

Freedom from having an insurance corporation rescind your health insurance coverage when you become ill because of a technical error or inadvertent mistake. You cannot be denied coverage because of some artificially determined ‘error’ on an application.

Freedom to appeal a decision by a health insurance corporation in an independent review. You may now appeal decisions concerning coverage and claims.

Freedom for small businesses to receive health insurance tax credits to help them provide health insurance coverage for their employees.

Freedom from worrying about whether your health insurance plan covers preventative medicine. Blood pressure screenings, mammography, cholesterol screening, colorectal cancer screenings, and other preventative medical screenings must now be covered.

Freedom from being charged unreasonable rates for health insurance plans. Insurance corporations must now justify their rates if the states so decide. In areas like rural northern Nevada in which there may be only one company writing policies this is important.

Freedom to choose between nursing home and home based health care services for elderly family members. Under the ACA states may offer community based or home based services for the elderly under Medicaid instead of having to rely on institutional services.

Freedom to know how hospitals rate in terms of treatment for heart attacks, pneumonia, and surgical care. The best health care consumer is an informed health care consumer, and the ACA helps make consumers better informed through reporting systems.

Freedom from paperwork. Under the provisions of the ACA doctors, hospitals, and labs can “bundle” their billings for care for a particular episode covered by Medicare. This will save time, paper, and confusion.

Freedom from being charged more for a health insurance policy because of your gender or health status. Being a woman will no longer be a “pre-existing condition.”

Freedom to participate in a clinical trial. Health insurance corporations will no longer be able to deny coverage or limit it because you choose to participate in a clinical trial.

Freedom to participate in your current health care plan, or choose to participate in a health care exchange if your employer cannot provide a plan. Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance Exchanges.

And Bill, note that 9 of the 16 contain limitations and restrictions on practises that were standard in the insurance industry.

Okay, we could all come up with better plans, but what this gives is still miles ahead of what we had and what you'd have us go back to, trusting that we could get a better plan through the congress that is aware of our previous 'failure.'

[paula b]

Well put, Jim. And be safe down there in DC today, you guys!

[Prup (aka Jim Benton)]

Paula: thanx, though, xcept for the peroration, the piece was entirely DBs.

I hope Sir C is alright, that was, according to the Waether Channel and NBC">http://www.nbcwashington.com/news/local/Records-Could-Be-Broken-as-DC-Heats-Up-160732845.html">NBC Washington one hell of a storm. (Which local right winger or preacher will be the first to blame it on Roberts?) Apparently power is dubious for the whole area for a while, and today looks really bad. And the storm killed at least 4 people.

Speaking of Roberts, the new meme of the weekend -- from Michael Savage, Bryan Fischer, at Matt Drudge, among others, is that Roberts ruled the way he did because of the epilepsy medicine he's on.

[Sir Charles]

I am doing fine. It is a beautiful morning here but we remain without power -- as do some 1.5 million people evidently. I hope the power comes back before the heat does. Right now the windows are open and all is well, but I had a pretty miserable night's sleep.

[Bill H]

Prup, of these "freedoms" you cite, all of them are things which you obtain by purchasing them with your own money from corporations, or require you to do so in order to exercise the "freedom" at issue. That's what counts as "freedom" in America today? Freedom is the things that we can buy from corporations, or the inability of corporations to refuse our money?

Ten of those "freedoms" are going to increase the cost of insurance, unless you believe in some form of magic which allows a corporation to pay out more in benefits and not increase the amount that it must collect in premiums. If you think that the magical power of the "individual mandate" is going to pay for that then you have the "rich fantasy life" that Sir Charles accused me of having. For one thing, I have seen no actual study which shows that the number of healthy enrollees is sufficient to pay the cost of the ten costly "freedoms" which you tout, because no one knows the actual numbers of either those costs or how many will actually enroll. Somebody merely came up with the "brain thought" that healthy prople should be able to offset the additional cost, and that somehow morphed into it will offset the cost.

Two of those "freedoms" apply only to Medicare, and the "bundling" will have little actual effect even on Medicare patients.

"Freedom to know how hospitals rate in terms of treatment for heart attacks, pneumonia, and surgical care." If I have a heart attack, I hope to hell my wife does not spend time calling all of the hospitals in San Diego to find out which one offers the best deal on treating my heart attack. You do realize that "consumer choice" and a "competitive market" are Republican arguments for removal of regulation, don't you?

This obsession to connect "freedom" with the requirement to purchase from corporations and with legislation which affirms corporate control of health care is mind boggling.

[Prup (aka Jim Benton)]

Bill: That I get a little tired of a lot of people here -- not all -- who have never really known what it is like to live for decades without any insurance at all, how tricky it was, sometimes borrowing money -- or having a friend pay -- if I absolutely HAD to go to a doctor, nut mostly trusting to time to heal whatever I had, because time was -- sometimes -- the only thing I could afford. (Since I rarely had a job with paid sick days, sometimes 'time' was also unaffordable.)

But I was luckier then than I was in 2002, when a long time foot problem, one I'd had for over 30 years, suddenly flared up and became so infected that it went from (on Saturday) my FP saying 'it doesn't look that bad but I'll set you up with the podiatrist in the office" to (on the next Friday and the podiatrist) "Report to the hospital at once and maybe we can save your foot!"

But even if we had had insurance, I would have been screwedm because the foot problem was a 'pre-existing condition' that wouldn't, probably have been covered. We would have been sued -- we almost were anyway -- if the hospital hadn't screwed up so badly that it almost gave me a broken leg -- when i was reporting for a follow-up visit.

And while we now own -- with my brother-in-law -- the house we live in, because Em's parents deeded it to us, we wouldn't have been able to accept if the suit had gone forward, or it would have gone straight to Kingsbrook.

As for lifetime limits, well, Em's had physical problems all her life, exacerbated by emotional problems -- and, for much of the earlier part of her life had insurance paid for by her parents (who could have kept her on their policy longer with the ACA). I can't totall all she's spent, even with me, but she had two extended hospital stays (Blood clot and severe asthma attack), my operation, her therapy that is over $15G alone, and one -- not too expensive -- medicine that totaled the same just since I knew her. Add several much more expensive medicines, including "psychotropics" and asthma medicines, and she'd be pushing the 'lifetime cap' by now.

Then there are other people who want to take part in clinial trials -- but can't without the ACA. In some cases the clinical trial will show the new medicine or procedure is worthless, others will show it is valuable and will save many more lives than just the participants in the trial.

Then there are the people who hate their fucking job, but don't dare leave it becase -- pre-conditions again -- they won't be able to get new insurance at a new job. (And there are still those few states who consider 'domestic violence' as a 'pre-existing condition' that allows an insurance plan to deny coverage.)

And those people who had a procedure done, assuming it was paod for, and discoved their policy has been a victim of 'recission' because of some trivial mistake they made in filling out the original forms, and thus found them owing a bankruptcy-onducing bill.

Now sure, sure, these people are, from your view, simply 'collateral damage' that need to be accepted so that money can be kept out of the hands of those eeevul insurance companies -- even though a good part of their eevul has been regulated against.

But, from my personal perspective, as well as my overall humanism, I'm sure you understand that I beg to differ with you.

[beckya57]

I just clicked on the link about Roberts being on anticonvulsants (i.e. anti-seizure medications). This is low even by wingnut standards. I'm no Roberts fan, even after the ACA decision--Toobin's reporting shows that he was the genius behind CU, one of the worst SC opinions ever--but there are some places you just aren't supposed to go, and questioning someone's mental faculties like this is high on my list. I had no idea Roberts was on those meds (and it is true that they can affect cognitive functioning to some extent), but obviously he's managing just fine. Something tells me that if the left had blamed CU on his meds the right would have been in full attack mode. My husband just reminded me of the claim that Michael J. Fox was faking his Parkinson's symptoms. These people truly have no decency. Who was the guy who called out Joe McCarthy for having no decency? We could use him right now.

Sir C, hope all's well there. I lived through a hurricane in Houston in August, which of course knocked out the power, including the AC. I feel your pain.

[Bill H]

Prup, I am not unsympathetic. I have been without insurance myself for long periods, being self employed for some eighteen years. I walked on a leg with an unhealed shattered fibula for eight years, which caused level 7-8 pain every time I turned a corner. I finally saved up $3800 to pay cash to have it repaired at a charity Osteopathic hospital.

I do not, however use my individual problems as a measuring stick for national policy, in the first place, and having insurance would have been far from the best solution in the second place.

Putting bandaids on a broken system is better than nothing, and I'm not saying the bandaids should not have been applied. I have said that repeatedly in this forum. I am objecting to an attitude which claims that we are on the way to a system that is no longer broken, and we are nothing of the sort. Not as long as doctors are making multi-million dollar incomes, drug companies are charging $100 for a 50-cent pill, and hospitals are charging $300 for five minute's use of a blanket. Covering everybody with insurance does nothing, nothing, nothing to address any of that.

[Paula B]

I don't remember anyone here saying the ACA was the be-all/end-all for health care reform, but rather a step in the right direction. Most of us wished it had gone much further, but we certainly didn't want to sit in the same stagnant spot where we were, before the law was passed.
And, I don't think you're going to get much argument over health care costs, although there's nothing simple about that either. I may be opening myself up for attack here on specifics, but I can tell you -- after two major surgeries in the past year or so -- that special blanket a highly trained nurse wraps around your body before you go into the operating room, and whatever magic it contains at a very important moment in an extremely delicate process, may be worth every penny the hospital charges. What that specific thing costs or doesn't cost is not the point. Those are the details that have to be worked out, once the framework is in place to make decent care available to everyone. Believe me, the comparative effective research-component of the ACA is going to force some real change in coverage and costs, eventually. But to get there, we needed to restructure the insurance framework and expand availability.
The ACA is a process, not a magic bullet. We'll be hammering out the details for generations, just as they are and have been in (dare I say?) Europe. But at least, we've made the first step.

[Bill H]

Don't get me wrong; we may not be on the same page, but we're in the same book. I certainly don't want the damn thing repealed or overturned, and I don't harbor any illusions about it being socialism. Not that the latter would be all that bad, really, given that Social Security is supposedly a form of socialism.

[nancy]

I do not, however use my individual problems as a measuring stick for national policy, in the first place, and having insurance would have been far from the best solution in the second place.

This is where I can't follow you, Bill. Sooner or later we all have our individual problems as a measuring stick. People we care about have a premature baby, contract pneumonia, break an arm, get an intractable MRSA infection, have an ER asthma run or two or three, break a rib going down the front steps in the snow, etc. Not to mention try to care for unexpected and unwanted chronic conditions. Common and unavoidable stuff. Your out-of-pocket pay-as-you-go model just doesn't work. Not currently. Nor does not understanding that sepsis can be an 8:00 am to 8:00 pm death sentence without immediate care. That's where lots of people have been until now. And would stay without the assurance of what the ACA will offer. And it will be reviewed and adjusted over time.

[beckya57]

My husband and I have been lucky enough to escape any major medical bills. I have 2 friends who have not been so lucky. One, a dentist, had her hypertension horribly mismanaged by her doctor--a board certified nephrologist (kidney specialist) who wouldn't bother to do the scans needed to find out why her HTN wasn't budging after putting her on 6--yes, you read that right, 6--medications. She actually had a tumor on her adrenal gland. She finally went into hypertensive crisis, needed immediate surgery, and almost died. She also spent 9 days in the hospital, and they ended up owing over $40,000, even though they had good insurance. The other is (ironically enough) a doctor, who has a mentally ill daughter who has been in and out of hospitals over the last year. They also have insurance, but the bills have been horrendous. These are good people, well-educated, employed, responsible, who just happened to have some bad health breaks in their families, and ended up with huge bills despite having insurance. And of course these are the "lucky" ones; there are also millions of people in this country who have no insurance and can't get health care at all. I remember a young woman I encountered once as a nurse who had a dental infection, who couldn't get care; this had happened to her before, and she had ended up with endocarditis (an inflammation of the heart muscle) as a consequence. She was at risk for this happening again, and there wasn't anything she could do about it. And of course the treatment for the endocarditis--which the taxpayers paid for--was much more expensive than the dental treatment would have been. Stories like these happen all over this country every day. This is why the ACA is so necessary. Would I rather see a single payer system? Sure. But that's probably not going to happen in my lifetime; this country is just too hysterical about Big Gumminent to support that. The ACA isn't perfect by any means, and will need a lot of tweaks, but that's the only way social legislation ever gets done in this country. The original Social Security legislation was very limited and quite discriminatory against some groups. It had to be modified over and over again, but it was a start, and a framework that could be built on. The ACA is the same way. We just have to make damn sure the GOP doesn't take over the government in this election, because they are dead serious about getting rid of the ACA, and have no intention of replacing it with anything meaningful.

[Bill H]

Nobody should ever have a medical condition that remains untreated. I am not some kind of monster that wants people to die horribly of untreated MRSA.

But the common welfare and the summ of individual welfares are not the same thing. Ideally, we would put an armed guard in front of every house in every city 24/7/52 and assure that no one is ever murdered in their sleep. That is the maximun assurance of individual welfares. Can any city, can the nation afford to do that? Of course not. So a story of one person who, in my case, had an unhealed splintered fracture of the fibula for eight years which caused serious pain when walking is not a matter of national concern. It simply cannot be. It concerned me for eight years, but I did not, and do not, expect that Congress or the President of The United States should give one single thought to my damned fibula.

My concern is not that Congress did something bad with ACA, they did not, it's a reasonably good thing. My concern is that they did not even try to do anything better on this or on so many other issues. They do not introduce a bill if the Republicans even make any noises about voting against it. Not once do they try to pass the better legislation and let it fail, they negotiatite it down vefore even trying to succeed. Make a deal with drug companies, for instance, before the negotiations even start.

I played football for eight years. We won a lot of games and we lost some. Sometimes we went into a game knowing the other team had a far better record than us and that there was little chance we could beat them. We took the field anyway and did our best to win, and we actually won a few of those games. If our team name had been "Democrats" we would never have taken the field. We would have just tossed a towel out onto the field and forfeited the game because we would have known we were beaten.

Democrats say that Republican are preventing them from doing better, but proof of that would be legislation that actually failed in voting, not watered down crap that Democrats surrendered on before it even came to a vote. Lose the good bill first, then come back with the "compromise legislation." Today's Democrats introduce the compromise first.

[low-tech cyclist]

the common welfare and the summ of individual welfares are not the same thing.

Maybe not, but there damned sure should be a reasonably close relationship between the two. If the sum of individual welfares is bad in some area, that means a LOT of individual people are having the same or similar problems. We're not talking about outliers here.

If you'd said that we shouldn't be making decisions on what the government should or shouldn't do on the basis of outliers, I'd agree with you, Bill. But your situation with your fibula wasn't an outlier; there are apparently a million or more Americans who are forgoing badly needed health care like that because they have crappy insurance, or none at all.

Look, I believe we need a progressive movement that will take on the "malefactors of great wealth" to borrow a phrase from a guy whose face is on Mt. Rushmore, and fight the battles that will reduce their influence over our politics. As Atrios often says, it's their country; we just live in it. And he's all too correct on that.

But in the world we're in, if we wanted a major expansion of health care access to something at least approaching universality, we had to do it on their terms if at all.

But the fact is that it will greatly reduce the number of uninsured people in this country, and it will ensure that insurance really IS insurance - that is, that the insurance company can't drop you the moment you're sick, or limit their coverage with annual and lifetime limits. And overall, it won't cost any more nationally than what we're paying now.

That's a big fucking deal. It's worth celebrating as a major achievement. It's worth fighting in this coming election to protect and defend this victory, and look forward to the prospect of improving it down the road. But it's easier to build on something that's already there than to start from scratch.

[Bill H]

"If you'd said that we shouldn't be making decisions on what the government should or shouldn't do on the basis of outliers, I'd agree with you,"

Then, in in justifying ACA dont talk to me about one person who lacked health insurance, even if that person is yourself. One person without insurance and in pain does not justify the nation as a whole spending billions of dollars. Tell me about the 25 million people who you believe should be helped. Every time I have challenged this bill, the response has been, "Well, I was without insurance and it was awful." So was I, and I agree with you, but that does not justify Congressional action.

Then tell me why we should settle for this action without even trying to do anything better first. This as a second choice after we tried to do something better and failed, sure, but why settle for this first?

"Because," you say, "something better would not have passed." How do we know that when we did not even make the attempt?

[beckya57]

Bill--Many of the Dems did try to pass a public option--a much less drastic move than pushing single payer--and they couldn't. This wasn't just about the Republican obstruction, there were also Dems that didn't support it, for a variety of reasons. As for trying and failing, need I remind you that every Dem president since FDR, and a couple of Republicans too, has tried to get a health care bill passed?? This wasn't the first try, this was the 10th or so--I've lost count. This was the best bill we were going to get in this environment. Now we have to defend it, win this election, and build on it. This is just a start, but it's a huge improvement over the status quo. As for spending billions of dollars, you've fallen for GOP propaganda: the bill is designed to control health care spending, not wildly increase it, by getting rid of waste like Medicare Advantage, doing comparative effectiveness research, etc. I don't get your argument about not talking about people who don't have health insurance; there are millions of people that don't have it who will under ACA.

[low-tech cyclist]

Bill - 'we' who? Progressives pushed hard for a public option; the Dems in Congress weren't biting. 'We,' by my definition of 'we,' tried, but it wasn't gonna be enough.

If your 'we' is the Scared Rabbit Party, aka the Democrats, that's a whole 'nother thing. But enough of that 'we' is a bunch of people who don't think like us that it can't really be 'we' for me. Or for you, in all likelihood.

[Joe S]

Bill H, I also don't know what you mean by "we haven't tried." The Democratic Party is not a completely (or even in places, majority) liberal party. When liberals and progressives have tried to defeat conservative Democratic senators (and generally moderate Democrats of all stripes), progressives have been universally defeated. Blanche Lincoln turned back her primary challenge. Joe Lieberman ultimately defeated Ned Lamont. Here in Illinois in Congress, Ilya Sheyman ran a specifically liberal campaign against Brad Schneider and lost. Thomas Geoghan (famed social democrat) lost in his run for Congress. Liberals have tried to take over the Democratic Party to no avail for nearly a decade.

To say that "we" didn't try is wrong. Progressives tried and failed (so far) to try and move the Democratic Party left for nearly a decade. To be blunt, your claim that progressives didn't try to pass more liberal legislation (including a public option) has something of a "the enemy is East Asia" quality to it.

[Bill H]

Well, okay, let's play semantic games with my use of "we." Congratulatiions, you got me; I was imprecise. I meant the present Democratic leadership. Yes, past Democratic leadership has tried to pass health care reform and failed, and that is exactly my point. This Democratic leadership doesn't even try.

"If at first you don't succeed, give up and do something half-assed."

I offer an olive branch in saying that we are reading from the same book, that we have some common ground, and no one takes it. The criticism continues about how wrong I am not to adore the ACA in all of its glory.

[Prup (aka Jim Benton)]

Bill: First, seriously, can you read? Or are you still seeing what you expect to see? As far as I can recall, not one of us has criticized you for not "adoring' the ACA -- because none of us do. We have, I believe unanimously, declared that it is a flawed system, that each of us would have preferred the same type of system you would, more or less.

What we have, repeatedly said is two things. First that, if we'd tried to pass a more radical change and failed, there is almost no chance -- judging from every experience we've seen -- that we would have gone for a 'fallback' position of Obamney Care. We would have just chalked this up as another loss.

And -- the second point -- is, we would have failed. We would have failed because of a Republican filibuster almost certainly, but forget that, forget, for the moment, the existenece of the Republicans, forget the House, forget the necessity that Sir Charles keeps on insisting you realize, that we needed some of the corporate interests not to oppose whatever we came up with. No, just look at the Democrats, because we couldn't have mustered 51 votes for any sort of radical change.

Bill, we pay a ridiculous amount of attention to politics here. We know a lot about each of those Senators -- as did the White House. (We also know something else important, that the 'classic practices' of promising someone something for their vote -- okay, we'll build an airport in your district, or support this candidate of yours -- or even of perfectly legitimate 'log-rolling' no longer are possible with the net and the 24-hour news channels. The one attempt that the White House made with Ben Nelson not only backfired -- and the promised 'reward' had to be withdrawn -- but even got mentioned in Scalia's dissent.)

Okay, let's look at what we had. First, Minnesota's seat was vacant until June, when Coleman finally conceded to Al Franken. Until June, that was a vote we didn't have.

There were three Senators, Blanche Lincoln, Mary Landrieux, and Ben Nelson who we only barely, and with great protest, kept 'on board' even for the ACA. They never would have gone along with anything even slightly better. And you can probably include Mark Pryor with them.

We had two Senators nobody trusted, Lieberman and Roland Burris, either one of whom could have sabotaged things for many reasons.

Specter was still a Republican until April, he wouldn't have been countable on.

Then you have a large bunch of 'centrist Democrats' who were willing to go along with the ACA, might have gone along with a similar but better version, but who were highly questionable when it cane to a major and radical change. And it is a long list. "Scair" McCaskill, Evan Bayh, Mark Begich, Kent Conrad, Max Baucus, Bill Nelson (FL), Jim Webb, the Udalls, Tim Johnson even Bob Casey. 11 Senators, and I would like you to tell me which of them you'd be sure were supporters of your plan. (And, along with Burris, there were the other newcomers, the other 'draft replacements' Gillibrand, Kaufman, Bennett, and a newcomer like Hagan, from a very conservative state. Now Gillibrand turned out to be far more liberal as a Senator than she had been as a Representative, but we couldn't count on that.) Somehow you have to craft a bill that will keep at least 10 of these fifteen Senators with you, hope that you keep either Burris or Lieberman, and that would give you your majority -- if Franken is seated, and if both of the dyin' lions (no disrespect meant) survive until after the vote.

We have the advantage of hindsight, of knowing we would have Specter and Franken and that Kennedy and Byrd would survive, we know that Gillibrand was a solid vote -- but they didn't know that when they were deciding -- as far as they did, remember, I have plenty of blame to go the White House's way -- what Bill to present. I can't think of anything close to what you wanted that would have kept 51 Democrats on board -- they had to risk needing more than that, for the 'not sures.'

(And, of course, in the REAL world, anything slightly more radical would have been filibustered, and there were enough certain votes to cross over -- Lincoln, Ben Nelson and Landrieu -- that it would have been unbreakable.)

No, they didn't try hard enough to get a slightly better variant of what they came up with, Obama displayed major lacks of leadership and political skill -- even not having a bill ready 'on day one' and saying 'Okay, start here' was a
major blunder -- but they couldn;'t have gotten what you want, They didn't try because they knew it was hopeless, and if it wasn't, if I and they, and everyone I have read who has actually studied the people involved, are all wrong, show me the votes you would have been sure of that could have -- even without a filibuster -- passed your proposal.

[nancy]

Prup, Aren't we kind of finished with this exchange? I know I am.

[Prup (aka Jim Benton)]

Actually, no I am not, and would only be if I were convinced Bill H was a pure troll, totally insincere in his position -- and I have no evidence that he is, especially after reading his own blog.

It was Crissa who facepalmed over having yet again to explain the ACA to her acquaintances. By having Jayhawk as a 'sparring partner' I at least hope that I can firm up my arguments, because Bill is not at all that rare as a progressive who wishes that SCOTUS had overruled so we could 'start over again.' Even Michael Bryan and Pamela Powrs Hannley of Blog for Arizona have said the same -- and they are usually much more sensible.

Besides, it gives me a chance to 'kick off the side of the pool' and get back into another main current, the Scalia dissents, and the speculation as to why Roberts switched at the last minute to uphold the ACA.

(There seems to be no doubt at all that that is what happened. Scalia's repeated referring to Ginsburg's concurrence as a 'dissent,' see Brad De Long, has no other explanation I can think of.)

But if Bill wants to keep getting up, I'll keep swinging -- and you guys can just ignore us.

As for the Roberts switch, that should take a whole new 'thread arc' and it does give me a shot at getting back to my parsing of the Scalia AZ dissent -- and even this one. And that is simply too much fun to abandon -- particularly as I had just reached the Obama rant-rap part of it.

[Bill H]

"...show me the votes you would have been sure of that could have -- even without a filibuster -- passed your proposal."

Jim, you accuse me of not reading? Where did I ever say I thought anything better would pass? I repeatedly said try to do something better, let it fail and then compromise. I know it would fail, and I don't need detailed explanations of why it would fail because there is one far more simple; campaign contributions from corporations for reelection is more important than governance.

The "votes you would have been sure of" indeed. Because you don't even introduce a bill until you know in advance that you have enough votes in your pocket to assure that it will pass. Introducing a bill and having it voted down "makes you look weak." And I'm not imagining that, Nancy Pelosi has actually said it, as has Harry Reid, and more than once. I pay attention to politics too. Far better to not introduce the bill at all and then whine about how the Republicans "won't let us do anything."

Obama made a deal with drug companies killing Madicare negotiations and reimportation before negotiation sessions began and at the same time made a similar deal with hospital organizations. The first action on "health care reform" was made in secret and was a concession to corporations which was against the interests of the people. And no one on the left, no one, will brook any criticism of "Obama's signature legislation."

And yes, nancy, I'll give up here, because we have in this nation a distressing acceptance of the control of our government by corporations and by careerist legislarors who act for eternal reelection and partisan power rather than proper governance. We prefer to "act within the system" in the vain hope that the system will somehow change itself, having no recognition of what the outcome of Obama's "hope and change" campaign actually does to that illusion.

[Prup (aka Jim Benton)]

Bill: This is what confuses me about you. You go on, perfectly sensibly arguing your position -- incorrectly, I'd contend, but still sensibly -- and then you make a comment like "And no one on the left, no one, will brook any criticism of "Obama's signature legislation.""

Bill, that's why i asked if you could read. All of us here, I believe, would describe ourselves as 'on the Left' and every single one of us, me above all, HAS criticized the ACA, Obama's bungling in introducing it (my specialty) and the compromises made to get it passed -- even if we agree they were necessary.

And, btw, I would consider you as someone 'on the left' as well, or maybe as a Left Libertarian. How would you describe yourself -- and just for my own curiosity, are you someone who is/was a fan of Heinlein, Poul [sic, not "Paul"] Anderson and Gordy Dickson? You come across as someone who was partially shaped by them -- particularly their books from the 50s, 60s, and early 70s. If you don't know them, I'll ship you a list or mention some good examples here or on your blog.

[Paula B]

Bill H: We prefer to "act within the system" in the vain hope that the system will somehow change itself, having no recognition of what the outcome of Obama's "hope and change" campaign actually does to that illusion.

And you would prefer, what, blowing things/people up? Maybe you spent too long in the military, Bill.

[Paula B]

I know my last comment wasn't very kind but, frankly, I don't like the tone of this exchange and agree with nancy that we should move on.

[low-tech cyclist]

Well, okay, let's play semantic games with my use of "we." Congratulatiions, you got me; I was imprecise. I meant the present Democratic leadership. Yes, past Democratic leadership has tried to pass health care reform and failed, and that is exactly my point. This Democratic leadership doesn't even try.

OK, so we both have problems with the way the Democrats in Congress do their business.

If it makes you feel any better, for the past 40 months, I've felt exactly the same about the Obama Administration's unwillingness to start off with a larger stimulus proposal than they did.

However, I think there's a big difference here. If one side wants to spend $1.2 trillion but the other side only wants to spend half that, you can meet in the middle somewhere. You can start off pushing the better bill, and wind up with the compromise bill.

With health care reform, the differences were of type. So you've got to push the bill that you'd like but that will fail, then you've got to try again with the 'real' bill.

Medicare for all, for instance, is a completely different thing than Romneycare/Obamacare. And with a lot on its plate, Congress in 2009 didn't have time for two serious attempts to push a bill. I suppose Nancy Pelosi could have scheduled a pro forma vote on Medicare for all, but she couldn't have invested any time on it. And it would have gotten fewer than 100 votes, just because the Democrats are what they are.

(Would it have made it easier or harder to pass the actual bill, or would it have had no effect? Who knows? Would Pelosi have wanted to take a chance on its having a negative effect? I bet not.)

The Democrats are what they are. You and I want them to be better than they are, and we are right to want that. The issue of how to turn the Dems into a party that will, at a minimum, take progressive stances on issues where the majority of Americans support those stances, is one that I've spent hundreds of hours thinking about.

But expecting them to be something they're not, already, is a waste of time.

And ideal bill or no, expanding health insurance to 30 million Americans is a success worth celebrating. Sure, it's what our corporate overlords were willing to give us - after a lot of arm-twisting and log-rolling. They'd rather have given us nothing at all, but we managed to get that much. And we improved the insurance of millions more who had insurance that might've left them high and dry when they needed it.

I don't feel the least bit guilty about celebrating. Saying I shouldn't celebrate because...hell, I'm still not sure what your real objection to celebration is - because the bill's less than ideal? Because we didn't try for ideal before settling for what was possible? Anyway, I'm not seeing a good reason for NOT celebrating the survival of the ACA.

[Bill H]

I don't think my thing is "blowing things up" due to being too long in the military Paula. I was Navy, and "Silent Service" to boot, and we weren't all that into blowing up things. Stealth was our game and, as you are finding out, I'm not much into stealth any more.

"How would you describe yourself and are you someone who is/was a fan of Heinlein..."

Probably anti-establishment, or perhaps revolutionary, Jim, and yes very much Heinlein pre-The Moon is a Harsh Mistress and Poul Anderson. The civics lesson in Starship Troopers is for the ages. More conventional description would be socially liberal and fiscal conservative. I think there is much we should do, but we should never do more than we can, in the medium term, pay for as we go. Government debt in economic crisis is one thing, but to fail to pay that debt down in economic good times, as this nation consistently does, is irresponsible and, in the long run, self destructive.

Meeting in the middle of what two sides want is very much an honorable principle and I have never ranted about the size of the stimulus bill. My argument was the content of it, that it was too much tax cuts and social policy and too little stimulative spending. Compromise on size is one thing, compromise on principle is a different issue.

That is the nature if my issue with "health care reform," that the compromise was not with how much was going to be done but with the nature of what was going to be done.

When Democrats compromised on Social Security, they downsized by agreeing to cover fewer people to reduce the cost, but not on the principle of the program or what it would do. ACA compromised on the principle of the program itself, that rather than serving the needs of the people we would cater to the vested interests of the medical provider and pharma industries.

[Bill H]

Oh, yes, l-t-c, Pelosi could not have scheduled a "pro froma vote on Medicare for all," because Obama ruled it out before the health care reform discussion began. He said that it would be "too disruptive."

[nancy]

And yes, nancy, I'll give up here, because we have in this nation a distressing acceptance of the control of our government by corporations and by careerist legislarors who act for eternal reelection and partisan power rather than proper governance.

Why do you think that the Citizen's United decision has aligned and hugely angered people, across the spectrum, in this country?

Do you think you're unusual in having the current 'game' figured out?

Politics: the art of the possible. What's changing is what's 'possible', and the left didn't redefine that. See the inauguration eve dinner plans of the GOP, 2009. What I'd call a planned insurrection. And yes, that's probably hyperbolic. But true nonetheless in hindsight.

BTW -- My late father-in-law was Naval Academy '35 and on the bridge of the New Mexico in the Pacific, three minutes before a kamikaze attack killed everyone on it. Husband spent most of the sixties in the Polaris and DSSP programs, and later at the Pentagon as a much-feared young budget analyst. We're not all out-to-lunch lefties here.

[Sir Charles]

Bill,

As I have explained previously, Pelosi, who is one of the most effective liberals in the last fifty years, would not schedule a vote for a public option because she could not muster a majority for it.

A number of members of her caucus balked at an expansion of Medicare because the hospitals in their districts complained about the impact of low rates of reimbursement causing harm to their operations. And as I have mentioned before, these hospitals are often the largest employers in a given district.

Politicians are loathe to scorn the largest employers in their districts and are generally sensitive to their concerns.

[Bill H]

Sir Charles, I respect what you say even when I disagree with it, but you seem to be blowing a lot of smoke on this one. There is a significant difference between "Medicare for all," which Obama proactively vetoed, and the "public option" which was part of "health care reform" discussion.

It's hard to reconcile "one of the most effective liberals in the last fifty years" with someone who could not rally her own party to vote for the "public option" and was, by your own statement, kowtowing to the hospital industry.

Then you defend Democrats failure to support the "public option" by babbling about hospitals complaints regarding Medicare reimbursement rates, when the "public option" had nothing to do with Medicare but was a proposal for a government run health insurance plan independent of Medicare. One of the things that the plan would do was negotiate drug prices, which Medicare is not able to do.

And, politicians should not be "loathe to scorn the largest employers" but should be terrified of scorning the needs of the voters.

[Mandos]

The major disagreement here boils down to what

(1) What the starting point should have been.

(2) What the consequences would have been for these different starting points.

Folks like Bill H are accusing the Dems of starting from a point that was needlessly too low. They believe that given all the constraints, the Dems could have started asking for more, and worked their way down to a point higher than the current ACA. They're pissed that the Dems seem to have decided in advance that they wouldn't ask for me, and are therefore concerned that the Democrats are either incompetent or (more likely) bargaining in bad faith toward their own base. (And by implication in hock in some way to industries that don't have Americans' best interests at heart.)

And the counterargument is basically that if the Dems had asked for more, the system and the situation was primed to kill the whole process entirely, and they would have gotten zero.

Here's the deciding factor for me: there is simply a much larger fraction of the American population willing to go to the wall against any substantive health care reform then there are who would do the same for single-payer. It's really that simple. What the mushy middle wants or needs, doesn't matter in the face of the importance of the fringe.

Which leads to the bigger Democratic weakness (or deliberate failure, take your pick)---the refusal to understand the role and importance of "fringe" politics, and the subsequent refusal to cultivate a Democratic fringe.

But that's not surprising and is, as I think we all agree, a weakness of "centrist" ideology.

[Sir Charles]

Mandos,

I think that this is a problem of longstanding in the U.S., one which even plagued us to some degree during the New Deal when there was actually a serious left in America and a very robust labor movement and during the Great Society when organized labor was as influential as it had ever been. The drastic decline of labor has really dimished the constituency for social democratic politics in this country.

Liberals don't really want to encourage fringe left elements because of the bad experience with SDS in the Sixties and the sense that they encourage backlash more than anything else.

[Mandos]

Liberals don't really want to encourage fringe left elements because of the bad experience with SDS in the Sixties and the sense that they encourage backlash more than anything else.

But the price is ultimately that y'all end up alienating people like Bill H. This seems like a small price to pay, but this is the most otherwise active and passionate contingent of the "base." Once they conclude that their perspective has no influence whatsoever on the strategies Democratic leaders choose, a large portion of the "feet on the ground" disappear---making it even harder to push the USA in the direction it needs to go.

This is basically the Corrente phenomenon. They think you're wrong---and believe that they aren't even being given a chance to try.

[Sir Charles]

Mandos,

I will let him speak for himself, but I don't think Bill will would characterize himself in quite that fashion.

I think the absence of an institutionalized left is due in large part to the utter discrediting of the communist enterprise. The collapse of the Soviet Union was the final nail in the coffin in terms of any kind of Marxist-oriented politics remaining viable. And that is true not only in the U.S. -- the real origins of the term "American exceptionalism" -- but in the socialist parties of Europe that have largely abandoned anything like the old tendency toward nationalized industry and other more traditional leftist platforms.

I understand your point about having a kind of leftist vanguard to do what the more extreme right wingers have done -- move the ideological parameters of debate. I am just not sure though that in American culture this works. Certainly its manifestation in the late 60s aided immensely in the destruction of the New Deal coalition.

Sadly I think that the only way to move left of center ideas is to pick and choose arenas where common cause can be made with certain aspects of the corporate community to advance them. I think when one encounters full scale corporate opposition to anything in this country it is pretty much dead on arrival, because the American people do not see the world in anything like a Marxian manner.

Bill H,

There were a variety of possible public option approaches, one of which was the idea of allowing individuals to enroll in Medicare. That prompted tremendous opposition among the hospitals since Medicare reimbursement rates tend to be significantly lower than those of private insurers.

A public option approach where individuals would have been allowed into the FEHBP program would have not been much different than the ACA since the FEHBP largely uses private insurers to deliver benefits. It is not a government plan in the sense of Medicare.