Monday, September 14, 2009

Liberals: rethink tenets

I find Matt Miller's viewpoint and writing style refreshing. Both of these articles offer some ideas that are not bandied about, and are, thus, valuable. Orthodoxy needs to be subordinated to pragmatism.

Why Liberals Should Drop The Public Option - by Matt Miller

A dangerous sentiment on the left threatens to derail what could be the biggest progressive achievement in half a century. It's the view that any health-care reform that doesn't include a public option isn't "real" reform, and thus isn't worth doing. This mantra has become an article of faith among many Democrats who haven't necessarily thought through the matter but who take their cues from leaders advancing this argument. Unless liberals rethink this premise, and fast, Democrats will squander their best chance in a generation to end the scandal of the uninsured, bring health security to every American family and begin the long-term process of getting national health costs under control.

Take their cues is another way of saying repeat the same platitudes, make the same arguments, and not have original thoughts. It is just so easy to repeat what has already been said.

The first fallacy of the "public option or nothing" mantra is the notion that we'll never cover everyone without a Medicare-style program for Americans under 65. The experiences of Switzerland and the Netherlands prove that this isn't the case. Both have pioneered market-based universal health care. Both cover all their citizens using private insurers, and they do so for much less cost - 10 percent of gross domestic product for the Dutch and 12 percent for Switzerland, compared with 17 percent in the United States, where nearly 50 million people are still uninsured.

The public option has become the test, of both liberals and conservatives, the crux of the argument that often overtakes the real issue: health care reform. Conservatives use it to scream socialism and big government, and liberal try to refute the argument with logic.

Those countries also boast better health outcomes than we do, even when compared to states with similar demographics, such as Connecticut and Massachusetts. Sick people in both countries are pursued as customers by private insurers (rather than shunned, as they are in the United States) because health plans are paid more for sick enrollees via a government-designed system of "risk adjustment." The Swiss and Dutch achievements are important because conservative critics often act as though fully socialized systems, such as those in Britain and Canada, are the inevitable result of any drive for universal coverage. In fact, as these two countries show, it is possible to cover everyone without a "big government takeover."

Conservative critics will find fault with the President's proposed program, no matter what, but it is better to take away some of their ammunition by avoiding "a government takover." It might also make the system work more efficiently. The government is no model of efficiency.

US insurance companies have agreed to drop pre-existing conditions and to pursue the currently uninsured as potential customers. I've heard Aetna's CEO say so.

A related fallacy is that the public option is the most important issue to debate. It's not. The central progressive breakthrough in any reform should be to make it possible for every American to access group health coverage outside the employment setting - access that does not currently exist but which the proposed insurance exchanges would enable. What's critical, therefore, is the structure of these exchanges and the rules about who would be eligible to use them. Such questions have received disturbingly little attention but need to be front and center. For example, some legislation proposes barring people who enjoy employer-based coverage from seeking insurance from the new exchanges; this ban should be scrapped in favor of the choice proposal offered by Sen. Ron Wyden, under which employees could use the cash their companies spend on their benefits to buy coverage they prefer at the exchange.

The insistence on pushing the public option threatens to derail the effort of reforming the health care system sufficiently to cover everyone, and make it work somewhat better.

I respect those in my party who seek the single-payer system into which the public option might eventually evolve. But I don't agree that it's the best answer for the United States. Though single payer has merits, especially in administrative efficiency, it would also likely freeze in place our fragmented, uncoordinated system of fee-for-service care. It would encourage providers to goose volume (to boost their incomes) rather than improve quality and would offer greater rewards for providers of acute care when we need a fresh focus on chronic disease management. Single payer also asks government to do things I don't think it is competent to do, such as setting prices across a large swath of the health sector in ways that seem certain to create damaging rigidities or resource misallocations (as happens in Medicare). Finally, if government is the sole payer, provider payments will become even more politicized than they are today. On the eve of beneficial innovations in drug therapies, devices and cost-effective ways to deliver better care, it is ill-advised to make the government's hand too rigid. Private health plans have many flaws, to be sure, but if sensibly regulated they're likely to respond more nimbly to disperse medical innovations.

Why is a single-payer system what the left wants? I do not want government running health insurance to the exclusion of all other players. I want everyone to be covered, and I want some cost reductions and efficiencies introduced into the system. Don't make the government's hand too rigid; allow for flexibility.

Liberals should make peace with the notion that a regulated market of competing private health plans can be the vehicle for getting everyone covered. Yes, it means that unlike some other advanced countries, we'll have billions of "health" dollars siphoned off by middlemen and marketers. But if liberals think of it as a jobs program, they'll learn to love it. If everyone's covered and insurer "cherry-picking" is dead, health insurance will come to look more like a regulated utility.

And, although Con Edison and its cohorts are no great models of benevolence, they are well regulated and don't deny anyone electricity because of a pre-existing condition of darkness.

Those on the left still seeking incentive should consider: In 2006, Sen. Ted Kennedy urged Massachusetts Democrats to support Mitt Romney's plan for universal coverage via a competing system of regulated private insurers, paired with an individual mandate and subsidies for low earners. Kennedy knew this would become a model for a bipartisan fix for the country. Now, a Kennedy-approved model is within reach. Liberals, far from resisting it as a setback, should celebrate it as a triumph.


Matt Miller, a former Clinton White House aide, is a management consultant and the author of "The Tyranny of Dead Ideas." In recent years he has advised and given paid speeches to doctor groups, hospitals, pharmaceutical firms and insurance companies, as well as to low-income advocacy groups promoting universal coverage.

from The Financial Times

Lessons For Obama From Ted Kennedy's Noble Flops

by Matt Miller

Edward Kennedy fought to expand health coverage for 40 years, yet millions more Americans lack insurance today than when he started, and bankruptcy due to medical bills has become a uniquely American shame.

The senator for Massachusetts, who died last month, fought perenially to raise the minimum wage, but that wage is lower today as a percentage of average hourly earnings in the US than in 1970. Kennedy also fought to improve schools in impoverished neighbourhoods. Yet today, among advanced nations, 17 boast higher student achievement than in the US alongside test scores less correlated with a child's socio-economic status.

For all Kennedy's efforts, in other words, the fabled "land of opportunity" now offers its citizens a smaller chance of moving up from their economic status at birth than do France, Denmark, Norway, Sweden, Canada and Germany.

These observations are not meant to be churlish or in bad taste; Senator Kennedy has rightly been hailed as a passionate voice for the voiceless and a master of the legislative process. But any assessment of his legacy is incomplete if it fails to ask why American liberalism's modern icon proved so ineffective in persuading his country to share his vision.

This is not a matter of abstract interest. President Barack Obama stands little chance of succeeding in the coming healthcare endgame without understanding why, for all his passion, Kennedy could not make the sale. No man can reverse the tides of history, perhaps, but it was not inevitable that American politics would lurch so far to the right over the course of Kennedy's career. The US economy more than doubled in real terms between 1970 and 2008. Why wasn't America inclined to devote a portion of this bounty to mend the problems Kennedy identified, instead of allowing many of them to worsen?

There is no single answer. But one reason was the sense among voters that liberals tended to worry more about the poor than about the struggling middle class. This same sentiment now threatens Mr Obama's health reform.

"We have to do better at making this issue a moral imperative," Tom Daschle, former Senate majority leader (and Obama confidante) told the New York Times Magazine last month. "This in many respects is the civil rights battle of the early part of this century." But middle-class voters do not see healthcare as a "civil rights issue" - a cause in which they should enlist to bring justice to others. With soaring premiums and shrinking and precarious coverage, the 85 per cent of Americans who have health insurance see reform as a matter of economic security for their families.

Unfortunately, the American left has for years defined the issue predominantly as a matter of ending the scandal of the uninsured. They have misled the public with the incoherent claim that expanding coverage to 50m uninsured Americans would be a way to save money.

The Democratic argument has failed to emphasise how health reform can deepen the economic security (anmd improve the health status) of the middle class. Yes, one part of that argument is to ensure that no American in the 21st century goes without coverage. But the liberal instinct - to focus first on the neediest in ways that lead squeezed middle-income voters to conclude liberals want to take their hard-earned money and spend it on someone else - helps explain why Kennedy-style politics never prevailed.

Democrats need to frame their goals as inclusive measures to promote security and opportunity in a global economy - improving the life chances of society's most luckless but also bolstering the security and prospects of America's vast middle class. This is also the only way to persuade average Americans to pay for such policies, which eventually they must.

The White House is scrambling to repair its argument on healthcare to win over the middle class. But similar cases and policies must be framed if Democrats are to build on Kennedy's noble failures and make real headway on schools, wages and more.

This demands a new way of thinking. It took an act of imagination for a son of wealth and privilege such as Edward M. ?Kennedy to devote his life to helping those who had little. It will take another act of imagination for liberals to fulfill Kennedy's dreams by aligning them more closely with middle-class imperatives in a global age.

No comments:

Post a Comment