Tuesday, October 13, 2009

The Democrats' Difficulty: Five Thoughts on the Baucus Bill

The Senate Finance Committee is poised to vote today on Chairman Max Baucus' health care plan.

If one had to bet, one would bet that the Democrats are likely, in the end, to "get something." Public option? Probably not. Universal coverage? Definitely not. "Bending the curve" on costs? Definitely not. But that's OK, because "muddling through" is always a good option in a democratic society. The joke floating around town is that if a piece of paper bearing only the words, "Health Care Reform Act of 2009" floated onto Barack Obama's desk, he would happily sign it and take credit for it--mission accomplished.

But the question is, Why has it been so hard for the Democrats? After all, there's a Democratic president who campaigned on healthcare reform, and who won the biggest landslide for a Democrat in more than four decades. And the Democrats have huge majorities in both houses of Congress.

So why the difficulty? I can think of five reasons, which are full of implications for this bill as it struggles to come to life in the years ahead.

The first reason is the simplest: Obama shot his fiscal wad on Wall Street bailouts, and auto takeovers, and stimulus packages. As Obama said of the national fiscal situation on May 22, "Well, we are out of money now." And as I wrote in June for US News,

When confronted with a choice between healthcare for the poor and the near-poor on the one hand, and the continued overstuffing of the overclass on the other hand, Obama made a decisive choice: He chose the overclass. He put rich people first.

It's a first-class-first process ably described by the economist Mancur Olson, and any number of economists way to Olson's left--the rich belly up to the food table ahead of everyone else, eat everything they can till they are done, and then the middle class and the poor are left to fight over the crumbs.

The second reason for the difficulty is the public perception that the current plan is a welfare plan in disguise. The common jibe among Republicans is that Obamacare will degrade coverage for 250 million or so Americans so that Obamacare can function as a voter-registration plan for 30 or 40 million Americans. Benjamin Barber-type “Strong Democracy” is popular enough, if you are inspiring the broad middle to take greater control of their own lives, in an Andrew Jacksonian sense, but if the thrust of contemporary liberalism proves to be just a veil ill-concealing yet another welfare program, well, the middle class is unlikely to like it. As the late Daniel Patrick Moynihan long lamented, in recent decades, the national Democrats have seemed mostly incapable of thinking of a plan for helping the middle working class, as opposed to the poor or some other avant-garde group. (Or the rich, see reason #1 above.)

The third reason is the manifest failure of government to prove its competence. A century ago, Max Weber could write, with a straight face, that the reason for the rise of bureaucracy was its "technical superiority." Times have changed. Today's federal government is not exactly bureaucratic, of course. Policymaking has been substantially outsourced to judges, lawyers, and outside activists--and contractors seem to be doing a lot of the in-house work. But by any name, or in any form, the business of the federal government does not smell sweet to most Americans. When today's liberals say that "health care management" is the answer, with them, of course, doing the managing, some Americans think "death panels," and plenty more are skeptical that any kind of government management can work.

The fourth reason is the breakdown in the mutuality that is needed for a welfarist, communitarian ethos to flourish in a nation. That breakdown was incapsulated in "The Heckle Heard 'Round The World," that is, Rep. Joe Wilson's "You Lie!" catcall against President Obama when Obama said, in his September 9 speech to Congress, "There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false — the reforms I’m proposing would not apply to those who are here illegally." Whereupon Wilson erupted.

Let's step back from the theatrics of that incident and think about the basics of the plot: A white Southerner rudely calls out an African American for saying that illegals--most of whom are Hispanic--would not be covered. Whereupon Wilson apologizes, but more profoundly, the Senate Finance Committee takes extra measures to make sure illegals aren't covered, thereupon lending credence to Wilson's shouted charge.

The point here is not to defend Wilson or his manners. Instead, the point is that the Democrats, trying to manage their rainbow coalition, feel electorally vulnerable on the question of whether or not their healthcare plan will cover illegals--and with good reason. Everyone knows that they want to cover illegals, as a matter of social justice, and everyone who thinks about public health realizes that some provision needs to be made so that nobody is walking around coughing up tuberculosis on the streets. Like any other contagious disease, TB is completely agnostic about legal vs. illegal.

The broader issue crunching down on the Democrats is welfare-state liberalism vs. multiculturalism. As Harvard's Robert Putnam has noted, along with many others, the communitarian ethos that upholds the welfare state is based substantially on ethnic trust and national commonality, and those bonds of affection and unity have a way of breaking down amidst multiculturalism. Welfare states thrive in homogenous countries, they are smaller and less expansive in heterogenous countries--and as for really heterogenous countries, well, they have a way of becoming ex-countries, viz. the USSR, Yugoslavia, Czechoslovakia, and so on.

The fifth reason for the Democrat's difficulty is the basic flaw in the intellectual model: "health insurance reform" is not the goal of most Americans. What the American people really want is cures. You don't go to the doctor because you can, because the government has given you some card entitling you to low-tech care. Nor do you go to the doctor to show off the intellectual ingenuity of your health savings account. Instead, you go to the doctor to get better. Ask yourself: Where in the Obama pitch is there any discussion of actually curing anything? (One doesn't hear much "cure talk" among Republicans, either, but they, being the minority, aren't the issue right now. In the next Congress, or the one after that, they might regain the majority; we can revisit them then.)

The story of 2009 is the apotheosis of the left-liberal idea--inflected by "Club of Rome"-ish environmentalism and residual enthusiasm for barefoot doctors--that we have enough health, or maybe even too much health. So don't worry about the creation of health; in fact, the creation of new medicines needs to be restrained, in the name of "cost control. The main imperative is the redistribution of health, not the creation of health.

Here at Serious Medicine Strategy we think that redistributionist ethos is bad politics and even worse for medicine, but the Democrats now have their moment.


  1. And the real problem is that once again, government is trying to solve a problem it created by creating more of the problem. Big government and bad taxation policies created both demand-pull and cost-push inflation, which resulted in selective scarcity. So now the government wants to increase funding and availability without increasing supply, which it can only attempt to do by crudely putting lids on costs. The American people are smart enough to understand this instinctively, even if they cannot express it.

  2. Jim, I agree wih you on a number of points, but I also disagree with you.
    Points of contention:
    1: Yes, O blew his wad on other initiatives that will prove to be fiscal disasters, and some that may prove to be his, and the Democrats' undoing, like the cap and trade bill. This has only gone to intensify the nation's distaste of overbearing govenment, that may be well-meaning, but has too many sour tastes to be palatable as a whole: Like the stimulus bill coincidentally favoring "shovel ready" (read union) jobs. But we have also heard about way too many very bad clauses and initiatives in the House healthcare bill, so although we have a generic distaste for government meddling, we have specific hatred for parts of this bill.

    2: I specifically disagree wih your concept that the upper class is being served first. Over 90% of American Citizens (most of the middle class, of course) have healthcare, and the vast majority are happy with it. The plain fact of the matter, as Ted Kennedy proved, is that even though a multi-option plan is perfectly doable and reasonable, and in fact, is comfortably used by 90% + of the American public, no matter what their income level, there will always be people, like the Kennedys, who will want to buy "better" healthcare. Obviously, as in Kennedy's case, that didn't "bend" the outcome for him.
    You might have a point about the fact that investors in the health insurers have a profit motive, but this is a tangential point, and I don't think this is what you were getting at.

    Third point, totally agree.

    Fourth point: We all know that Obama lies. He lied to get into ofice, he covered up things that might damage him (like who paid for his Harvard education), and he continues to lie, pull campaign tricks, like loading "town halls" with plants, or at best, speak from ignorance. We all know it, on both sides of the aisle. But worst of all he is an ideologue who is pushing an agenda that is not resonating with the vast majority of Americans, even though he pretty much ran on that same agenda (but no one believed him!)

    Obama proved that point last week, when he went in front of the House Hispanic Caucus and told them that we need to pass an immigrant amnesty bill, so the aliens would not be illegal, and they oculd get their healthcare according to the "no illegal aliens" restrictions of the healthcare bill. At best, this proves his disingenuity, and his "gaming the system."

    Five: Right on. People are essentially content with the healthcare situation they personally see.

    Synopsis: If you wrote your article backwards, you would have had most people going along with your thesis till the end. You blew me away with the first two points.

    There are very straightforward solutions to the healthcare problem. I'll be glad to let you in on them, if you ask.


  3. You can apply the classic question: Are the better policies those that divide the pie more fairly or those that grow the pie? Growing the pie has the nice advantage of making it possible for everyone to get bigger and better pieces of the pie.

  4. 1. Obama's bailouts from Bush's mess. Lets not forget who started the bailout (and who's leadership resulted in the sinking). Lets not forget Bush's bandaid for big-Automotive, etc.

    Let us not forget the 4 ECONOMIC STIMULUS BILLS signed by Bush....totaling more than Obama's, and all for minor downturns relative to what Bush left. This isn't even counting the deficit busting Bush tax cuts (which turned a record surplus into a record deficit).

    Selective memory on issues such as this displays: Where you are coming from (partisan hackery) and what you'll take to get to your forgone conclusions (irrational arguments).

    2. This might possibly make sense if the Baucus Bill had a public option....it doesn't. How people perceive a plan which relies entirely on private insurers as 'government takeover' is beyond me.

    Your #2 point only goes to prove that your opposition is knee jerk and not at all based on the facts.

    3. Wrong, again. Medicare costs vs private insurance - there really is no comparison. Or look at the cost of the UK's NHS vs our private insurer system. Case closed.

    4. Keep praising the Southern Strategy, cause that's the last place your party is relevant - the South, and remote all while enclave states. The Republican party remains strong in every place lacking an ounce of culture or diversity...for good reason.

    5. They want cure's vs reform....you just argue semantics. In another breath you'd say 'incremental change'....what you really want is status quo or just a hand off to big insurance.

    Health reform will pass this year. It will have a public option with some 'minor' compromise. It will serve as voter registration for the Democrats because they will see how much better it is than the horribly corrupt profit-based system we have now.

    Eventually...probably when my daughter is my age.....that public option will kill private insurers, and I will dance on their grave.

  5. You want to "dance on the grave" of the best medical system this world has ever seen?