Will health reform pass?

As I write, at the end of July 2009, the fate of Obama's health bill seems uncertain. Listening to public commentary, the most likely outcomes are either outright defeat of anything, or passage of something that just rearranges the deck chairs on the Titanic. But quite possibly something better is being forged behind the scenes; we won't know until we see it.

If the result is a debacle, I believe that it will again illustrate a hard truth about popular democracy. Liberals, and intelligent conservatives, tend to look at trends, forecast future consequences, and advocate action to deal with those consequences. But most voters do not operate that way; their forward vision stops at the tip of the nose. Given the desire of vested interests to preserve the status quo that enriches them, and the persuasive power of propaganda, this voter orientation towards the immediate makes change very difficult. Change happens only when the problems with the present course of action hit home broadly and forcefully. That's why the villainous Bush and Cheney team got close enough to re-election in 2004 that Kerry's blunders put them over the top. While any thinking person could see how terribly they were governing, the robust stock market and high employment at the time kept their evils from hitting home broadly and forcefully enough.

In other words, if the health plan loses, it will not be due to Obama's errors. He has in fact proceeded with enormous care and skill, building on the brilliant Clinton White House's effort and correcting its errors. The loss, if it occurs, will be due to timing: the fact that not enough voters have suffered sufficiently from the present setup, so that they remain susceptible to the mendacious scaremongering of the Republicans and the special interests who wish to maintain the present lucrative system.

Perhaps the loss will politically cripple Obama. Whether it does or not, though, it will mean that health reform must wait a while longer: until more employers drop the coverage, more obese people lose their insurance, and more people are turned away from overwhelmed emergency rooms to die in the streets.

Health Insurance

Costs and Revenues
For whatever reason, US ideology makes it impossible to have a single payer system. In addition, the major players in the for-profit health system are too powerful to attack directly. That is why we have this repellent spectacle of the Democrats dancing around trying to make fundamental improvements in outcome by snipping and tugging at the system's edges.

Everybody knows that a number of measures, if seriously pursued, would sharply reduce costs. I would start by beefing up enforcement to prevent the endemic fraud in Medicare, Medicaid, and other gov't programs. There are plenty of other good ideas around.

Dealing with malpractice would also have a major impact. The basic problem is that medical communities don't police themselves, government won't, so the lottery-like litigation system is all we have. I suggest that states create boards consisting of retired professionals (doctors, lawyers, accountants, actuaries, etc.) to review every malpractice claim in what would be essentially an arbitration hearing. The board's opinion would be appealable, and if reversed a board with different members would hear the case all over again. A worker's comp system of valuing such intangibles as pain and suffering could be created as well.

One of the striking things about the debate on revenues is how much everyone seems to ignore Obama's clear and simple point: that of all the possibilities, doing nothing is the most expensive. So if the CBO says this plan will "cost" x billion, that's without subtracting the cost of the present system; it's comparing the new cost, not with the higher one currently in place, but with no cost at all. Idiotic!

There are also various ways of generating revenue that don't seem to be on the table at all. For example, increase the Medicare copay. Or, since so much of the cost falls in the last 6 months of life, require a copay by the estates of the deceased.

Sotomayor Hearings

These disgraceful hearings have allowed the Republicans to define what constitutes appropriate judicial behavior, framing the issue in an extremely false and childishly simplistic way, as Professor Gerken notes. This has seriously misled the viewing public about judges and the Constitution. These hearings have allowed Justice Roberts’s simplistic and misleading baseball umpire analogy to become the dominant image of judging. If that’s all judging amounts to, as the Republicans have loudly claimed, then why shouldn’t we elect know-nothing judges rather than have high-level committees select qualified appointees? Why should the American Bar Association have a say? Why should they be paid so much? And if big corporations and political ideologues want to waste their millions getting sympathizers elected, what’s the harm? These hearings have publicized and legitimized a bufoon’s idea of the judicial function, in place of the traditional American understanding that sees the judge, particularly the Supreme Court justice, as one who applies to difficult issues a wisdom rooted in high intelligence, broad experience, and deep learning.