To Know the ACA Isn't to Love It

Fareed Zakaria writes,

Many liberals believe that the Affordable Care Act — Obamacare — is unpopular only because most Americans don’t understand it. There is some truth to this: Studies show that the core provisions of the bill are more popular than the bill itself. But there’s also a reason, rooted in reality, why many Americans worry about Obamacare — its cost.

Starting with the opening two words (How many liberals? Do you care to name one?) Zakari's thesis is problematic. I think it would be fair to say that "many liberals believe that the ACA is unpopular because the Republicans have targeted public opinion on the individual mandate, which they know is its least popular aspect, and the media has largely been pliant or ineffective when responding to that position. But while it's true that on the whole, were they to in fact look, people would find a lot of elements of the ACA that they like, and that a better understanding of the bill might have made Republican demagoguery less effective, the best you're likely to do is convince people that on the whole the ACA is better than doing nothing. That it may turn out to be a starting point for serious reform, but that the process of reform is far from over.

But really, while I will grant that the issue of cost is occasionally raised, you can track public opinion through the resonant elements of Republican demagoguery: "Death panels", "Government bureaucrats choosing your doctor", "The government taking away your insurance," "Your employer may stop offering insurance", "You'll have to buy insurance you can't afford..." When you hear details on cost, you get stuff like this:

Former Massachusetts Gov. Mitt Romney's campaign and a like-minded conservative group launched seemingly uncoordinated but highly telling attacks Monday morning, both accusing President Barack Obama of trying to change Medicare dramatically, if not end the program outright.

And this:

"There's only one president in history who's cut $500 billion out of Medicare, and that's your guy, Barack Obama," Romney said recently. "And if I'm president, I'm going to preserve Medicare. I'm not going to cut $500 billion out of the Medicare that we have."

Yes, it's true that the Republicans have played a very good game of suggesting that "they" will be paying for health insurance for an undeserving other, never mind that many of the people targeted by that message will receive substantial benefit and subsidy from the ACA, but please - let's not pretend that cost control is a serious factor in the opposition to the ACA. For goodness sake, I saw a poll this morning that showed that far more people have an opinion on the validity of the Supreme Court's ruling than actually know what the Supreme Court did - when did this debate become rational?

I agree with Zakaria's larger point about the importance of having players in the game who take the long view on health, who in a market-based model of insurance may forego short-term profits in favor of achieving more substantial long-term savings that result from an insured person's improved health. I agree with him that consumers are poor consumers in a healthcare market due to asymmetry of information - and let's also mention undisclosed incentives held by the people recommending care, the difficulty of comparison shopping, and the lack of opportunity to comparison shop for sudden illness or traumatic injury.

But let's recall: flawed though it is, the ACA did include some serious steps to try to determine what treatments work and to compare the cost-effectiveness of different treatments. Those provisions were weakened in response to right-wing demagoguery, but some serious efforts remain. What's going on right now? Are the Republicans suddenly shifting gears and embracing a sensible, data-driven approach to determining the best, most cost-effective treatments that deliver the best options? Hardly.

Let's also be honest, if the public were concerned with all of the issues Zakaria raises, the Ryan "plan", voucherization of Medicare, transforming Medicaid into block grants, a Gingrichian assumption (or is it a pretense) that putting more of the cost of healthcare onto the backs of consumers will make them more informed consumers as opposed to less able to afford needed care, would be laughed out of the room. Yet it's their "serious" alternative to the ACA, as pushed by "serious" columnists like David Brooks.

So why don't we start again with the facts: Much of the ideological opposition to the ACA results from deliberate misinformation injected into the debate by the Republican Party and, but for that demagoguery, it would not necessarily be popular but it would be relatively non-controversial, would include additional measures to improve care and lower costs, and could be approached as a starting point for the additional reforms that we need to try to create a sustainable system of health care in this nation.

Big Doesn't Always Mean Beautiful

Fareed Zakaria writes,

The Obama campaign’s attack ad about Bain Capital presented a simplistic picture of a complicated reality. Private-equity firms can play a crucial role in keeping companies competitive. And although some firms have engaged in some bad practices, on the whole the industry has grown so large because it performs a useful function.

I am not going to argue that private equity serves no purpose, to deny the possibility of a collateral benefit to the public or even to the businesses in which they're involved as they seek to extract their profits, because that would be untrue. But at the same time the fact that an industry exists and is large does not mean either that it supports a useful function for society. I don't want to read too much into Zakaria's shorthand - in stating that private equity "has grown so large because it performs a useful function" he is not saying that every industry that grows large and rich performs a useful function. In a perverse sort of way, there might be truth to the generalized statement - trade in illicit and diverted drugs provides a service wanted by drug addicts and is a bona fide multi-billion dollar industry - but I expect that Zakaria means "to society as a whole". And if his statement is so qualified, again with the illicit drug industry as an example, size and wealth is no guarantee of usefulness.

When discussing private equity, the important thing to remember is that a private equity company's principal "useful function" is to maximize return for its proprietors and investors, and that they tend to think and act in the short-term. There can thus be many contexts in which a private equity company's approach to an investment may be at significant odds with what is in the long-term interest of society, or even of the company they acquire. When private equity companies mess things up for the rest of us, they can still turn a huge profit - or get the benefit of a government bailout. It's all part of a game in which any benefit to society is incidental.

The "Debt-Reduction Sales Tax"

Fareed Zakaria recently ribbed Darrell Issa over Issa's use of euphemisms, suggesting that politicians' use of euphemisms is cowardly, and that those who use them are either lying or at best trying to hide the truth. For some reason this came to mind when I read about the lastest "budget task force" proposal from Pete Dominici Alice Rivlin, and its "debt-reduction sales tax".

We would dramatically simplify the tax system, establishing individual tax rates of 15 and 27 percent (from the current high of 35), cutting the corporate tax rate to 27 percent (from 35 today), ending most deductions and credits while simplifying the rest, and ensuring that nearly 90 million households no longer have to file returns. To reduce the debt, we would supplement our spending cuts with a 6.5 percent "debt-reduction sales tax."

I tracked down a longer version of the report and, although it found room for four pages of photos and bios of the contributors, it omitted any hard numbers.

Correct me if I'm wrong, but I believe if we kept income taxes 0.5% higher - that is, reducing them to 15.5% and 27.5% (they would eliminate intermediate brackets) the tax revenue raised would be substantially greater than that which would be raised through a new national sales tax. So why not keep things simple and impose a 0.5% or even a 1% "deficit reduction surtax" on income taxes until the deficit disappears? Or, more honestly, just set those tax brackets at the slightly higher rate because it's not as if we're really going to eliminate the national debt, is it....

Seriously, if they want to make a policy case for why we should create a new, regressive national sales tax system, imposing significant costs of tax collection and remittance on the nation's businesses, rather than setting the income tax at a slightly higher level, let them make it. Their use of a euphemism suggests either that they can't make a compelling case for the sales tax, or that they don't want to approach the issue honestly. I personally see no sign of honesty in their choice of euphemism because, contrary to what its name implies, I simply don't see that such a tax will ever go away.

The Childish Nature of American Politics

My, how American loves leadership. The country loved George W. Bush when he "led" us into two completely unfunded wars, costing in the $trillions. The seniors loved George W. Bush for his "leadership" on Medicare, giving them another unfunded benefit projected to cost about 3/4 of another $trillion over the next decade. The nation, most notably the wealthiest 3% of the nation, is angry that G.W.'s unfunded tax cuts might not be extended - who cares about the unfunded $trillions lost to the tax cut, or that the cuts were scheduled by Bush to expire as part of the maneuverings to ram them through Congress without adequate funding or consideration of the future. That is leadership, American style, and the Republicans had his back.

Meanwhile, three items on our national budget prevent us from having any reasonable expectation of a balanced budget in the short- or longer term: Military spending, Medicare and Social Security. Bush, a self-described war president who had launched those two unfunded wars, was interested in increasing military spending. And he just got through making Medicare less sustainable, so he wasn't about to send the contradictory message that it was a pressing financial priority. So he picked the easiest of the three, and a long-term thorn in the side of the Republican Party, and announced a partial privatization plan for Social Security.

The question at this point is not whether Bush's plan was a good idea. It was poorly conceived - or, I suppose, well-conceived if you would have been among the money managers who received a government license to skim a percentage off of people's private accounts as "compensation" for your services. The question is not whether private accounts would have produced a greater return than treasury bonds. If you weren't already aware that it's foolish to believe that the stock market only goes up, the financial industry collapse and current recession should have set you straight. The question is, what price will the public pay for reform? What happened when the Grandpa Simpsons of the nation (that is, all of them except this one) got wind of the notion that somebody might be trying to cut their Social Security, the Republicans who had been so happy to push through Bush's $trillions in unfunded tax cuts and expenditures scurried for cover.

Some cynicism is appropriate here. Had Bush been serious about Social Security reform, in the sense of making the books balance for the indefinite future, he could have found enough Democrats to support reform. It's been done before - some minor tweaks to contributions, payouts, and the age at which you are eligible for partial or full benefits, and suddenly the program is projected to be sound for another century. Bush preferred to keep the system in a state of crisis, or more correctly something that could be misrepresented as a state of crisis, to make people believe that change must occur, and that it must occur quickly. Because it appears that about the only time you can get the public behind something that might involve even slight sacrifice is when you are dealing with imminent catastrophe. Bush's goal was not to fix the Social Security system, it was to undermine and privatize that system.

But what happened to any sense that you can lead a society toward an improved long-term outcome through some modest, short term shared sacrifice or adjustment, rather than waiting for that crisis? Absurd? Take a look at Ruth Marcus:

I write this from a perspective of sympathy with Obama's aims and overall support for his performance over the past two years. But Obama's dismissive analysis omits the non-emergency choices he made - primarily to press for and, in the end, muscle through the passage of health-care reform - and the ensuing discomfort of voters.

Discomfort that is entirely understandable, even to those of us who supported health-care reform.

Marcus speaks of how various Obama Administration ideas created "perceptions of intrusive government", but elides any mention of the intentional distortions that fueled those misperceptions. The health care reform plan that she sees as "too much" for the American people to take, of course, is similar to the Republican counter-proposal to the Clinton plan from twenty years ago, and is almost identical to the plan implemented for Massachusetts by once and future Republican Presidential contender Mitt Romney. "Cap and trade" was similarly a Republican idea, once championed by John McCain and supported in the tentative Democratic legislation by Lindsey Graham. The auto bailout started under the Bush Administration, and the larger financial industry bailout was also a continuation of Bush policies. By the time of the election, anybody paying attention was aware that the auto industry "takeover" had turned out to be a remarkable success.

So Marcus appears to be saying that as long as there are groups willing to play off of the public's fears and insecurities, even if it means portraying as frightening the very policies they once endorsed, and even if it means refusing to work for better solutions in order to obstruct reforms they concede are necessary, it's best to do nothing. The Obama Administration was not acting like G.W. on Social Security reform. It repeatedly reached out to and included Republicans in the drafting of its legislation, and to entice Republican support and contribution. It's possible that had the Republican Party been less interested in obstructionism, something they correctly anticipated would help them in the 2010 election, and more interested in forming good policy, we would have passed a better healthcare reform bill without the public misconception that this is a big government bill that's going to destroy health insurance as we know it.

If you look at the few Republicans who are willing to articulate a healthcare policy, you tend to see the Newt Gingrich brand of reform - eliminate comprehensive health insurance in favor of catastrophic coverage and health savings accounts. If you come down with cancer, you're covered. If you develop a chronic health condition, you had better either be born rich or keep your job because you're going to pay for that out of your "savings". What if your salary is to meager to allow for any appreciable contribution to your health savings account? Well, that would be your problem, wouldn't it. And do you know how we get to that system from the one we have? By forcing a crisis. The bad news for the Republican Party arising from the modest healthcare reform bill is that it forestalls catastrophe, and creates a framework through which an alternative to the Gingrich-style system can evolve without the current system first reaching the point of catastrophic failure. So yes, they ginned up hysterical opposition to a center-right reform bill and are screeching about repeal. But in the view of Ruth Marcus, all of that is President Obama's fault - it's too scary when the government tries to act in a grown-up manner and prevent things from reaching a crisis point.

Fareed Zakaria was on Real Time last week, and reminded Adrian Fenty that it's better to serve one term in office with real accomplishments than to serve multiple terms with little to show for it. Even though he's among the first to trumpet his own accomplishments, Fenty didn't seem comfortable with that idea. (What's the first thing a politician thinks of when he wakes up in the morning? How to get reelected.) But Zakaria's point is valid, and it's one I wish our political leaders were mature enough to internalize. It would also be helpful if our political press weren't so happy to cover the horse race instead of the issues and, after egging on the mud-slinging and "objectively" refusing to separate fact from fiction, weren't so quick to blame the politicians who try to show actual leadership, make tough decisions, and prevent crises for getting ahead of the American people.

Some People Just Don't Get It

MSNBC's Fareed Zakaria complains about skepticism toward Bush's speech on democratizing the Middle East,

Sometimes I think that president bush’s critics need to put up a sign somewhere in their rooms that reads: "Some things are true even if George W. Bush believes them."

What he is obviously missing is that the objections and skepticism are not directed toward Bush's words, but reflect the fact that Bush isn't being taken at his word. It is wonderful to speak of "compassionate conservativism", being a "uniter, not a divider", of a "clean skies" act to prevent pollution, of "leave no child behind" policies to fix our nation's schools, and of bringing democracy to the world.... But why is it that the reality always seems to fall so far from Bush's platitudes?

Also, isn't this the type of philosophy that caused "conservatives" to attack Carter as a wide-eyed dreamer? Yet when Bush adopts a similar philosophy, right-wing rags like the New York Post reinvent it as:

An eloquent, often moving restatement of American foreign policy at its most generous and idealistic, the speech put the wars in Iraq and Afghanistan in a historical context that went way beyond narrow conceptions of national interest or, for that matter, partisan politics.

What's the difference between "then" and "now"? Are the right-wingers who have spent two decades savaging Carter's foreign policy now tacitly admitting that he had it right? Or are they so ignorant of history, and so eager to save Bush from himself, that they'll glorify every word he utters no matter how inconsistent with his party's past practices and philosophies, and no matter how much at odds his words are with his actions?

When it comes to democracy and the Middle East, Bush can win over his skeptics by living up to his words. I won't hold my breath.

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