Howard Dean’s Bombshell

He wants Senate Democrats to start all over, and use reconciliation to pass health care reform next year, because, he contends, without a public option or the Medicare buy-in replacement, the current bill isn’t worth passing.

Jane Hamsher (no surprise) seconds Dean. “From what we know about the bill, it is worse than passing nothing,” she says. So do Darcy Burner, a former House candidate, and so do pretty much all the health care reform activists as opposed to policy wonks. There has been a sharp difference of opinion for some time now between those on the left who felt the public option was more important than the overall bill, and those who took the view that the underlying legislation was more important. As Greg Sargent notes, the response among liberal bloggers to Howard Dean’s call to “kill the bill” is falling rather neatly along that same dividing line:

There’s a debate raging in the blogosphere about whether the Senate bill has been so watered down that it’s time to try to kill it, and one thing that’s interesting is how cleanly it breaks down as a disagreement between operatives and wonks.

The bloggers who are focused on political organizing and pulling Dems to the left mostly seem to want to kill the bill, while the wonkier types want to salvage it because they think it contains real reform and can act as a foundation for further achievements.

In the former camp are bloggers like Markos Moulitsas, former House candidate Darcy Burner, and the Firedoglake crew. They mostly deride the bill as a giveaway to the insurance companies that does nothing for consumers. A quick rundown of their opinions right here.

In the latter camp are wunder-wonk types like Ezra Klein, Jonathan Cohn, and Nate Silver. They all make expansive arguments that the current legislation contains real reform and indeed represents a fairly immense progressive achievement. A quick rundown of their opinions here.

I respect the activists’ passion and sincerity, but I do not agree with them at all — although at one time, I would have. I think the underlying policy is more important than whether we get everything we want in the first round. One of the reasons I feel that way is the length of time we’ve been trying to get health care reform: All my life. That’s since 1950, for who those who don’t know. I think activists are being very naive if they think we can start from scratch and get the best parts of this legislation — or any parts of it at all through reconciliation. If it dies now, it’s dead. Maybe not forever, but for another couple of decades for certain. And I’m not willing to see that happen.

More commentary here.


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  1. Dr J and Kathy, if I may intrude, I like to add another point that I've brought up before.

    First my current experience with the poor. My boss is both a landlord of cheap apartments and uses a lot of minimum wage and cash workers, so I get to see a variety of people that are solidly poor. I've met people who can't be helped because they are simply too lazy. I know people who have run into unexpected disasters that just need temporary help to get through the recovery. I know people who have persistent problems (promiscuity, excessive violence, and relying on borrowing are common ones) that keep them from ever recovering. I know people who have messed up their lives (I was just talking to a guy who got caught years ago with a meth lab), but are sincerely doing everything they can to recover. Those that are recovering are the easiest to help. Those that are happy being poor, or prefer their problem to the solution, can't be helped.

    My big problem with the current state of public (and many private) assistance programs, is that they treat only symptoms, but not causes. Those that can't or won't take care of kids that they produce need to be separated from the opposite sex. Those that make enough money, but borrow too much, need budget counseling. And, yes, there is a place for counseling, especially marriage and family counseling, and treatments, as any clergy or shelter can tell you. But right now, there's no coordinated approach to assistance programs, and no clear path back to independence.

  2. In a group of millions of low income people, some minority fraction will decide it's easier to camp out in the park and live off the dole.

    Okay, but then you reduce or end those people's benefits, right? It's not an issue of defunding the programs or lowering the level of services that are provided in general.

    My common sense tells me that the more we pay them, the bigger that fraction will be. I hate camping too, but I'm sure I have my price.

    I'm not seeing how you reach that conclusion. Benefit amounts are not increased arbitrarily; they go up (to a maximum that is usually very low relative to the cost of living) according to a person's specific circumstances — as they did in my case. If the maximum benefit payment is not enough to keep the people who need that payment afloat, then how would increasing it change the basic infrastructure of the system whereby if you don't follow the rules or meet the conditions (absent a good reason, of course), you get cut off? In New Jersey, and I'm sure it's the same everywhere else, if you have an appointment with your caseworker to review your benefits and you don't show up, and you haven't called ahead to say you have to reschedule (and have a good reason for doing so), you will lose your benefits. I'm not understanding how this would not address the problems you raise.

    Taxes kick in, but more importantly benefits drop out as your earned income rises, so your effective income stays about the same.

    Okay, I get what you're saying now, but how is cutting benefits going to solve that problem if people can't live on the income they get from available jobs? It seems to me the solution is either to let people keep more of their benefits until their earned income rises above a given level, or creating more jobs that pay better wages. You can't solve these problems by cutting off benefits in a low-wage and/or jobless economy.

    And the difference is sometimes about working harder. Some fraction of the people could do things to earn more, for example taking a full time job rather than a part time one, and we should design benefits programs carefully to make sure it's worth their trouble.

    Taking a full-time job rather than a part-time one. Taking a full-time job rather than a part-time one.

    [Pause while Kathy takes a deep, deep breath and counts to 10.]

    That sounds like a great idea, Dr J, in an economy where there are full-time jobs, and those full-time jobs match the skills and experience of the job-seeker. Unfortunately, we have been in an economy for at least two years now where there are no jobs at all, much less full-time jobs. Even before this latest crisis, we have had for years now (actually decades — since Reagan) a low-wage service economy in which employers have increasingly adopted a business model of short-term and/or part-time work forces without health insurance or other standard benefits (sick time, etc.).

    I would ask you to consider the proposition that in the vast majority of instances, people take part-time jobs for one of two broad reasons: (1) There are no other kinds of jobs available; or (2) Their particular circumstances do not allow them to work full-time. Examples of this might include having a physical, psychological, or developmental disability that puts limits on the kind of work one can do and for how many hours; or having one or more small children and no access to full-time secure child care; or having a medical issue that isn't necessarily a disability but makes it hard or impossible to work full-time.

    Long story short, the phrase “taking a full-time job” implies an ease of action that does not accord in most cases with actual reality. If it were as easy as that phrase makes it sound — that you can just “take” a full-time job like you would walk into a store and “take” items off the shelf and walk up to the cashier and pay for them — we wouldn't even be having this discussion.

  3. Those that can't or won't take care of kids that they produce need to be separated from the opposite sex.

    I know I'm going to regret asking this question, but my curiosity overwhelms me. How specifically do you propose to separate negligent or incompetent parents from the opposite sex?

  4. Wow, an interesting side discussion has developed from this. I've only had time to skim the other comments but want to respond to some of what you asked/wrote here Kathy and possibly touch on a few of the other commenters' points.

    I'm puzzled about what you mean here. I was actually suggesting the opposite — what some people consider “rational thought” about policy-making doesn't always adequately consider the real experiences of individual people's lives — as in “social programs are not really good for people although they may be popular” contrasted against “social programs save lives, I know because they saved mine.”

    OK, well this is why I tried to paraphrase what I thought you meant, because I wasn't sure I was inferring correctly. To some extent, I don't think you can fully separate emotional arguments from the ones based on cognitive reasoning. But in your initial comment, you referred to fearmongering over national defense, for instance, and how that manipulates people into accepting and/or supporting certain defense policies and excessive spending. What I'm saying is, that the same thing applies to social program spending- if we focus so much on anecdotes to play on people's sympathies, that too is an emotional manipulation. There is obviously a place for pointing out the more emotional appeals (if everyone lacked empathy, you could create a society based on social Darwinism which could be considered successful by the standards of those non-empathetic people- but that's not the kind of society that most real people (who do have feelings and empathy) would consider desirable to live in.) There's also a place for emotions in the defense policies, because a society of people who completely lacked or ignored fears would end up ignoring real threats and failing to be prepared to defend itself. Fear, like empathy, is actually a necessary part of rational thinking as long as it's not overblown (there's actually been some recent research on the interconnectedness of emotional and cognitive based thinking- where they've studied people with brain disorders or injuries who lack function or connectedness of the emotional brain centers and they've found that these people don't do well on some thinking tasks that we'd consider rational or cognitive; the emotion is actually necessary for good decision making in some areas.)

    So if I've expressed that in a way that makes sense, and if you agree, then again we're talking about possibly a difference of opinion on where to draw the lines. I think perhaps that I worry more about emotional hype and manipulation in public policy making when it comes to social welfare programs, while your concerns are mainly over the manipulation involved in defense policy (but that we both see the basic concept of manipulation of voters by the politicians in each case.) Would you say that's accurate?

    I understand your point here, but couldn't you say exactly the same thing about any other area of national spending? As in, “I don't disagree at all that we need to have a strong defense, but that doesn't mean I approve of all the wasteful spending and unnecessary programs that are in place”? Or, for that matter, as in “I don't disagree at all that we need to provide ways of increasing economic opportunity to those who are able to work, but we also, equally, need to recognize that 'the struggle for financial freedom is unfair' (to quote Savage Garden!) and that adequate resources need to be in place to ensure that people have at least what they reasonably need to be physically and psychologically secure and healthy.”

    I agree with almost all of that (and that's one reason it's important not to overdo the emotional appeals because when they go too far then people don't stop to consider whether the spending is wasteful or if it's properly limited and targeted for maximum effectiveness.This particularly becomes true when we get into typical partisan baiting policy 'debates' where one side is whipped into a frenzy to defeat those who oppose their party's policies on the basis of the other party not 'caring' enough- there's a tendency then not to reflect on what the spending will actually accomplish because it becomes all about beating the other people whom you've become convinced just don't care about the problem.)

    Anyway, the only part in the above excerpt I'm not sure I can agree on is the struggle for financial freedom being unfair because I don't know the context of that statement and I think we probably disagree on that basic concept of 'fairness' in terms of economics and the government's role.

    Why do you believe that human needs programs “crowd out” other, economic opportunity-producing resources? Why can't we have both?

    Because resources are always finite. Even in a generational sense, having an expansive government social contract which provides a lot of distribution of wealth to citizens and might work in the short term will then become a problem when more and more people are on the receiving end instead of on the productive end. If programs are well designed to provide temporary assistance and bridge toward making people productive again, that's all well and good- but US welfare programs of the Great Society didn't do that and some of the Democratic Socialist states of Europe either have or are now beginning to feel these strains too.

  5. They can answer the questions about you that I can't–whether you're a virtuous person who deserves a hand or a slacker who made her bed and ought to lie in it–whether some help today will leave you better off tomorrow or just enable worse problems. IMHO these are critical questions, but they're no-fly zones for government institutions and people who don't know you personally.

    I actually agree with Kathy's response to this, that private charities actually rarely do assess these things. The only types that do that to some extent are those that incorporate the ideas that ProfElwood mentioned which attempt to get to the root causes and structural problems in the person's life instead of just providing temporary solutions.

    The same is true of individuals helping friends or family members. It's always a dilemma- how much do you have a right to intervene in a person's affairs if you are helping them out of a jam? We've struggled with this many times and are in the midst of it right now with one family member. I don't want to tell him how to live his life, but if I'm going to provide financial support I want it to be something that has a better long term effect so I want to know that he has a plan in place after our initial assistance runs its course- otherwise we're just delaying the inevitable and really our contribution will be a waste (not helping him in a meaningful way, and costing us other opportunities where we could have used the money for our own family's needs or to help someone else.) Obviously this exploration of options and long term planning should be done tactfully and not in a judgmental manner- the point isn't to shame someone about coming to you for help or to criticize him/her for choices that were previously made which may have resulted in the current crisis, but hopefully to get him to more carefully consider future choices.

    In addition to all of this though, one difference between public assistance and private is that in the latter there is at least the possibility of a personal relationship which can be more supportive of long term efforts to improve the situation. There's also, not shame, but a sense of propriety, when a personal relationship exists. If the beneficiary is treated with respect but also some accountability, he/she has greater impetus and ability to change his/her life situation in a more significant way instead of bouncing in and out of a public safety net.

  6. I think perhaps that I worry more about emotional hype and manipulation in public policy making when it comes to social welfare programs, while your concerns are mainly over the manipulation involved in defense policy (but that we both see the basic concept of manipulation of voters by the politicians in each case.) Would you say that's accurate?

    It's not necessarily about manipulation, and it's not just about manipulation. It's about the attitude we take toward disagreements about spending levels and allocation in the case of defense and military policies in general, versus the attitude we take toward those same types of disagreements in the case of domestic spending on social programs and human needs services. In the latter case, we conclude that there is something fundamentally flawed in the very concept of social programs and services. We have to keep it as limited as we possibly can, because in its essence, it's a concept that is very worrisome and dangerous.

    With defense and military issues, we do not make that same assumption when faced with revelations of wasteful spending or poor allocation choices, etc.

    In addition, I don't agree that paying attention to documented need — i.e., real people's experiences — is the same thing as using “anecdotes” to make policy. There's a difference between anecdotal evidence of need, and using real stories to illustrate the undeniably massive numbers of Americans going through real suffering in this economic crisis. We don't need anecdotes to tell us that the poverty rate is rising, that food insecurity is increasing, that food stamp usage has skyrocketed, that people are losing their homes, that food pantries cannot keep up with the demand. We already know these things — anecdotes merely serve the purpose of making them more real to people who aren't experiencing them or who doubt that the problem is as serious as it actually is.

    Because resources are always finite.

    Ahhh, would that this attitude would be uppermost in people's minds when the subject is the impact of the American way of life on global economic sustainability and climate change!

    Even in a generational sense, having an expansive government social contract which provides a lot of distribution of wealth to citizens and might work in the short term will then become a problem when more and more people are on the receiving end instead of on the productive end.

    There has never been an “expansive government social contract” in this country. Never. Ever. And for almost 30 years now we have had a low-wage service economy that has not allowed unskilled workers or workers with outdated skills to find the kind of employment in the private sector that could pull a person out of poverty or out of the twilight state of hovering just above the poverty line. In order for your scenario to work, one must have a productive economy already in place and ways to draw in the kind of people who are usually enrolled in social programs. Otherwise, you will simply be taking programs and services away from people in the absence of well-paying jobs they can walk into.

  7. OK, I give up on trying to find common ground. I apparently thought we agreed a bit more than we actually do but were putting emphasis in different areas. I guess not.

  8. How specifically do you propose to separate negligent or incompetent parents from the opposite sex?

    I didn't specifically suggest anything. I was only trying to give examples of principles that could be used to build programs, not the programs themselves. My criticism is about the entire approach that we take with welfare. As CStanley alluded to, and I've dealt with personally, the goal is to help people get back on their feet, but not help them to be comfortable on the ground.

  9. Maybe our common ground is that we both care deeply about these issues and are genuinely trying to express the truth as we see it in thoughtful and intelligent ways.

  10. Yes, I would agree with that.

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