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.

Author: KATHY KATTENBURG

110 Comments

  1. I might still disagree with you in general about many aspects of healthcare “reform” Kathy, but I respect the fact that you have matured out of the “activists” way of thinking that Dean suggests.

    On another note: Howard Dean is pretty much advocating the kind of thing that you went after Joe Lieberamn for with your assumptions as to his motives, ie., being willing to engage is disingenious mens reconciliation) to achieve a political end.

    You respect their ” passion and sincerity” when they make such a statement, but assume that Lieberman lacks it without such a bold declaration from him.

  2. On another note: Howard Dean is pretty much advocating the kind of thing that you went after Joe Lieberamn for with your assumptions as to his motives, ie., being willing to engage is disingenious mens reconciliation) to achieve a political end.

    Leonidas, that is SO absurd. It really is.

    I'm upset with Howard Dean for saying he wants to kill the bill and I strongly disagree with him, but there is no reason to doubt that he is motivated by a sincere desire to achieve effective health care reform. Lieberman is not motivated by a concern for health care reform. He doesn't want to kill this particular bill in order to get a better one. He wants to kill health care reform, period.

    Howard Dean is acting from a good faith belief that this bill will not help Americans who are suffering and dying for lack of health insurance. That's why he wants to kill the bill, whether he's right or wrong about that, that's his motivation. Lieberman is not operating in good faith at all. He doesn't give a damn about health care reform. His motive is to kill whatever the Democrats want in a health care reform bill because he is consumed with hatred and the desire for revenge.

    Honestly, Leonidas, sometimes I wonder about you. Being able to make basic distinctions like this is a key part of normal human intelligence.

  3. He wants Senate Democrats to start all over, and use reconciliation to pass health care reform next year,

    Sorry but reconciliation is not a sincere efforts, its using a hyper partisan political trick to try and thwart the process as intended.. It was when the GOP used it, it is when Dean advocates it. It is an insincere effort to perform the proper duties of Congress.

  4. And filibustering every single piece of legislation the Democrats put on the Senate floor is not hyperpartisan? There is nothing hyperpartisan about using reconciliation to pass a bill when the opposition party will not even let a bill — any bill — come to the floor for an up or down vote and when the majority party has done everything — literally everything — possible to address the opposition party's concerns. The filibuster was NEVER intended to be used this way — to enable the minority to block the entire policy agenda of the party that won the election. Do you actually think it's the normal, regular way the Senate is supposed to operate, that there is no such thing as passing a bill with a majority vote anymore — that every single bill requires a supermajority to pass?

  5. It's interesting that several major pieces of legislation passed under President Bush, including No Child Left Behind, Prescription Drugs for MediCare, and Tax Relief, to say nothing of the AUMF, Patriot Act, and funding for the Surge. He also got two USSC appointees through the confirmation process. Yet Bush had nowhere near the margins in the House and Senate that Obama has today. While the Republicans did control the Senate, it was at most with a 55-45 majority.

    While I recall a great deal of grousing and complaining by Republicans, I don't recall people loudly proclaiming the country to be “ungovernable”. Indeed, the legislative accomplishments noted above show that it was not.

    No Child passed the Senate 87-10. It had almost as many Republicans vote against it as Democrats. http://www.senate.gov/legislative/LIS/roll_call

    Prescription drugs for Medicare passed the Senate 76-21. Not even close to filibuster territory.

    The most obvious explanations for the current polarizing stalemate are that the Democrats are less competent than the Republicans were at getting legislation passed, and/or that they have become so beholden to their far left base that they are alienating the center which should be providing enough votes to pass major legislation. I think it is a combination of the two. Major legislation under the Bush Administration was sufficiently moderate to attract large numbers of Democrats in support. Bush also played an active leadership role in shaping the agenda, oftentimes to the distress of members of his own party (Amnesty for example). But he got many of his major initiatives passed.

    The dismissive way Obama (“I won”) has treated the opposition, and the far left wing tilt of the party base (“dump Lieberman”) may have resulted in an historic act of self-immolation. The question is whether Health Care Reform serves as a learning experience for the party in power, or further raises the sense of outrage and entitlement voiced by the Howard Dean left wing of the party.

    Personally, I think the Democrats have made such a hash of health care reform that I hope that this horrible piece of legislation does not pass. Which puts me on the same side as Dean, but for obviously different reasons.

  6. At least the Democrats are being honest. Unless the health insurance reform bill kills the health insurance industry and unless it creates a massive new entitlement that will be funded by borrowing money, then the Democrats are not really interested in suppport it.

    I guess until all of the U.S. has the problem of Detroit, Los Angeles, or Baltimore, the Democrats will not be content.

  7. I guess until all of the U.S. has the problem of Detroit, Los Angeles, or Baltimore, the Democrats will not be content.

    I guess until all of the U.S. has the successes of Mississippi, Alabama, or Louisiana, the Republicans will not be content.

  8. Can you describe, Kathy, what components of the current bill you believe will have positive effects?

    I heard one pundit last night say that Dems should pass it because it will achieve two goals- near universal coverage and an end to the practice of denying insurance coverage for preexisting conditions.

    Are these the main features that you see in the bill?

    If so, why spend nearly a trillion dollars to accomplish this? Both of those things are done through mandate and regulation, which doesn't necessitate that kind of spending (presumably there will be some spending to pay for the mandated coverage for the working poor though.)

    I think what some Dems are failing to consider is the backlash. Once this amount of money is committed to 'reform', if real reform isn't accomplished then I doubt the public is going to support more and more spending in the hopes that they eventually get it right. We're already seeing backlash because of ARRA, and the lackluster effects of such massive spending.

    So although I am not a fan of purism of the type being displayed by some on the far left, and I don't agree with what they think should be in the bill, I have to agree with them that this bill needs to be put out of its misery. I think it's completely misguided to think that passing this could represent a good 'first step'.

  9. While I probably would not agree with what Howard Dean would propose, and certainly don't agree with reconcilliation as a means of passing critical legislation that will have a permanent impact, I agree with him to the extent that the legislation currently working its way through congress is so deeply flawed that a new beginning is in order. In saying that, we should also recognize that both sides of the aisle, as well as a host of special interests, are responsible for this mishmash.

    On a broader perspective, there seems to be a theme developing within the Obama administration. They appear eager to bring special interests to table for buy-in, but in the process lose sight of the mainstreet objective, ala bank bailouts, auto bailouts, stimulus bill and now healthcare reform.

  10. The filibuster was NEVER intended to be used this way — to enable the minority to block the entire policy agenda of the party that won the election.

    I agree with you and we've had this discussion before on TMV. I think the current filibuster rules are a farce.

    What you propose though is to also use reconciliation in a way it was never intended. This is the “two wrongs make a right” justification and you should not support it any more than you should support the misuse of the filibuster.

  11. leo
    “Sorry but reconciliation is not a sincere efforts, its using a hyper partisan political trick”

    yeah, that hyper-partisan majority rules in a democracy is really so radical. puullllleeze

  12. As much as the nation needs healthcare now, this may be the most prudent and meaningful path after all. Dean comes up with good ideas now and then.

  13. CS
    “If so, why spend nearly a trillion dollars to accomplish this? Both of those things are done through mandate and regulation, which doesn't necessitate that kind of spending (presumably there will be some spending to pay for the mandated coverage for the working poor though.)”

    Though you and I have disagreements concerning health care coverage, I totally agree with your sentiments here. I also saw that the right to import drugs back into the US at great savings also has been removed from the bill. Just another example of cost savings neatly being snipped from the current bill.

    let it die, and let 51 votes decide this. Prior to 1917, that was how Congress worked.

  14. tidbits wrote: “I agree with him to the extent that the legislation currently working its way through congress is so deeply flawed that a new beginning is in order.”

    Absolutely tidbits, If the current bill passes it will look, taste, and smell like Part D Medicare… A fiscal disaster.

    A disaster that will: a) appear to be exclusively the fault of the Democrats (and it might well be!) and b) be so damaging to the average Americans belief in our governments ability to do anything about the health care problems we are facing and thereby making any future attempt to actually “reform” health care impossible.

    Let them eat cake!.. a cake with a big red “R” on it.

  15. I had these criticisms even when there was a toothless “public option” involved. If they really want to work on the foundations then they should pass a bill very limited in scope that would target preconditions, drug imports and allow interstate competition/nonprofit collectives. That wouldn't cost very much money at all and do far more to reduce healthcare inflation than this plan (in any of its forms). As <a href=”http://themoderatevoice.com/42378/want-to-help-the-uninsured-just-give-them-insurance-already/”I've noted before, the uninsured problem should be tackled completely differently.

    Oh and I have been convinced that some sort of tort reform is necessary too, not because of the actual level of money currently spent, but because of the effect it has on delivering care. Also I can say conclusively that well over 50% of the problems in health care are due to doctors, administrators and internal culture that no bill can affect, and until that is addressed then things will continue to spiral out of control.

  16. The filibuster was NEVER intended to be used this way — to enable the minority to block the entire policy agenda of the party that won the election.

    Sure it was. Its entire purpose is to prevent tyranny of the majority.

    The 'problem' is always the same – the side it may be used against rails about it 'thwarting the will of the majority', while the other side wraps themselves in self-righteousness about 'preventing the rights of the minority from being trampled and/or protecting America from extremism'.

  17. Now that Dean has jumped on the “to lousy to pass” bandwagon, I guess we see a little break in the fog.
    I was never a fan of Dean, but what I thought was goofiness, was probably passion.
    It's ironic, that starting from two different viewpoints, that Dean and Joe wind up at the the same junction.

  18. dd, it is ironic indeed, particularly since Joe doesn't seem to care about much except himself, whereas Dean has always advocated for the people who tend to be disenfranchised.

    Kathy, I appreciate your POV on this situation and while I'd rather see incremental progress than no progress, I am deeply disappointed in this devolution. Anyone who looks at the big picture (objectively) realizes the failure of worthwhile healthcare reform must be laid at the feet of the GOP (except when Nixon was actually trying to do something about it), but I still am disgusted with the rather gutless performance of the democrats and would rather see Dean's scenario be realized. That said, how hard would it be to get traction at this point?

  19. Maybe after trying all the wrong ways, and committing so hard to doing “something” this year, they'll have painted themselves so far into the corner, that their only remaining option will be to tackle all the special interests. Joe (yes, you've all made it quite clear how popular he is with you) said [something like] there would be no way to do real reform because the special interests are making it politically impossible — the Democrats could get their real revenge by proving him wrong.

  20. My fault, I was trying to subtly say that they both could have good motives.
    So, I guess you just want it to be, Joe= bad, Dean= good. Fair enough.

  21. America is of course a Constitutional Republic, not a Democracy. But in the context of ObamaCare those appealing to our democracy by bemoaning the filibuster and praising Dean for speaking for the “disenfranchised” ought to consider that a long string of polls has demonstrated that most American voters oppose the passage of this bill. While most favor health reform in general, they do not favor the passage of bills currently before Congress.

    If we were following the “Principles of Democracy” the current legislation would have been scrapped months ago.

    If any group has been disenfranchised in the process, it is the majority of Americans who oppose the bill. Not only might it be passed over our objections, but we are not even allowed to know what it contains or how the latest version has been scored economically. Our elected representatives have demanded rushed decisions, held the language secret, and cut deal after deal behind closed doors without our consent or at times even our knowledge. That track record of secrecy and deceit puts the lie to attempts to appeal to lofty rhetoric.

    Oh, and $ 300,000,000 in tax payer dollars to buy one vote? What 'democratic principle' does that rest on? At least Lieberman didn't sell his vote to the highest bidder and brag about how much he got for it.

  22. The filibuster was NEVER intended to be used this way — to enable the minority to block the entire policy agenda of the party that won the election.

    (AR) Sure it was. Its entire purpose is to prevent tyranny of the majority.

    The filibuster was intended to be limited to the oratory stamina of the one exercising the filibuster, not as a convenient administrative maneuver that goes on forever.

  23. I'll bet forty people can speak in rotation for a long long time. What you are talking about applies to a filibuster by a single Senator or a small handful of Senators.

    The filibuster has been around since ancient Rome and been in use in the USA for about 150 years. Whether it is good or evil depends entirely on whose ox is being gored at the time it is employed. I seem to recall many high minded appeals to the glories of the filibuster by liberals back when the Republicans were pursuing the evil “nuclear option” to overcome the blockade of Bush nominees. If the GOP ever retakes Congress I predict they will once again attack the filibuster as the tool of the daemons. In fact I'll lay money on it.

  24. Note to Democratic Congress:

    1. Get your asses in gear and pass the bill you want, through reconciliation.

    2.. Kick Joe Lieberman's ass so far out of the party that he'll need a pick axe and helmet-light to find his way back to Washington. Not only does he not caucus with the Dems, but he loses all committee chairs and seniority. Stop kidding yourselves–HE'S NOT ON YOUR SIDE!

    3. Next time, let the Reps filibuster. A REAL, honest to goodness, bring-in-the-cots-filibuster. Preferrably over Christmas, where all of America can see just who has their best interests at heart.

    4. Historically, you're going to lose seats in 2010. Deal with it. Pass the legislation you want to pass, that you think is the best thing for the country and take the hit like adults. Nobody likes the dithering, it's probably losing you more support than just passing the bills.

  25. Get your asses in gear and pass the bill you want, through reconciliation.

    This presumes that there's a bill that all of the factions of the Dem Congress 'want', which is not the case.

  26. I guess you just want it to be, Joe= bad, Dean= good.

    It has nothing to do with what I “want it to be” (if only ;-) … but with what it is.

  27. Whether it is good or evil depends entirely on whose ox is being gored at the time it is employed.

    The filibuster has been misused by both parties and which party employs it has no bearing on whether it's “good or evil”. You are correct though that partisans will continue to attack or defend it based on what it gets them in the short run.

  28. But there is a bill that the majority of both houses can agree on. It's the obstructionist sideshow that's watered it down to what it is today. It is a handful of people that have precipitated the changes we've seen over the last few months. They have now negotiated themselves into obscurity, as far as I'm concerned.

    Lieberman, in particular, has not been negotiating in good faith.

  29. The filibuster was intended to be limited to the oratory stamina of the one exercising the filibuster, not as a convenient administrative maneuver that goes on forever.

    Wrong again.

    In the United States Senate, the Senate rules permit a senator, or a series of senators, to speak for as long as they wish and on any topic they choose, unless a 3/5ths of the Senate (60 out of 100 Senators elected and sworn), brings debate to a close by invoking cloture. According to the Supreme Court ruling in U.S. v. Ballin (1892), changes to Senate rules could however be achieved by a simple majority:

    The constitution empowers each house to determine its rules of proceedings. [...] The power to make rules is not one which once exercised is exhausted. It is a continuous power, always subject to be exercised by the house, and, within the limitations suggested, absolute and beyond the challenge of any other body or tribunal.

    The constitution provides that 'a majority of each [house] shall constitute a quorum to do business.' In other words, when a majority are present the house is in a position to do business. Its capacity to transact business is then established, created by the mere presence of a majority, and does not depend upon the disposition or assent or action of any single [144 U.S. 1, 6] member or fraction of the majority present. All that the constitution requires is the presence of a majority, and when that majority are present the power of the house arises.

    Nevertheless, the current Senate rules state that 67 votes are required for future rule changes.

    In current practice, Senate Rule 22 permits filibusters in which actual continuous floor speeches are not required, although the Senate Majority Leader may require an actual traditional filibuster if he or she so chooses.

    In 1789, the first U.S. Senate adopted rules allowing the Senate “to move the previous question,” ending debate and proceeding to a vote. Aaron Burr argued that the motion regarding the previous question was redundant, had only been exercised once in the preceding four years, and should be eliminated. In 1806, the Senate agreed, recodifying its rules, and thus the potential for a filibuster sprang into being. Because the Senate created no alternative mechanism for terminating debate, the filibuster became an option for delay and blocking of floor votes.

    The filibuster remained a solely theoretical option until the late 1830s. The first Senate filibuster occurred in 1837. In 1841, a defining moment came during debate on a bill to charter the Second Bank of the United States. Senator Henry Clay tried to end debate via majority vote. Senator William R. King threatened a filibuster, saying that Clay “may make his arrangements at his boarding house for the winter”. Other Senators backed King, and Clay backed down.
    [edit] 20th century and the emergence of cloture

    In 1917, a rule allowing for the cloture of debate (ending a filibuster) was adopted by the Democratic Senate at the urging of President Woodrow Wilson. From 1917 to 1949, the requirement for cloture was two-thirds of those voting.

    In 1946, Southern Senators blocked a vote on a bill proposed by Democrat Dennis Chavez of New Mexico (S. 101) that would have created a permanent Fair Employment Practices Committee (FEPC) to prevent discrimination in the work place. The filibuster lasted weeks, and Senator Chavez was forced to remove the bill from consideration after a failed cloture vote even though he had enough votes to pass the bill. As civil rights loomed on the Senate agenda, this rule was revised in 1949 to allow cloture on any measure or motion by two-thirds of the entire Senate membership; in 1959 the threshold was restored to two-thirds of those voting. After a series of filibusters led by Southern Democrats in the 1960s over civil rights legislation, a “tracking” system devised by then Majority Whip Robert Byrd was put into place. Tracking allows the majority leader – with unanimous consent or the agreement by the minority leader – to have more than one bill pending on the floor as unfinished business. Before the introduction of tracking, a filibuster would stop the Senate from moving on to any other legislative activity. With a two-track system, the Senate simply puts aside the filibustered measure and moves on to other legislation.

    Finally, the Democratic-controlled Senate in 1975 revised its cloture rule so that three-fifths of the Senators sworn (usually 60 senators) could limit debate. The filibuster or the threat of a filibuster remains an important tactic that allows a minority to affect legislation. Senator Strom Thurmond (D/R-SC) set a record in 1957 by filibustering the Civil Rights Act of 1957 for 24 hours and 18 minutes, although the bill ultimately passed. Thurmond broke the previous record of 22 hours and 26 minutes which Wayne Morse (I-OR) had established in 1953 protesting the Tidelands Oil legislation.

    The filibuster has tremendously increased in frequency of use since the 1960s. In the 1960s, no Senate term had more than seven filibusters. One of the most notable filibusters of the 1960s was when southern Democratic Senators attempted, unsuccessfully, to block the passage of the Civil Rights Act of 1964 by making a filibuster that lasted for 75 hours. In the first decade of the 21st century, no Senate term had fewer than 49 filibusters. The 1999-2002 Senate terms both had 58 filibusters. The 110th Congress broke the record for cloture votes reaching 112 at the end of 2008, though cloture votes are increasingly used for purposes unrelated to filibusters.

    See also: Filibusters and Cloture in the Senate, Congressional Research Service Report for Congress

  30. DaMav said:
    “Major legislation under the Bush Administration was sufficiently moderate to attract large numbers of Democrats in support.”

    That's because Bush figured he could bypass anything “moderate” in the legislation with a signing statement and do as he pleased. /snark

  31. People I disagree with are all the time negotiating in bad faith. Go figure. It's almost like its settled science.

    Mary Landrieu, who voted for the measure getting 300,000,000 in taxpayer dollars and bragging about it, now that's “good faith” negotiating right? And yet she has the same number of votes in this as that awful Joe Liebermann!

    And how about Harry Reid? Has he demonstrated good faith by holding the language of the bill as an Official State Secret? Is that good faith negotiating? Or the White House cutting a secret deal with Pharma, and denying they did what they later admitted that they did. Good faith again?

    Seems there is plenty of bad faith to go around. Or maybe it's just sausage being made to specs, as usual.

  32. Hyper partisan? It is the Filibuster rule since 1975 that causes this issue. The Constitution says a simple majority i.e. 51 votes is suficient to pass the bill. That is the 'American' way. The Senate rules are there own. If they want to pass healthcare, then they should change their rules, do the nuclear option.

  33. Good history lesson, AR. Thanks.

  34. A razor thin majority of both houses, perhaps- which is to say that you're advocating the 50+1 strategy for legislation that will make sweeping changes to our entire healthcare system and economy. I'd also say that the slight majority who would vote to pass the current bill would do so out of partisanship, elbow twisting, and bribery, rather than conviction that the bill represents actual reform.

  35. Works for me.

  36. When these folks start moving the goalposts every time everyone *else* thinks there's a deal in place, get back to me.

  37. Yup.

  38. Dems, it's time to start acting like Republicans. Enough being nice, enough compromise. Get the f**king bill passed, by whatever means necessary. You can always go back and fix it later.

  39. I fail to understand what you even like about this bill.

  40. Wrong. Listen to Dean. Don't pass a faulty compromise, it lowers your party considerably. We need you guys to balance out the crazy reps. out there.

  41. So since there is a deal in place on the Stupak Amendment that passed the House, we won't be moving the goalposts on that one, right?

  42. This Congress does not have our “best interest's ” in mind for the coming year.

    Maybe we should throw all the bums out and start over.
    Dean is right. This fiasco needs to be started over. Transparency as promised, CSPAN debates and actual bi partisan work toward a fair health plan that includes everyone.

    AND I HAVE SOME OCEAN FRONT PROPERTY IN ARIZONA TO SELL YOU.

  43. In the United States Senate, the Senate rules permit a senator, or a series of senators, to speak for as long as they wish and on any topic they choose, unless a 3/5ths of the Senate (60 out of 100 Senators elected and sworn), brings debate to a close by invoking cloture.

    AR we can argue over the different shadings and changes over the years but I read this as the original intent being to allow Senators to speak as long as they wish, not to delay a vote without actually speaking. Indeed your post notes that no longer requiring continuous floor speeches represents a change. I do enjoy your posts and agree with you more often than not.

  44. Well, if you'll notice, DaGoat, I'm the one who doesn't want to scrap this bill and start again. That said, I do try not to check the Comments on a full stomach, because it does make me want to regurgitate reading the hypocritical ravings of some people here who make not a peep when the minority party holds up stacks of legislation and grinds Senate business to a halt and then protests with self-righteous cries of two wrongs don't make a right when some Democrats want to use reconciliation — an equally legitimate procedure when used the way it's meant to be used — to pass a bill that actually has the support of well over 51 percent of the Senate but can't even be voted on because Republicans would rather obstruct a vital piece of legislation than accept they can't defeat it the democratic way.

    Clean up your own damn house before pointing fingers at the Democrats'.

  45. Stupak is a distraction, at best. Throw the anti-choicers a bone. They're probably sincere. End of story.

    Be like sharks, keep moving forward.

  46. let it die, and let 51 votes decide this. Prior to 1917, that was how Congress worked.

    Let 51 votes decide this? Isn't that exactly what Republicans would rather filibuster literally every major piece of legislation to prevent?

  47. Any future attempt will be effectively dead anyway. The Democrats will not get a chance to pass any other health care legislation if this one fails.

  48. Sure it was. Its entire purpose is to prevent tyranny of the majority.

    Um, to prevent tyranny of the majority, yes. But not to replace that with tyranny of the minority.

  49. That said, how hard would it be to get traction at this point?

    I'm not clear on what you mean by this. Are you asking how hard would it be to get health care reform passed if this bill is killed and Democrats try again? If that's what you're asking, my answer is, very hard. It would not happen. And even if it did, the best parts of the underlying bill (the ones that make it worth passing even w/o the public option) might not stay in.

  50. Joe Lieberman IS the special interests.

  51. The Democrats will not get a chance to pass any other health care legislation if this one fails.

    Be still my heart. Actually they could pass the Republican Proposal on Health Care Reform by a large bipartisan majority tomorrow morning. With the kind of numbers that Bush rang up on some of his big legislative initiatives as I point out near the beginning of this thread. They would earn the gratitude and credit of the nation for governing from the center instead of the far left. I keep hoping Obama will wake up and see the opportunity of dumping the radicals who pull his strings but I fear he may actually be one of them.

  52. Bombshell?

    Not really. I don't think many people even noticed.

  53. But not to replace that with tyranny of the minority.

    Oh? NOW you are concerned about tyranny of the minority?

    So, I guess that means you no longer support equal opportunity laws or gay marriage, and you DO now support school prayer.

    Were you against filibusters when GW was trying to put conservatives on the federal bench?

    I am going to go WAY out on a limb and guess the answer is 'no' to all the above. You simply object when it goes against your wishes.

  54. Be still my heart.

    Yes, of course, you would feel that way. That's why the GOP is fighting so hard to kill this bill.

    Actually they could pass the Republican Proposal on Health Care Reform by a large bipartisan
    majority tomorrow morning.

    There is no Republican “Proposal on Health Care Reform.” If you're talking about that three-point thing saying sell insurance across state lines, no more lawsuits, abolish Medicare, and privatize Medicaid (I'm sorry, four points not three), that's not a health care reform proposal. That's fish wrap.

    With the kind of numbers that Bush rang up on some of his big legislative initiatives as I point out near the beginning of this thread.

    Like Social Security?

    But seriously. The few legislative initiatives that Bush's Congress passed were passed because Democrats did not try to obstruct them. That's because Democrats care about policy more than they do ideology. Even when the legislation is rotten, if the underlying policy is good, they will try to make the legislation better. The Democrats are not the Party of No.

    They would earn the gratitude and credit of the nation for governing from the center instead of the far left.

    No, they wouldn't. They might earn the sarcastic and contemptuous gratitude of congressional Republicans for enabling them to get their majority back, but most Americans would be disgusted with Obama's inability to make the change he was elected to make, and they would vote him out of office.

    Which is, obviously, what Republicans (like you) want, right?

    Why on earth would Republicans in Congress be opposing health care reform so ferociously if they thought passing it would piss off the American people and harm Pres. Obama's popularity? They know darn well that health care reform is a central reason why Obama was elected, and if it passes, his popularity (and that of the Democrats in general) will zoom up. They have to kill it at all costs. If they thought it would HURT Obama, DaMav, they would be falling all over themselves trying to pass it.

    Honesty, DaMav. Honesty. Honesty. At least be honest.

  55. Democrats care about policy more than they do ideology

    BS. They care more about re-election than anything else. Whatever votes they took as a party, is was because the poll numbers at that moment said it was the right thing to do. Same for the Republicans. They are equally venal.

    Of course, real policy differences do exist, as the health care debate shows, but all-in-all, as Mark Twain said, “It could probably be shown by facts and figures that there is no distinctly American criminal class except Congress.”

    You are shining your lamp in the wrong place looking for your honest man, Ms. Diogenes of TMV.

  56. You are shining your lamp in the wrong place looking for your honest man, Ms. Diogenes of TMV.

    This actually made me laugh.

  57. Indeed let us be honest.

    In May 2009 four Republicans introduced the Patient's Choice Act, summarized here
    http://online.wsj.com/article/SB124277551107536

    The 248 page bill is found here: http://www.house.gov/ryan/PCA/

    In June 2009, Republicans introduced another bill, highlighted by CNNmoney here
    http://money.cnn.com/2009/06/17/news/economy/re

    Features of the bill included the following:
    ·~”Pools” of insurance. It would let states, small businesses and others group together to offer lower-cost, health care plans. Such pools would have to offer, at a minimum, any coverage that is provided in a majority of states.
    ·~Medicaid transfer. It would allow Medicaid users to take the value of their Medicaid benefits and transfer/apply those to a private health care plan instead.
    ·~Boosting of health care savings accounts. It would increase incentives for people, especially those in lower income brackets or over 55, to build up HSAs.
    ·~Automatic insurance. It would encourage employers to sign up their workers for health insurance automatically, so that employees would have to “opt out” of coverage if they didn't want it.
    ·~Longer coverage for youths. It would allow dependent children to stay on their parents' policies until they are 25.
    ·~Promotion of wellness at the workplace. It would encourage employers to reward employees for improved health.
    ·~Expansion of community health centers.
    ·~Mobile health care. It would allow Americans to maintain their specific health insurance policies when they lose or leave jobs.
    ·~In-home care. It would provide financial help and encourage more in-home care over institutions.
    ·~Limitations on malpractice lawsuits. There is general agreement over limiting such lawsuits, but a deep divide exists over exactly how much.

    As the year progressed and the Democrats increasingly broke deadline after deadline, more Republican proposals were introduced:
    Empowering Patients First Act (Republican Study Committee Health Care Reform Bill, introduced July 30, 2009)
    Improving Health Care for All Americans Act (Shadegg Health Care Reform Bill, introduced July 14, 2009)
    Medical Rights & Reform Act (Kirk-Dent Health Care Reform Bill, introduced June 16, 2009)
    Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act (Gingrey medical liability reform bill, introduced June 6, 2009)
    Small Business Health Fairness Act of 2009 (Johnson small business health plans bill, introduced May 21, 2009)
    Promoting Health and Preventing Chronic Disease through Prevention and Wellness Programs for Employees, Communities, and Individuals Act of 2009 (Castle Wellness & Prevention Bill, introduced July 31, 2009)
    Improved Employee Access to Health Insurance Act of 2009 (Deal auto-enrollment bill, introduced October 15, 2009)
    Health Insurance Access for Young Workers and College Students Act of 2009 (Blunt bill to improve health insurance coverage of dependents, introduced October 21, 2009)

    In addition, Sarah Palin endorsed a number of broad principles based on CATO approaches to a more market oriented approach to health care. “…such policies include giving all individuals the same tax benefits received by those who get coverage through their employers; providing Medicare recipients with vouchers that allow them to purchase their own coverage; reforming tort laws to potentially save billions each year in wasteful spending; and changing costly state regulations to allow people to buy insurance across state lines.”
    http://online.wsj.com/article/SB100014240529702

    All of these efforts were totally ignored and disregarded and indeed trashed by Obama and the Democrats in Congress. They thought they didn't need the input or cooperation of Republicans.

    Now you may personally disagree with these proposals and have every right to do so. You may even hate them. But how does it further “Honesty. Honesty.” to summarize these bills and papers as a “four point thing” and claim that there is no Republican “Proposal on Health Care Reform”?

    Just because it doesn't weigh in at 2000+ pages and cost a trillion plus dollars does not mean there is no merit in such initiatives by Republicans. Adoption of any of these strikes me as far more sensible than cutting hundreds of billions of dollars in Medicare funding and sharply raising taxes during a recession. Maybe we have a piece of cake and save the rest for later instead of demanding every whim and fantasy be sated. Our country works better when everyone brings something to the feast and progress is usually made in small steps.

    “Honesty. Honesty”. At least let's be honest.

  58. Well, I apologize for saying the Republican proposal only had four points. It has ten points. One of the points — allowing young people to stay on their parents' health plans (those parents who have health plans) until age 25 — might actually help someone.

  59. Thanks, Damav. Great rebut.

  60. It's too bad the discussion keeps getting sidetracked because I'd like to hear from the couple of people here who still support the Senate bill (or at least what little we know about it's current form) a response to our question- what is it that you still feel is worth supporting here?

  61. Sooooo….how 'bout them climate change meetings?

  62. what is it that you still feel is worth supporting here?

    I thought Atul Gawande, in one of his reliably lucid New Yorker articles, presented a good case for it.

    He identifies runaway costs as the fundamental problem and likens it to the runaway food costs we were facing at the turn of the 20th century. Then, as now, we had many theories about how to improve efficiency, but no one knew which to trust or how to re-engineer a whole culture around it.

    We ultimately solved the food crisis, more dramatically than anyone might have dreamed at the time. Mr. Gawande credits the USDA for turning the problem around by sponsoring experimentation in great variety and at large scale. He's bullish on the Senate bill precisely because it's a big hodge-podge of government-sponsored experiments.

  63. Actually, Bush's tax cuts (which is what I assume you mean by “Tax Relief”) were passed using reconciliation.

  64. Once this amount of money is committed to 'reform', if real reform isn't accomplished then I doubt the public is going to support more and more spending in the hopes that they eventually get it right.

    I agree that's a danger, but then you have to recognize that much if not most of what was most strong and “reforming” if you will, about this legislation, was stripped out of it to please the “centrists.” The public option, obviously, which has enormous support. And also the Medicare buy-in, which actually was one part of the bill that would have phased in almost immediately — I think I heard by June 2010 if the bill were passed now. That would have greatly helped the bill's popularity, don't you think?

  65. Mary Landrieu, who voted for the measure getting 300,000,000 in taxpayer dollars and bragging about it, now that's “good faith” negotiating right?

    Um, yeah. It is. You know why? Because after Reid promised her that money in exchange for her vote to release the bill, SHE VOTED TO RELEASE IT. She didn't up the ante by finding something else she needed in exchange for her vote.

    That's what “good faith” means, DaMav.

  66. Christine, for me it's the thirty million people who would be insured, and the reforms (limited though they may be) to stop insurance industry abuses. And the expansion of Medicaid coverage.

    And beyond those specific things, it's also the general idea of the “foot in the door.” The legislation can be improved over time, but not if there is no legislation.

  67. And also the Medicare buy-in, which actually was one part of the bill that would have phased in almost immediately — I think I heard by June 2010 if the bill were passed now. That would have greatly helped the bill's popularity, don't you think?

    Possibly, but popularity doesn't necessarily mean good policy. Giving things to people which they want or perceive that they need is a pretty easy way to buy support (and future votes for incumbents) but it isn't a great way to govern. And when the policy ends up having unintended negative consequences, it does often backfire so as not to even have the expected political benefit for the party which pushed for it.

    And there are all kinds of potential (even likely, I'd say) unintended consequences associated with early buy in for Medicare. Basically either people have to buy in by paying full premiums (which doesn't help people who are in that age bracket and can't afford this) or the govt subsidizes the premiums (which adds to the already unsustainable entitlement obligations relating to this program.) It's anyone's guess as to what segment of the 55-64 population would choose this option- it might encourage more people in that age bracket who have health problems to enroll as opposed to getting a bigger pool of healthier people into the Medicare system.

    And even if the goal of expanding the pool of healthy people in Medicare is acheived, there's still the problem of price fixing which means more providers shifting costs to privately insured patients, more providers cutting back on the number of Medicare patients they will see (which is already a problem in some locations), and just the general problems of costs going up when you increase demand for a service without increasing the supply. That's the general problem of ALL of the arguments about universal coverage supposedly helping costs- because the resources don't increase to meet the increased demand, you drive prices up instead of down for the services themselves. You can't look at insurance coverage costs without looking at what happens to the costs of the healthcare services themselves when you change the dynamics of who is 'in the system'. In fact Dave Schuler at The Glittering Eye has shown some convincing evidence that much of the inflation in healthcare costs corresponds to the Medicare program itself, because the population getting healthcare services increased so dramatically in the 60s with the implementation of the program.

    Anyway, the basic point is that you can look at the policy in a political sense of whether or not people will 'like it' or you can think more carefully about whether or not what people might like is actually good for them, and/or good for the population as a whole. Social welfare programs often meet the first hurdle but fail the second, particularly in the longer term as the unintended consequences kick in and costs escalate beyond what was originally projected and beyond what is sustainable.

  68. Christine, for me it's the thirty million people who would be insured, and the reforms (limited though they may be) to stop insurance industry abuses. And the expansion of Medicaid coverage.

    And beyond those specific things, it's also the general idea of the “foot in the door.” The legislation can be improved over time, but not if there is no legislation

    Thanks for the response. That's pretty much what I assumed you would say. As I already mentioned though, the costs associated with getting that limited amount of 'reform' (things that could be acheived other ways for far less money) make it a nonstarter, and a bill which moves things in the wrong direction, as far as I'm concerned (and I believe most voters see it that way too.)

    So, the foot in the door is unlikely to give the Democratic party any vote of confidence to continue then with further 'reform.' If I were looking at it from partisan interests, as a Republican, I'd say go for it Dems and then damn the consequences. But I'd prefer that we not pass bad legislation, no matter who benefits politically.

  69. We ultimately solved the food crisis, more dramatically than anyone might have dreamed at the time. Mr. Gawande credits the USDA for turning the problem around by sponsoring experimentation in great variety and at large scale. He's bullish on the Senate bill precisely because it's a big hodge-podge of government-sponsored experiments.

    Yeah, I saw that article and some blog discussion about it. I found in unconvincing, mainly because the two things (agriculture and medicine) are too dissimilar. I don't think there are the same kinds of efficiencies to be found in the practice of medicine that existed in farming. To the extent that some efficiencies can be found, or incentives realigned to reduce costs, I'm all for it of course (and I have to say, it's a shame that we haven't heard more about all of these supposed pilot programs that this author describes in the current bills, and I can only take his word on it that they're there at all because the proponents of the bills attempt to sell them without describing any of the ways that the bills might attempt to actually reign in costs of the medical care itself- instead it's all about cutting insurance costs by setting mandates.)

  70. I'd wager there are similar factor-of-ten kinds of efficiency improvements to be had in medicine that we saw in agriculture. And some similar challenges achieving them. Medicine, like farming, often comes down to how individual practitioners do their jobs, and they do it the way they've been doing it for 30 years. You can't get a whole culture to change by fiat.

  71. I doubt it. I agree there's a lot of room for improvement in medicine, but not in similar ways to agriculture. And that's a function of what we expect from medical care- it has to be provided locally, so you can't have economies of scale like we now have in farming. It has to be duplicated in every single community, with all kinds of specialists (this would be analogous to having ALL varieties of crops grown locally, everywhere). We expect the quality to continue improving, and we want everyone to have access to the highest quality regardless of their ability to pay (the equivalent would be organic arugala and free range, high quality meats for all at the price of iceberg lettuce and cheap hamburger.)

    Even some of the experiments that the author described which do make sense (looking at models like Mayo, for instance) are fraught with potential reasons that they may not work on a larger scale. Mayo is unique because it attracts the highest quality doctors, who in part are attracted by the prestige and the opportunity to work in such an environment. By definition, you can't duplicate the top end of the bell curve across the board. Also, Mayo hospitals exist in large population centers so that they can have their own economy of scale to support a full variety of specialists who can work together symbiotically- but that too can't be duplicated in rural areas.

  72. Those are interesting assumptions to poke at, CS. How much care really does have to be provided locally? Sure, the dude with the tongue depressor needs to be local, but specialists can and sometimes do render opinions from far away. What is a specialist, anyway, but someone with a wealth of knowledge about one subject? The notion that knowledge must be local looks rather quaint in the information age. Hospitals certainly need not be local for many treatments; once you're talking about a $10K hospital bill, a $500 plane ticket looks pretty cheap.

    Your assumptions about the highest quality doctors remind me of another new yorker article on the rise of caesarian sections, which ultimately raised the question about whether medicine is an industry or a craft. To a large extent it is still a craft today, just like farming was a century ago–it's practiced by individuals, locally, at their own discretion, based on their own experience, and outcomes hinge tremendously on doctors' personal skills. Best practices are so non-standardized that it's meaningful to talk about the “highest quality doctors” the way we talk about basketball stars. That all sounds overdue for a change.

  73. I recently went to a conference of research physicians and one presentation literally said that the craft of being a doctor hadn't changed at all since the bloodlettings days. They strongly believed that all advances were primarily by either accident or a few individuals clearly showing that the best practice was completely wrong.

    That turning out to be a widely held belief amongst research physicians and say that the current culture has nearly no tolerance for systemic approaches.

  74. I think there's plenty of room for improvement and systemic changes, and I agree with Mikkel that there's resistance to that- but I also don't think it's quite as bad as the two of you are alleging. In specialty practice there are meaningful 'best practices' which become standard and disseminated through conferences, peer reviewed journals, and associations of specialists…and practitioners do abide by them. The problem as I see it is that such best practices are developed in an environment that's highly influenced by pharmaceutical companies and others with financial interests, without pushback from any group that would be on the cost efficient side. Add to that the tort situation, so that a nonconventional approach becomes risky and so the recommendations of the AHA or other such groups becomes sacrosanct.

    A good example is coronary artery disease, where the current standards are to implant drug eluting stents in most cases. This has come about after initially the standard was balloon angioplasty to expand blocked arteries, and then bypass where arterial grafts were used, and then metal stents, and then when those were becoming reblocked (because the metal scaffolding stimulates fibrous tissue to implant and form a new blockage), the next evolutionary step was to drug eluting stents which help prevent reblockage.

    All of this is considered as standard practice to 'prevent' heart attacks, but obviously involves very expensive surgical procedures and prosthetic devices. Meanwhile, some cardiologists noted that the standard approach and focus on screening for blockages (sometimes called the 'plumbing approach') was missing a fair number of people who would then have heart attacks. That's because many times an artery goes from zero blockage to 100% occlusion very suddenly when plaque and clots break free. A much better approach then, which would likely be a cheaper prevention mode and would prevent more heart attacks, is to treat CAD as an inflammatory disease instead of a plumbing disease- which means prevention through much more aggressive use of statins and dietary therapy, and screening for overall levels of plaque via specialized CT scans. There are a small number of preventative cardiologists who take this approach, but they're few and far between and fighting an uphill battle against the powers that be in the AHA. I imagine this sort of thing is duplicated in most specialties, too (particularly when it comes to potential preventative or treatment options based on nutrition or nutraceuticals, or lifestyle improvements, because there's not enough financial interest in researching or pushing for those types of interventions.)

  75. The vast majority of “best practices” have never actually been shown to be more effective on the population level. The researchers at this conference hammered over and over again that most quantitative assessment is through randomized blind trials that have very specific population groups and that there is no methodology in place to figure out population efficacy except through anecdote. Their issue isn't that the practitioners don't abide by the standard practices, but that they don't critically assess the pluses and minuses of a particular approach, and so it's difficult to figure out what's going on.

    I wish I could get some of the graphs they showed. It demonstrated that mortality rates and cost for several conditions varied by 6-7x (and there was nearly no correlation between expenditure and outcome). But they really have no idea why there is that discrepancy.

    There was widespread agreement that trying to do comparative effectiveness research was so hard because there are so many proponents that want to push more intervention and the newest stuff…even though most of the time there is little evidence in many cases.

    Many people complained about the resistance from most doctors to a methodical approach, even going so far as to say they were “ostracized” for suggesting it. One physician was a former engineer and said that he changed how his unit was setup and saw a 30% decrease in deaths, but eventually left that hospital because there was such resistance to adopting it.

  76. I also agree that legal issues are a problem. They were talking about this one procedure that had been standard for a long time and seen as immoral not to do, but eventually someone was convinced to let it go through a study and the study concluded that it actually was harmful to the patients…a finding that was supported through larger adoption.

    Obviously the administrators that let them do that were really really sticking their necks out since if it hadn't worked out they could have been in serious trouble.

  77. I don't think what we're each saying is very far off from one another. You may be more correct having talked to insiders who are observing the phenomena, while I'm looking at it as an outsider and doing some comparison between how I see the human medical field operating as compared to my own field. In vet medicine, there's far more of the art of the individual practitioner making individual decisions (which seemed to be what Dr. J sees in human medicine and I don't think there's all that much of that.) There's also far less concern about litigation, which accounts for a lot of the freewheeling. And while that's not always great for best outcomes (it puts so much of the outcome resting on the abilities and judgment of the practitioner), there's also a big difference in our field economically because we do bear the market forces of cost to the consumer. So, in terms of cost effectiveness our model 'works' better even though it's highly individualized instead of based on widely held best practices based on empirical evidence.

  78. I just want to point out again that although I am critiquing the article based on my own opinions of how much efficiency we really might be able to squeeze out in medical practice, I really don't object at all to his basic thesis that these kinds of experiments are positive (even if I were to be proven right that some of that wouldn't work.)

    Again, my main objection to his article is that he overlooks the elephant in the room. No matter how many 'pages' of the bills are devoted to these kinds of cost reduction seeking measures, the huge expenditures in the bills come from the attempts at insurance reform, not healthcare delivery reform- and that itself is a reason to oppose the bills. Strip out everything EXCEPT the policy experiments he's talking about and then the analogy to the ag policy experiments will be more apt and I'd be more agreeable.

  79. The doctors envision “best practices” as being highly individualized. They want to start collecting massive amounts of data to figure out what why some treatments work on some people and not on others and then characterize their own patients accordingly. They say that people need to start looking at individuals as their own “ecosystem” where the interventions that are made are dependent on what the healthy state looks like.

    So while they are very much for largescale mining and empirical evidence and want that mindset to become standard, they also want to start pushing the message that there is really no such thing as the “average” patient.

  80. Well, that makes sense if you basically conceptualize a three tier hierarchy or evolutionary scale.

    Lowest order is almost completely intuitive, based on the art of medicine, with certain individual practitioners having ability to 'guess' at the best approach for each patient. Dr. J's comment seemed to suggest that modern medicine still pretty much operates that way, which I don't believe is accurate.

    Second order is where I believe we are now- 'best practices' have been developed and disseminated, but these are at best based on statistical averages and sometimes don't even have that level of evidentiary support (largely because of research promoted by those with a financial interest, which distorts the level of certainty to imply that a therapy is 'best' even though that's far from proven by the amount of research that's been done.) This removes a lot of the physicians' individual judgment, which perhaps raises the quality of care for those patients being treated at the lower end of the bell curve but reduces the quality for those whose doctors might be able to provide even better individualized care if they were free to think outside the box.

    What I think you are saying these doctors want is to raise the level of evidence so that the rising tide will lift all boats- allowing practitioners who may not be as skilled or intuitive to have a basis for finding the best possible care for each patient, instead of relying on generic recommendations that might (again, at best) be good on a population level but not an individual one.

  81. CStanley and mikkel, my head is hurting from your discussion–in a good way. Rather than dispute the salient points you have both made, may I just suggest that the problem that I see, on the ground level, is that *people don't care how much health care costs* because they aren't paying the bills!

    Bascially, people are greedy. There, I have said it. They want what they want, and they want someone else to pay for it. And far too often, the doctors have an incentive to give them that unnecessary test, that fantastically expensive life prolonging drug (even if it only prolongs life for a few days), that questionable procedure, all at enormous cost to you and me, the taxpayers.

    The behavior and attitudes of the American people must change, to truly contain health care costs! How do we accomplish *this*?

  82. Totally agree, Vera. That's exactly why I don't agree with the liberal approaches to reform, because I feel they do nothing to even attempt to realign the incentives or put market pressure where it needs to be.

    Unfortunately I have to run now- because I anticipate you might ask how a conservative approach might do what I'm suggesting. At some point I'll either have to rewrite bullet points I've listed in previous comments here, or search the archives and copy and paste them. Other conservative commenters like Dr. J, DaGoat, and Casualobserver have discussed some of the ideas as well.

  83. the costs associated with getting that limited amount of 'reform' (things that could be acheived other ways for far less money) make it a nonstarter, and a bill which moves things in the wrong direction, as far as I'm concerned (and I believe most voters see it that way too.)

    The public option lowers costs, Christine. So does expanding Medicare coverage. None of the Republican “ideas” I've seen mentioned would do a thing either to lower costs or to insure more Americans. This is the essential contradiction in the GOP position. They say they want cost containment, but they oppose most vigorously the parts of health care reform that would contain costs the most.

    As for your statement of belief that most voters see it your way, too, I mentioned in my other comment that both the public option and Medicare expansion are wildly popular. And besides, you told me in your reply to that other comment that “Giving things to people which they want or perceive that they need is a pretty easy way to buy support (and future votes for incumbents) but it isn't a great way to govern.” so I assume you feel that way regardless of whether you personally support the policy or not.

    If I were looking at it from partisan interests, as a Republican, I'd say go for it Dems and then damn the consequences.

    Except that that is NOT what the Republican partisan interests in the Senate want. They want the Democrats to listen to Dean and kill the bill, precisely because they know passing it would be a huge political win for the Democrats. It happens to be good legislation, at least relative to the status quo, but Republicans in Congress are not looking at good or bad from the viewpoint of public policy. They want to defeat Democrats in the midterms, and then in 2012, and that's much less likely to happen if Democrats pass this legislation.

  84. 'best practices' have been developed and disseminated

    I think you're using a narrow definition of “best practices” that looks only at treatment choices. These are important, but they're just one aspect of the choices practitioners make.

    The New Yorker article gave a great example of another choice: the $1000 worth of sterile supplies the surgical team opened and didn't use. I'm going to venture to guess that's not a “best” practice at all. But august specialists will not be discussing it at conferences because it's blindingly obvious to anyone who's paying any attention to what things are costing. And they're not.

  85. On one hand, I want reform. People should not be forced into bankruptcy due to medical bills. Everyone deserves basic care.

    But what everyone does not deserve is a banquet of health care options that they can endlessly gorge themselves upon, at others expense.

    How can we reconcile these two positions?

  86. My quick and dirty response to that is to establish what we'd consider 'the basics' and use social welfare programs to make sure that everyone has access to that level- and then as much as possible, make people more directly responsible for costs for those higher levels of service. That's the concept that the GOP was starting to move toward with establishment of HSAs and catastrophic health insurance, and subsidization of the same for people who couldn't fund such things on their own.

  87. The public option lowers costs, Christine. So does expanding Medicare coverage. None of the Republican “ideas” I've seen mentioned would do a thing either to lower costs or to insure more Americans. This is the essential contradiction in the GOP position. They say they want cost containment, but they oppose most vigorously the parts of health care reform that would contain costs the most.

    The exact opposite is true according to nonpartisan analysis like the CBO.

    And besides, you told me in your reply to that other comment that “Giving things to people which they want or perceive that they need is a pretty easy way to buy support (and future votes for incumbents) but it isn't a great way to govern.” so I assume you feel that way regardless of whether you personally support the policy or not.
    First, the public option is certainly not 'wildly popular' anymore, if it ever was (it only polled well when people didn't know any of the specifics. But yes, I do stand by my statement that popularity shouldn't be the main selling point- take Medicare for example- popular among recipients, but the problem is we can't afford to keep providing the same level of service that the past and current users enjoy (let alone expanding the liabilities.)

  88. I think you're using a narrow definition of “best practices” that looks only at treatment choices.

    Yes, because that's the way it's defined currently by the industry. Medical journals and professional associations publish 'best practices' which are all about treatment protocols, and nothing to do with cost efficiency.

  89. 'best practices' which are all about treatment protocols, and nothing to do with cost efficiency.

    Yep. Hence my bold predictions that there are factors of 10 in efficiency waiting to be had.

  90. Anyway, the basic point is that you can look at the policy in a political sense of whether or not people will 'like it' or you can think more carefully about whether or not what people might like is actually good for them, and/or good for the population as a whole.

    Actually, the basic point, here and anywhere else, is that good public policy is defined by how effectively it does address what the population as a whole needs and wants. Americans are dissatisfied with the health care status quo because it doesn't work for the people who need it the most, and the consequences of the people who need it the most not getting it, adversely affects all the rest of the population. Obviously, “you can't please everyone” is a caveat that applies to everything in life, but making health care public policy that serves the interests of private insurers and their lobbyists rather than the public that government officials are bound to serve does not help anything, either.

    Social welfare programs often meet the first hurdle but fail the second, particularly in the longer term as the unintended consequences kick in and costs escalate beyond what was originally projected and beyond what is sustainable.

    This is a danger that has been clear and present in other areas of national affairs for many years. Two examples that come to mind are tax cuts and defense spending. Both wildly popular among certain segments of the American public — especially those that will most benefit from them. Tax cuts are routinely used by presidents and other government officials as popularity boosters. Yet their efficacy as public policy is very much open to debate. Same with defense spending. Defense spending and tax cuts are often very popular — in the former instance, especially when administrations can gin up the levels of chauvinistic nationalism to fever-pitch proportions by inventing or exaggerating an external threat (always more sexy than internal threats like poverty and illness) — but they all too often have unintended consequences (such as a dearth of emergency personnel and equipment in the event of natural or man-made disaster) and lead to escalation of costs beyond what is sustainable.

    This doesn't mean that defense spending is bad policy, or that tax cuts are never good public policy. And in fact, very few people would argue the reverse. People just don't tend to think we should throw the baby out with the bathwater when it comes to defense spending and tax cuts, but somehow when it comes to public policy to address social and human problems at home, the problem becomes the concept of “social welfare programs” in and of itself, rather than an issue of which expenses are most necessary and effective at achieving the goals we've defined.

    The above is my “political policy” argument. This next one is more experiential. And this is the part where my temperature starts to rise, and I have to be careful to remain civil and respectful. (I say that out loud because it's my way of helping me do that, like announcing to the dinner party guests that this helping will be your last helping).

    When you say that “social welfare programs often meet the first hurdle (of popularity) but fail the second (of whether what people like is actually good for them, and good for the population as a whole), I suppose you could argue that, as one member of the “population as a whole,” you are in a position to opine about that, although I would disagree with your conclusion. However, unless you have actually had occasion to need and use social welfare programs, you are not in a position to say whether such programs are good for the people who use them and want to see them remain and get stronger.

    Needless to say (because I've said it — oh, how many times before? Maybe dozens?) I have, and I am. Here are some of the social programs I have used:

    Unemployment Insurance (which I had until it ran out and I did not qualify for an extension. And yes, I looked for work, found a job, and was laid off in three months because they had no work. Yes, I know, I don't know why they hired me in the first place, either.)

    General Assistance (“welfare”– specifically, the welfare program for adults without dependent children).

    Food Stamps.

    Temporary Rental Assistance

    Home Energy Assistance Program (State of New Jersey, Department of Community Affairs).

    Social Security Disability

    Mountainside Hospital Charity Care Program (I'm not certain about the funding sources for this one, but the hospital does get funding from the state, so it's possible some public money may go to this — something I should find out about; I'd really like to know).

    Of these programs, I no longer need (and am no longer enrolled in) General Welfare and Temporary Rental Assistance. But when I did need them, and was in those programs, they were very good for me. I promise you that. The General Welfare was only $140 a month (that's the maximum), but added to other, irregular and not guaranteed sources of help (my brother, my synagogue, etc.), and believe it or not, it made a difference. Before this period in my life, when I supported social programs but hadn't actually used them, I would have said that $140 a month, even for a single person with no dependents, was nothing. Well, it IS ridiculously low, but now I know it actually can make a substantive difference when you have absolutely nothing. It can. And it does. And I'm grateful it was there when I needed it.

    Temporary Rental Assistance paid my entire rent ($950/month) for six months. I was only able to get it because I was going to be evicted — but not just in danger of being evicted; I had to show the TRA people documented proof that I had been notified I would be evicted. I actually had a court date and managed to negotiate a 10-day grace period from my landlady's attorney (during which he agreed not to actually file the eviction papers he was going to file) because I was still waiting to hear if my TRA application would be approved, and it was.

    During that same period, I was also waiting to find out whether my application for SSD would be approved. The TRA was my means of survival (not being evicted) while I waited to find out if I would get SSD. I applied for that in Dec. 2008, I got the TRA in March 2009, and my SSD application was approved in July 2009.

    I am still dazed and disbelieving at my salvation. For 10 years I struggled with financial doom, and tried everything I knew to save myself — selling my house, looking for work, training for work, finding work and getting laid off, working with a jobs counselor (oh! that was a social program too! I forgot about that one: The job counseling was a program within the state Division of Vocational Services), and a lot more.

    If it had not been for these social programs — most notably the Temporary Rental Assistance and then the SSD, which I was very, very lucky to have approved initially and not have to appeal — I would have become homeless and had to live on the street or in a shelter.

    Now, as I said, I no longer have (or need) the welfare check. I no longer have (or need) the TRA. I still qualify for food stamps, but only $69 a month — when I had no income I was getting the maximum, which was $160 until Obama raised it to $200 a month. But that's fine; I don't need $200 a month anymore.

    I still don't have health insurance (under SSD, I will be enrolled automatically in Medicare two years after the date I was approved for SSD), so I must continue to rely on Charity Care for now. And in fact, I am currently in the process of trying to get it renewed (it must be reapproved yearly). As of the moment, I actually don't have Charity Care or any other form of health insurance.

    Some (many?) may be taken aback at how openly I reveal all these personal details. Believe it or not, I don't do it easily. I never know what reaction I'm going to get, and the cruel remarks I sometimes have gotten in the past do hurt and anger me — I'm not totally evolved yet. However, I do it, because if the absolute, indescribable, hell of fear, suffering, loneliness, and despair that I've gone through for a decade is good for anything, maybe it can serve a larger purpose if it makes others feel less alone and more hopeful, and even more important if it helps others — like you, maybe, Christine — understand just a little better that what might seem “not actually good for people” to you may actually be not just good but life-saving for people living in circumstances that I pray you will never experience. And I do pray that, Christine. No one should have to go through that kind of s**t just for the purpose of understanding better. You get to gain the understanding the easy way — look at it that way!

  91. Kathy, it's really hard for me to respond to the personal anecdotes that you shared. I gave it some thought and mainly feel that anything I could say would be too easily misinterpreted in an impersonal kind of forum like this, and I wouldn't want that to happen so I won't directly address it. I do wish to ask you though, not to make assumptions about my own life and the relative 'easiness' of it. I'm sure you are aware that financial difficulties aren't the only kinds of hardships (not to mention the fact that I grew up in a household that would at times have fallen below today's poverty threshhold, and I saw my parents' heroic struggle through raising four kids and supporting my grandmother, somehow, through all of that.)

    I do mostly agree with your comments about public policy- as I read this, what you're basically saying is that the use of emotional appeals in attracting political support is a dangerous thing because it ends up bypassing more rational thought about the policy decisions. We apparently agree on the general concept, but we'd probably have to agree to disagree on where the lines should be drawn. In other words, I don't disagree at all that there should be 'social welfare programs' as safety nets- but that doesn't mean that I approve of all of the programs that are in place, or how much public money is expended in this way (including how much is wasted), nor do I agree with many of the calls to further expand their reach. I think when society expands these things too far, there's a crowding out of resources that could be better used to provide real economic opportunity to those who are able to work as well as crowding out of private sources of help for individuals.

  92. Ha…OK, touche. I'll readily concede that physicians generally don't think about cost when planning treatment protocols- but I still doubt the 'factor of 10' as well as the ability of those experiments that were proposed to get to much more efficiency (because I think the core issue is mainly the separation of the two people on each end of the transaction from the monetary considerations, and I don't see that most of the suggested reforms would change that dynamic.)

  93. Kathy, it's really hard for me to respond to the personal anecdotes that you shared.

    I respect that. And it's actually one of the reasons I don't take such self-revelation lightly. It didn't occur to me to say that yesterday, but just as I'm opening myself up to hurtful remarks by doing so, I'm also potentially putting others in an awkward position and running the risk of being seen as being manipulative. And that's not my intention at all. For me, it's a way of answering that age-old question, “Why is this happening to ME?” It's a way of giving it meaning so it doesn't feel so… well, meaningless. :-)

    I'm sure you are aware that financial difficulties aren't the only kinds of hardships…

    Indeed. I am very much aware of that, as well as the truth that most human experiences are interconnected, so that struggles that are not themselves financial can affect finances. Also, although I certainly don't presume to know all the possible specifics of your reference, I do have a partial sense of what you might be talking about, from things you've mentioned here in the past.

    I do mostly agree with your comments about public policy- as I read this, what you're basically saying is that the use of emotional appeals in attracting political support is a dangerous thing because it ends up bypassing more rational thought about the policy decisions.

    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.”

    Did you intend a meaning I'm not getting, or did you write the sentence unintentionally wrong? I just need clarification on that.

    In other words, I don't disagree at all that there should be 'social welfare programs' as safety nets- but that doesn't mean that I approve of all of the programs that are in place, or how much public money is expended in this way (including how much is wasted), nor do I agree with many of the calls to further expand their reach.

    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.”

    Also, in specific regard to this:

    I think when society expands these things too far, there's a crowding out of resources that could be better used to provide real economic opportunity to those who are able to work as well as crowding out of private sources of help for individuals.

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

  94. Kathy, I'm going to wade in too, with a bit of trepidation. I agree with Christine, it feels very awkward trying to reply to your personal story, and I'm struggling to articulate why.

    Mostly it has to do with the difficulty of setting your story in context. Anecdotes are always problematic in a public policy discussion, because for every one you hear there are a million you don't. But your personal situation came about in a rich context as well, which you're an expert on, and I know virtually nothing about. I can't google it, so the temptation is to speculate, probe, and second-guess, which would feel inappropriate to me and probably hurtful to you.

    Your personal context matters. You've described some serious problems in your life, and the gist of your message is that I (and many others) should be responsible for solving your problems–at least to the extent we as taxpayers can. I may be willing to take that responsibility, but I'd feel much better about it if I knew you were taking at least as much. That leads to a bunch of questions about how much responsibility you had in creating your problems to begin with, and how much you're taking to solve them going forward–none of which I'm in a position to know and don't feel it's my place to inquire.

    The conservative's answer to helping people in need is community-based charity. It's a great answer in a pre-industrial society that revolves around well-defined communities, because people know you. 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.

    So unfortunately the conservative's answer is less useful in an industrial, largely urban society, where communities aren't as strong or as long lived, and many people are simply without one. I don't know what the right solution is. I don't support just letting needy people rot, but I also don't support requiring taxpayers to take responsibility for everyone who's gotten in trouble. I appreciate the problem, and I wish I saw a tidy solution.

  95. You've described some serious problems in your life, and the gist of your message is that I (and many others) should be responsible for solving your problems–at least to the extent we as taxpayers can.

    Dr J, despite our disagreements on issues, you have never come across to me as an unkind or narrow-minded person, and I absolutely believe you are nothing but well-meaning and sincere in your comments. That's why I want to answer as thoughtfully as I can.

    This snip from your comment (the bolded part) is not what this is about at all. This is the heart of how conservatives view this issue, and it's not what this is about at all. It's SO frustrating. If I could get understanding on just this one point, I would feel like I had accomplished so much.

    Do you really think I wrote all that stuff because I believe everyone else should be responsible for solving my problems? That is NOT what it's about. Do you think I'm the only one who has or has had such problems? The entire thrust behind what I wrote — the entire understanding that I'm trying to get across — is that the kind of social programs we've been discussing *don't* waste money and *are* not just helpful but essential, to millions of people. I am the only story I can tell you about. I don't know anyone else's story well enough to tell you about. My whole point is that this subject is not about one person, or some specific number of persons, who “made bad choices” and now want everyone else to pay for them. My point is that this is ALL of us. ALL of us are at risk for the kind of troubles I went through. It can happen to *anyone.* There but for fortune go YOU, if you've been lucky enough to not have the entire roof of your world collapse and fall on you and feel like it's never going to end no matter how hard you try.

    My personal belief system tells me that human lives and fortunes are all connected, and that what happens to one, or 10, or 500, or 10,000, can happen to all. And even more than that, that the private misfortunes of large numbers of people absolutely affect the lives of everyone else in all kinds of ways, both large and small. It's to everyone's benefit to ensure that if people fall down, there are societal mechanisms to help them get up again. To you, you translate that to mean a handout for life, but that's NOT what it means. It means ensuring that appropriate resources exist in people's lives and communities so that people can do what they have to do to help *themselves* — to *save* themselves.

    I may be willing to take that responsibility, but I'd feel much better about it if I knew you were taking at least as much.

    Well, I am, and I have been for all these years, but that's really not the point — the point is that you can't be sure of that. But there's a larger point, and I'm not even sure how to label it, but it's something to do with our basic assumptions about the nature of life and human beings. There's a difference between your thinking and mine that's hard to get past, because it doesn't even occur to me to ask if people (in general, in a general sense) are really trying, or if they're slackers. You say you can't be sure people are not slackers unless you know them personally. I see it the opposite way. I never assume that any given person, or that people in general, having hard times ARE slackers unless I know from personal knowledge of them that they are.

    Maybe it's because of my own experiences — I really don't know for sure — but I *never* have the thought in my head that when I hear about people's hard times and struggles, I don't know if those people “deserve” my help — or deserve help in general — or if they made their own bed and got what they deserve. I just don't think that way. It wouldn't make sense to me to think that way, because I know what life is, I know the essential nature of human existence. Life is HARD. Life is damn hard. It doesn't seem like any kind of a stretch at all, to me, to assume that most people are doing the very best that they can — even when and if it might look to an outsider as though they could be doing more. You just don't know what people have gone through, or what their best looks like. Maybe it's not the best you could do. It's still the best they could do. People — not just me, everyone — have limitations in their lives of all kinds; no one knows what they are except for those people and those who know them best.

    I think you also vastly underestimate how difficult it is to do what many people — you, for example — would probably consider “making efforts to help yourself” AND simultaneously do what is necessary to survive in the moment. For me, I did look for work, as much as I could, but I was struggling against very serious clinical depression (that's my disabillity) that literally can make every waking moment feel like you are trying to move through an atmosphere made out of semi-hardened cement. The depression affected my self-confidence and my energy level. So at the same time that I was supposed to be sending out hundreds and hundreds of resumes and going on interviews several times a week (if I were to meet the definition of “helping myself”), I was also trying to find a way to pay for therapy and for anti-depressant medication. I was trying to manage creditors, car trouble, being hungry because I didn't have the money to buy an adequate supply of food, trying to find a way to pay the rent, calling people and trying to find *help* to pay the rent, going through incredible indescribable amounts of bureaucracy, trying to work on my job-hunting skills (which also involved qualifying for the program that would pay for that), trying to help my daughter manage her painful feelings about her parents divorcing, as well as trying to be a good mother in general, and I can't even begin to dredge up all the things I was doing simultaneously. They say that when you're looking for work, the search for work is your full-time job, but I didn't have that luxury. It's not easy to look for work when you also have to feed yourself and keep from getting evicted at the same time that you're doing the invisible emotional work with professionals to silence the voice inside your head that keeps telling you that you're incompetent, not good at anything that anyone would want to pay for, and just a total hopeless case. And yet I actually did look for work and went through several professional training programs to that end.

    I also, to repeat what I told Christine, relied on charitable and community services as well as friends, relatives (well, one relative, the only one I have), and religious leaders, but as much as it helped it was not enough. We are *not* living in a sparsely populated pre-industrial 18th century society anymore. We're just not.

    So this is all even more personal stuff, but if you can tell me another way, that doesn't involve all this self-revelation, to try and help people like you understand what people like me (and there are millions of people like me) go through, and why we're not slackers, and why it's in your self-interest to support avenues of help, both as a taxpayer and as a human being who might someday (God forbid) have problems that are so overwhelming they are difficult to manage, I am all ears.

  96. Kathy, I appreciate the reply, and I agree with much of what you're saying. We are interconnected, and all of us are at risk for falling on hard times. That's one of the reasons I support some manner of safety net.

    But how much safety net is the tricky question, and where I disagree with you is over your “we're not slackers” claim. You're not in a position to judge whether the millions of people you're advocating for are slackers or not, any more than I'm in a position to judge you.

    What seems to me indisputable fact is that there are slackers. San Francisco is several years into a homeless outreach program, which has succeeded in getting many people into help programs and off the streets, with luck for good. But it is facing diminishing returns from its efforts. Despite the availability of help and the increasingly aggressive entreaties of social workers, there are a bunch of people who would rather camp out in Golden Gate Park and live off what they can get in handouts and government assistance.

    They're a minority of course, and I wouldn't advocate ending the programs that benefit everyone else just to spite them. But it seems to me inevitable that the more we pay people who camp out in Golden Gate Park, the more will sign up for the job. AdelinesDad posted a link a month ago showing people trying to climb from $20,000 to $50,000 a year face an implicit marginal tax rate of 100%–that is, we're give them so much help at $20,000 that they have little to gain by working harder. I'm willing to pay for safety nets, I'm just not so keen to pay for hammocks.

    This sort of analysis may strike you as cold and lacking faith in the goodness of humanity, but to me it looks like plain facts and economics, the stuff of responsible policy decisions.

  97. You're not in a position to judge whether the millions of people you're advocating for are slackers or not, any more than I'm in a position to judge you.

    Okay, but that wasn't what I was saying. I'm not making a judgment on whether millions of people who need help either are slackers or aren't slackers. I'm saying that I don't assume that they are. Or, put in a slightly different way, I know that the problems I've faced are widespread, and I assume that the vast majority of people who experience such problems are doing the best they can unless I know otherwise. I realize you might reply that you are not assuming people are slackers, just aware that there *are* slackers, but I sense — although I may be wrong — that your uppermost instinct is to want to make sure that they are *not* slackers before helping them. My instinct, by contrast, is to help people whose documented, factual circumstances indicate they need help. If someone is cheating, or not abiding by the conditions for receiving help, then you deal with that. But it seems to me that the problem of the need out there is a bigger problem (I mean “bigger” in its broadest sense — it's a more serious problem, with larger implications) than the problem of someone taking advantage of social programs.

    But it seems to me inevitable that the more we pay people who camp out in Golden Gate Park, the more will sign up for the job.

    I'm not so sure about that. You couldn't pay me *enough* to camp out in any park, anywhere. I don't want to live that way. For whatever reason this minority of homeless people are impervious to offers of help, I think it probably has more to do with something emotional or psychological or personal that is specific to them than with a desire to get paid to live in a park.

    AdelinesDad posted a link a month ago showing people trying to climb from $20,000 to $50,000 a year face an implicit marginal tax rate of 100%–that is, we're give them so much help at $20,000 that they have little to gain by working harder.

    Numbers are My Implacable Enemy, Dr J, so please confirm that I'm understanding this correctly. Does this mean that between $20,000 and $50,000 of income, there is such a big increase in the amount of taxes you pay that it's not worth looking for a job that pays more? (And that's a better way to put it, imo — it's not about working harder.)

    This sort of analysis may strike you as cold and lacking faith in the goodness of humanity, but to me it looks like plain facts and economics, the stuff of responsible policy decisions.

    No, not cold at all, just short-sighted. I assume that most Americans are decent people who don't want other people to suffer — it's just that a lot of people really don't understand you get a much higher return on investment spending the money it would cost to send every 3- and 4-year-old in the United States to preschool than you get spending that same amount of money on purchasing X number of cruise missiles.

  98. I assume that the vast majority of people who experience such problems are doing the best they can unless I know otherwise.

    I assume that too, but policymaking isn't about making calls about individuals, it's about numbers. 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. 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.

    Does this mean that between $20,000 and $50,000 of income, there is such a big increase in the amount of taxes you pay that it's not worth looking for a job that pays more? (And that's a better way to put it, imo — it's not about working harder.)

    Taxes kick in, but more importantly benefits drop out as your earned income rises, so your effective income stays about the same. I found AD's original link. 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.

  99. 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.

  100. 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.

  101. 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?

  102. 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.

  103. 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.

  104. 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.

  105. 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.

  106. 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.

  107. 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.

  108. Yes, I would agree with that.

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