Health Insurance is Not an Ipod

The Wall Street Journal offers this typically inane criticism of the public option:

The 1,500 or so private plans don't produce enough competition? Making it 1,501 will do the trick? But then why stop there? Eating is even more important than health care, so shouldn't we have government-run supermarkets "to keep the private ones honest"? After all, supermarkets clearly put profits ahead of feeding people. And we can't run around naked, so we should have government-run clothing stores to keep the private ones honest. And shelter is just as important, so we should start public housing to keep private builders honest. Oops, we already have that. And that is exactly the point. Think of everything you know about public housing, the image the term conjures up in your mind. If you like public housing you will love public health care.

The are about a million things wrong with this "analysis." For starters, while there are lots of private health plans, most are regionally concentrated and don't compete with one another. In much of the country private plans enjoy near monopoly status. Second, if the difference in quality between a private and public plan is really as stark as the difference between public and private housing, then the private insurers really have nothing to worry about. As with public housing, only those who can't afford the private option will utilize the public one. Third, as Jamison Foser explains (h/t Steve Benen):

Supermarkets make money by selling people food. Clothing stores make money by selling people clothes. If they don't give people food/clothing, they don't get money.

Insurance companies, on the other hand, make money by selling people insurance -- and they make even more money by selling insurance, and then denying claims.

This is an excellent point, of course, but I'd go a step farther. Insurance just isn't like other products. It's not a tangible thing like a pair of jeans or an Ipod. It's not a service like house cleaning or hair styling. An insurance policy is not a product in any traditional sense. It's merely a promise to pay future bills, should they come due. To quote Chris Rock:

They shouldn't even call it insurance. They should just call it ''in case shit.'' I give a company some money in case shit happens.

Put bluntly, there is absolutely no reason to believe the government can't make this particular "product" just as well, if not better, than the private sector. Insurance policies aren't like consumer goods. People don't care who pays the bills as long as they get paid. Money is money. Private insurance isn't going to sound better, taste better, look better, or work better than public insurance. Indeed, as the saying goes, the insurance business is all about trust. What you're buying is a promise. And while the government may not be good at making stuff, it is pretty darn reliable. Bonds always get paid back. Social security checks arrive on time. And, importantly in this context, the government isn't going to drop you or rescind your policy at the time you most need it because you failed to disclose something in your application. This may actually be what scares private insurers the most. They've been hosing people over for so long that they've lost the public's trust. Many people would choose the public option simply because they believe the government will treat them more fairly than a private insurer, that the government will actually come through when needed.  That's exactly the kind of competition the health insurance industry needs.  

What do the world's "laboratories of democracy" tell us about health care?

Republicans, at least rhetorically, claim to value federalism and to believe that the states can function as "laboratories of democracy"-- places where policy experimentation can take place. Through this process, flawed policies are exposed and voted down and newer, better policies are given a chance to prove themselves. Over time, the policies that prove to be the best are adopted by other states.

For some reason, though, the only laboratories of democracy that matter to Republicans are those located within the United States.

This is especially true when it comes to health care. The United States is not the only industrialized democracy in the world. We are, however, the only one that does not guarantee basic health care to all of its citizens. When Democrats propose relatively mild reforms to our current dysfunctional system, such as creating a public insurance option, Republicans flip out and suggest that doing so will result in some sort of socialized health care dystopia.

But we don't need to travel into some hypothetical world to understand what universal health care looks like. There are literally dozens of countries in the real world that have functioning universal health care systems. Indeed, the verdict of the world's laboratories of democracy is pretty clear. Virtually all of them produce better health outcomes at less cost while covering everyone. We're the outliers. We're the laboratory that's stubbornly refusing to acknowledge that its experiment has failed.

To adopt the Republican position on health care requires believing that every other country in the world is wrong, that their policy experts are misguided and their citizens confused. Indeed it requires believing that the American people themselves are wrong, that despite endless opinion polls to the contrary, people in this country really love the system we have.

You would think that, at some point, these lovers of federalism would ask themselves why it is that no country in the world currently has (or has any plans to adopt) the kind of health care system they're clamoring for. After all, if the ideal health care system is one in which the government plays the least active role and lets the free market work its magic, you would think that some country would have already tried that by now. Such a policy is, after all, much easier to execute and to fund. It's infinitely less complex and requires much less government spending, so you would think that at least some group of lawmakers somewhere would have given the "do nothing" approach a shot. And if the results were as great as the Republicans claim, by now most countries would be following such a system.

Of course, the reason no one follows such a system is because it doesn't work. As economists have understood for many decades, markets don't work very well in the area of health care, at least if the goal is producing a world in which most people can afford care. Indeed, the reason we have a patchwork system of health care in this country is precisely because the market doesn't work and the government has been forced to step in and remedy its most glaring failures. Under a free market system, most elderly people are priced out of the market (hence the need for Medicare). Under a free market system, the poor can't afford health care (hence the need for Medicaid). Under a free market system, children of those without insurance have no access to health care (hence the need for S-CHIP). Every health insurance regulation or government program currently on the books was passed in order to address a significant failure of the market.

Other countries have confronted the exact same issues, but instead of trying to solve these problems piecemeal, they have opted for a comprehensive approach. In an effort to discredit the far better approaches taken by other countries, Republicans like to cherry-pick stories of people who were denied treatment or had to wait for treatment under a universal system (while ignoring the very same kinds of stories in our country). But here are some numbers they ignore:

The number of people in other industrialized democracies who go bankrupt as a result of medical bills = 0

The number of people in other industrialized democracies who lack access to routine medical care = 0

The number of people in other industrialized democracies who feel trapped at their jobs for fear of losing their (or their family's) health insurance = 0.

That last number is particularly galling given conservative reverence for entrepreneurism. Though it's difficult to quantify, I would bet that our dysfunctional health care system, more than any other factor, discourages entrepreneurial risk-taking in this country. Which makes all this talk about free markets all the more absurd.

Obama and Indefinite Detention

It's hard to know what to make of this Washington Post article, but it's certainly troubling. If there was anything comforting about Obama's previous--and very concerning--suggestion that some sort of indefinite detention program may be necessary, it was the apparent concession that it could only be done with Congressional approval. The most egregious aspect of the Bush administration's disregard for the rule of law was it's repeated willingness to not only act unilaterally and without Congressional approval, but in many cases to act in direct contravention of existing laws.

If the Washington Post's sources are correct, the Obama administration is now considering implementing an indefinite detention program via executive order, a move that would be troubling for any number of reasons and, as Glenn Greenwald explains, completely contradict Obama's rhetoric and record of statements on this issue.

So what explains this apparent reversal? Has Obama changed his views? Were his views never what we thought they were? Has he compromised his views for political reasons?

While it's never easy to read minds, if I had to guess, I'd guess the latter. I suspect that Obama entered office with the intention of ending the Bush administration's policy of indefinite detention, believing that he could either charge or release everyone currently in custody. And he can. The problem he's discovered is that there are a group of people--certain legacy Bush administration detainees--for whom there is not enough admissible evidence to successfully try but for whom there is enough "evidence" to make a strong public case that the person is dangerous. Having worked as a prosecutor, I can tell you that there is often an enormous gap between what you know and what you can prove in court and an even bigger gap between what you believe and what you can prove in court. And the problem isn't just about statements obtained through coercion (which are inherently unreliable anyway). Key witnesses can become unavailable. Physical evidence can be lost or tainted. Reliable evidence can be excluded because it was the fruit of statements or evidence obtained illegally. Some evidence may be unusable because it would compromise intelligence assets.  And all of these problems are compounded by time and by the manifest incompetence of the Bush administration. In other words, there are likely some detainees whom the administration genuinely believes are dangerous but for whom there is simply not enough admissible evidence to convict of a crime.

The result is a difficult political problem. If these people are released or charges are brought against them and then dismissed by a court, Republicans will pounce, accusing Obama of endangering the American people. All of the "evidence" against these people--most of it inadmissible-- will quickly find its way into the media through Republican leaks. We've already seen how Republicans reacted to the prospect of moving Guantanamo detainees to domestic prisons. Their reaction to this would be ten times as aggressive. And if, God forbid, any of these released detainees was ever involved in a future terrorist attack, the political consequences for Obama would be disastrous.

I guess this is a long way of saying that I think the best explanation for what's going on here is simple political cowardice. I suspect that Obama, if not subject to political pressure, would not be in favor of indefinite detention. But I think he's unwilling (or at least very wary) of giving the Republicans this kind of political fodder to attack him with. That's not a defensible reason for doing the wrong thing, of course, but I suspect that it is the explanation. Doing the right thing in this case would carry significant political risk.

As for the prospect of instituting such a program through executive order, as opposed to legislation, it's a bit of a wash. On the one hand, it would be deeply troubling to see Obama bypass Congress, which is something his predecessor was fond of doing. On the other hand, the courts will be much more likely to strike down unilateral executive action, which could result in some very favorable case law. Part of me suspects that the Obama administration may actually be hoping that the courts weigh in and limit what they're allowed to do. To the extent that happens, it provides them with political cover to do the right thing. Of course, such a strategy can also result in court rulings that uphold unilateral exercises of executive power, which is the worst of both worlds.

Whether or not we sympathize with some of the political difficulties the Obama administration faces, it is incumbent upon those of us who care about civil liberties and the rule of law to apply continuous and aggressive pressure on the Obama administration to do the right thing and to live up to the principles they claim to believe in. If there is no political pressure coming from the left on this issue, then the only pressure the administration will feel is demagoguery coming from the right. As discouraged as I've been by recent moves by the Obama administration, I've been encouraged and heartened by the principled criticism being leveled at the administration by people who undoubtedly voted for Obama. This kind of criticism was virtually unheard of during the first few years of the Bush administration, as Republicans rushed to defend every Bush administration decision and policy, no matter how contrary they were to principles they had previously claimed to cherish. Had there been more principled criticism of the Bush administration from the right, it would have been much harder for them to get away with much of what they did.

Where Did the Emails Come From?

(updated below--mystery apparently solved)

There's a lot of discussion tonight, on cable news and the blogs, about the embarrassing personal emails between Governor Sanford and his mistress. The emails were published by the State newspaper, which has apparently had them in its possession since December. The question I don't see anyone asking, though, is how these emails came to be in the possession of the newspaper. 

To her credit, Rachel Maddow did ask that question tonight, one of the reporters at the paper said that the emails had been provided to the paper by an anonymous tipster, and she implied that they had been provided independently to several different reporters since December. Given the unusually bold criticism of the Governor from many other South Carolina politicians over the last few days, including the Republican Lieutenant Governor, my guess is that the reporters at the State were not the only ones who were sent copies of those emails. Someone was clearly interested in blowing the whistle on Sanford.

But how would someone have obtained these emails? These were highly personal emails between Sanford and his Argentine mistress, neither of whom is likely to have wanted them published. And if it wasn't one of them, that really only leaves two possibilities: unauthorized access or official interception. The latter is obviously the most troubling possibility, and I hope that someone looks in to this further, if for no other reason than to rule that out.

It's not clear from the story whether Sanford was using a personal web-based email account (like gmail or yahoo) or his official state account. If the former, then I suppose just about anyone determined enough could have hacked into his account by guessing his password, the same way someone broke into Sarah Palin's personal email account during last Fall's presidential campaign. If it was a state account, then there probably needs to be an official investigation.

Whatever the case, it's more than a little problematic to have highly embarrassing personal emails of political leaders falling to the hands of random people. Whoever had these emails seems to have been intent on exposing Sanford, but it's easy to imagine people using emails like this to blackmail politicians. That's never a good situation.  

UPDATE: Good to see David Corn is asking the right questions.

UPDATE II: The New York Times seems to have found the source.

Bipartisanship on Health Care Makes No Sense

Whenever I hear someone call for a "bipartisan solution" to the health care crisis in America, I just want to pull my hair out. It makes absolutely no sense whatsoever. It's like calling for a bipartisan solution to the next presidential election.

Health care policy is a definitional issue in American politics. For as long as I can remember, the Democratic party has fought to increase the government's role in providing health care coverage for Americans while the Republican party has fought to reduce the government's role. The Democrats are responsible for Medicare, Medicaid, and S-CHIP; the Republicans fought all of those initiatives. On a policy level, the Democrats believe that the best health and cost outcomes can be achieved by increasing access and encouraging widespread use of routine and preventative medical care. Republicans, on the other hand, have routinely identified the problem as over-consumption of care. Their proposals to fix the system inevitably involve significant deregulation with the goal of encouraging the use of high-deductible policies to try to discourage personal consumption of health care. Nearly every Democrat (including the blue dogs and "centrists") believes this to be bad policy.

In other words, there is virtually no common ground between the parties. The parties don't even see eye-to-eye regarding basic goals and policy assumptions. So why on earth would anyone believe that there is a bipartisan solution to health care? If one side believes the answer is behind door #1 and the other believes it is behind door #2, the correct answer is never to walk into the wall between the doors. Yet any conceivable "bipartisan solution" to health care would amount to exactly that.

Furthermore, as a simple political matter, it makes no sense to seek Republican support. First, it's a quixotic quest. Putting aside the fact that the Republicans are determined to uniformly oppose any significant Obama initiative, on this particular issue, there are actual principles and core beliefs underlying that opposition. Yes, there is a lot of standard Republican propaganda and demagoguery as well, but beneath all that disinformation is an actual philosophical disagreement. I happen to think that Republicans are dead wrong about health care, but I don't question that their beliefs are genuinely-held.

At the end of the day, no matter how willing the Democrats are to water down their proposal, they are unlikely to get any Republican support. And even if they were able to woo a few Republicans, it would not provide any meaningful political cover. The Democrats would still own the final bill.

Which is fine, because there is virtually no political downside here. The Democratic party is already identified with the issue of health care. It's one of its chief strengths. Despite their reluctance to support anything progressive, the reason red state Democrats like Ben Nelson get elected at all is because of issues like health care, where most people side with the Democrats. And it's not like what's on the table now is particularly radical. We're talking about providing people with a choice, giving them a public health insurance option if they want it. Not only is that idea already wildly popular, but it has virtually no political downside. Republicans and the insurance industry will do their best to demonize such a policy, but at the end of the day, no one is going to be upset that they are being presented with more options, and many people will be immensely thankful for it. Once the dust clears and the bill is passed, there is almost no political risk.

So the goal here should not be bipartisanship. The goal should be come up with the policy that is most likely to be effective and then browbeat every last Democrat in the Senate until they're on board. I don't say that about every issue, but on this one, there is no other sensible option.

Giving Away Your Bargaining Chips

I'm starting to get very pessimistic about the prospect of meaningful health care reform ever happening. We have a popular Democratic President who was elected less than a year ago with a mandate to reform health care and a very clear plan for doing so. We have large Democratic majorities in both houses, including a soon-to-be 60 seat majority in the Senate. The public is massively in favor of comprehensive health care reform. And yet, the Democrats seem to lack the will to even get a meaningful bill out of committee. Ezra Klein reports that the Senate Finance Committee has now dropped the public option from its bill and scaled back the bill significantly. The new plan is relies on government-seeded health care "co-ops" to provide more options to consumers. Remarkably, the plan still contains a mandate to buy coverage (along with subsidies for those who can't afford the cost).

Ezra concludes that while the new bill is far less than he would have hoped for, it would still incrementally improve the overall health care landscape in this country.

I'm sure that's true, but there's a massive opportunity cost to doing health care reform this way. First, from a political perspective, there will never be a more favorable climate for passing health care reform. The stars are aligned right now. The Democrats control all branches of government and have significant popular support. And with wide scale unemployment and lack of job security, many people are either uninsured or desperate for a system in which they don't have to constantly worry about losing their health care coverage. As time goes by and the next election nears, it will only get harder to pass meaningful reform.

Second, when you try to do health care reform piecemeal, you end up sacrificing the bargaining chips you need to get everyone on board. To take the most obvious example, the public option is incredibly unpopular with insurance companies. They know that the existence of a public option will eat into their profits and force them to be more competitive. Indeed, that's the entire point. On the other hand, insurance companies love the idea of an individual mandate. If everyone has to buy insurance, that means more customers for them, and a bigger risk pool.

By including a mandate but not a public option, the Finance Committee is essentially giving away our biggest bargaining chip with insurance companies. Once a mandate is in place, the insurance companies will have what they want and will simply devote all their lobbying efforts to killing any future attempts to create a public option. It's just bad strategy.

And frankly, it's bad politics as well. Mandates will be easy to demagogue. People don't like being told they have to buy something, even if there are lots of exceptions and subsidies. If the law is ever passed, Republicans will run ads highlighting the fines and penalties in the law for those who don't buy insurance. These attacks will be much easier to defend against if the bill also gives people an inexpensive, reliable public option. People like choices, and a great many of them would prefer the option of being insured by the government, knowing that the government won't deny them coverage because of a pre-existing condition or rescind their policy without warning based on some trivial omission in their application.

Moreover, if you have a mandate without a public option, it means that 100% of the subsidies the government is paying out to help people buy coverage go directly to the insurance companies. This amounts to a massive give-away of taxpayer money. Again, the insurance companies get to have their cake and eat it too. They get a whole bunch of new paying customers and no new competition to keep them honest and control costs.

I really think the Obama administration is being too cautious on this. They need to take the helm and really, forcefully make the case for the inclusion of a public option. If the public option doesn't happen now, it's not going to happen.

The Oblivious Partisan

Partisanship is a funny thing. Most of us who care about politics are guilty of it to greater or lesser degrees. Even those of us who make a real effort to be fair-minded have a natural tendency to give the benefit of the doubt to those we consider to be on "our side" and to be quick to criticize those on the "other side." I know I'm guilty of this at times.

On the far extreme, though, there are people like Karl Rove, who are willing to make any argument they perceive to be in their immediate partisan advantage, without any regard for consistency. These people are shameless, but they know it.

Then there are people like Victor Davis Hanson of the National Review, who is relentlessly partisan, but also obsessed with pointing out how partisan he believes everyone else is. It's truly bizarre. In this post, for instance, Hanson finally gets around to addressing the people who have been critical of his stream of cynical posts this week criticizing President Obama's handling of the situation in Iran. He writes:

It is quite amazing to see the various, sometimes conservative, explanations that most liberal (including some rather extreme leftist) pundits have suddenly advanced to support the president's mostly do-nothing, say-nothing policy on Iraq [sic]: Mousavi is no different really from Ahmadinejad; our distaste would only empower the government; the resistance does not want or need the American albatross; we should have learned our lesson from 1953, or from Iraq, or from (fill in the blanks); it is such a relief to have a calm president rather than a President Bush shouting about freedom in the hearts of everyone; we can't do anything anyway; "Bush did it" and tarnished the American brand anyway . . .

Two reactions: (1) I doubt such supportive arguments would be now advanced should a President McCain have urged similar realpolitik; (2) Should Obama have come out a few days ago with ringing endorsements for those who wish free and fair elections, and had he given a Reaganesque embrace of the dissidents' bravery and idealism, I doubt we would be reading any of what we read today.

In other words, we are in an age of ipse dixit. And that is all ye need to know.

There is no doubt some truth to Hanson's counterfactuals. If a President McCain was reacting to the Iran situation the way President Obama is now (which wouldn't happen), there would undoubtedly be some Democrats and liberals who would try to score some cheap political points by criticizing his subdued response. Similarly, had President Obama publicly embraced the Iranian dissidents (which he's too smart to do), many Democrats would undoubtedly have come to his defense.

But here's something else I know with every fiber of my being. If a President McCain was acting the way Obama is right now, Victor Davis Hanson--and every last one of his colleagues at the National Review--would be lavishing praise upon him for his intelligent and pitch perfect response to the situation. And if President Obama had rushed to publicly embrace the dissidents, Victor Davis Hanson would have already cranked out ten posts, all of them dripping with condescension and scorn, criticizing Obama for his naivete and failure to understand the dynamics of the situation. And every last one of his colleagues would be piling on.

Is Hanson really so lacking in self-awareness that he doesn't see this? Is he really so blind to the forces of partisanship that drive him? At least Karl Rove doesn't waste everyone's time with this kind of self-delusional nonsense.

What Kind of Meddling Do They Want?

Over at the National Review, Michael Ledeen implores President Obama to intervene in the Iranian situation:

You're going to be accused of meddling anyway, since out there in the real world you are believed to be the leader of the forces of freedom and democracy. So stop pretending to be a sweet innocent, and get in there and fight for people who are dying in the name of our values, and who want to be part of our world.

There are so many things wrong with these two sentences. First, what sort of meddling does Ledeen have in mind? Other than making a strong public statement (one that would in all likelihood not be welcomed by or helpful to the protesters), what does Ledeen think Obama should be doing? Does he think we should literally "get in there and fight"? If not, what exactly is he calling for here?

Secondly, I think the protesters would take issue with the suggestion that they are doing what they're doing "in the name of our values." Mousavi and his followers have aggressively and shrewdly taken up the mantles of both Iranian nationalism and Islam. They're working "within the narrative" as publius aptly puts it. Indeed, this is precisely why they aren't asking for the United States to jump into the fray. Their internal credibility depends in large part on framing this debate as being about Iranian values, about Muslim values. It takes a special sort of myopia and nationalistic narcissism to see this as being in any way about the United States.

I have no doubt that the Obama administration is doing whatever it can, quietly and behind the scenes, to aid the reformers (such as their request to Twitter the other night to delay scheduled maintenance). But jumping into the fray publicly would so obviously be counterproductive that you really have to wonder whether conservatives want the reformers to succeed. It strikes me as bizarre, too, that conservatives are suddenly willing to ascribe so much magical power to Obama's words, as if a public show of support would somehow inspire the Iranian reformers to double their efforts. How is that belief at all consistent with the relentless criticism from conservatives of Obama's Cairo speech? Has Obama suddenly developed new powers of persuasion and inspiration that conservatives all believed he was lacking a few weeks ago? Can he now will the Iranian Mullahs into submission by the sheer power of his eloquence?

I give up. These guys aren't even trying to make sense.