Some time ago, in trying to explain a bit of the philosophy behind public policy, I identified a certain brand of thinking I call political nihilism:
A participant in the policy process who becomes unmoored from ideological preferences and personal passions finds himself in a dire situation. The loss of faith leaves him with only the cold embrace of cynicism. He can be little more than a "hired gun," choosing a side and playing to win by any means necessary. Politics and policy-making become solely about the acquisition of power or a simple love of the game. The notion of identifying desirable social goals and using policy to launch us in the direction of the Utopian's dream becomes quaint and, if anything, simply a tool in the political manipulator's arsenal. This sense of purposelessly drifting through the political landscape is what I'll call political nihilism (a usage of the phrase that differs a bit from what Wiki tells me is usual). It isn't any more endemic to society than is religious agnosticism but I suspect--as with religious agnostics--there are many adherents among us.
I think it's time to present an example of what I'm talking about.
I've been reading various alternative health care bills lately to see if I can identify one that has some potential for bipartisan support (there's actually a current Republican proposal I rather like that I'll post about sometime). Yesterday, I came across a doozy. But first I want to offer a little background on the current Democratic proposals that passed out of the House and the Senate late last year. So let's walk through some of the key elements.
● Insurance market reforms and the individual mandate. The Democratic bills institute guaranteed issue and adjusted community rating rules in U.S. health insurance markets. This means that insurers can't turn someone away based on medical history or pre-existing conditions and they can only vary rates in the insurance pool based on age, geographic location, and familial status (and even then there are limits to the allowed variation). These kinds of reforms are popular among the public and with good reason: the ability of insurance companies to cherrypick their pools by turning people away or charging women, the sick, or the elderly significantly more than they charge others strikes most people as unfair.
But medical underwriting (the practice of deciding whether to accept somebody into your insurance pool and, if so, whether to charge them more than everybody else) serves a purpose, even if it seems douchey on the surface. It helps to mute the influence of what economists call adverse selection, a process by which the composition of health insurance pools could disproportionately contain sick people, threatening their financial viability. If insurance companies have to accept you when you go to them and they can't charge you more than anybody else once you're in their insurance pool, why pay premiums every month when you're healthy? If you get sick, you can always go buy insurance without fear of being turned away or punished financially for your irresponsibility. It's actually a pretty great scam. But it means that these high-minded, popular limits on the abilities of those evil insurance companies to play their medical underwriting games actually threatens to destroy (or at least make exorbitantly expensive) health insurance itself.
So we need another piece of the puzzle. Some way to keep people from dropping out of insurance pools until they need to draw resources from them. Some way to head off the obvious scam that most of us healthy people would be tempted to run. That's where the individual mandate comes in. You incentivize people to enter (or stay in) insurance by threatening them with a tax penalty if they go without insurance. Make it so that it's not cheaper to be uninsured and there's no reason for people to go without health insurance. Then healthy people pay premiums and health insurance pools stay solvent. The only issue is that libertarians freak the fuck out.
● Financial assistance to low-income people. The only problem with mandating that everyone buy health insurance is that a number of people are uninsured because they can't afford to buy insurance (that's part of the problem we're trying to address here, right?). So you have to provide financial assistance to help low-income families pay their premiums. That, of course, is where the costs of the Democratic bills stem from and why you'll hear conservatives weeping that the bills cost almost $1 trillion over the next decade. But this assistance, along with the insurance market reforms, pushes us close to universal coverage. The House bill, by the way, contains a mandate on employers to provide insurance to their employees.
● State-based health insurance exchanges. Right now there are a few different health insurance markets. There's the large group market for big employers. Large companies either self-insure (they have enough people to make their own health insurance pool) or, if they do go to an insurance company, have a great deal of leverage in bargaining for decent plans because they can offer the insurance company thousands of new customers. There's the small group market, in which small employers (like mine) go to insurance companies and try to get some kind of deal but have considerably less bargaining power than big employers. And then there's the individual market for people who don't get coverage through their employer. This last one is expensive, opaque, confusing, and just difficult to navigate.
The Democratic bills create health insurance exchanges in each state. In addition to being governed by the ground rules we covered above (guaranteed issue and community rating rules), they are meant to be a more transparent, competitive marketplace than the individual insurance market currently is. These exchanges are envisioned as being a bit like the market in which federal employees choose their plans (the Federal Employees Health Benefits Plan). Check out the website. Click your state, get a brochure for all available plans, along with the rates. Easy, transparent, one-stop shopping. As time goes on, the Democratic bills allow small employers of larger and larger sizes to enter the health insurance exchanges with their employees. This effectively gives these small employers bigger pools with which to bargain with insurance companies because a transparent marketplace with a level-playing field is a competitive marketplace.
In addition to the ground rules for insurance companies operating in the new health insurance exchanges, insurers will face benefit standards (i.e. they have to offer at least a minimum package of benefits). The House bill sets up a panel of experts to determine what kinds of things should be included in minimum benefits packages.
● Taxes. The Democratic bills cost north of $900 billion over the next decade, yet they're actually projected by the nonpartisan Congressional Budget Office to reduce the deficit. They do this, of course, by coming up with revenue streams to pay for their spending (and then some). The House bill does this through a progressive income tax on millionaires. Every dollar you make in excess of $1 million gets a nickel taken out of it. And poor people get to stay alive. The Senate bill goes a different route. Instead of an income tax, it relies primarily on a tax on "Cadillac" insurance plans. That means if you have a very expensive insurance plan (costing more than $9,000 if you're a single guy or more than $24,000 if it's a family plan), you'll pay a 40% tax on it above that threshold. So if you have an individual plan costing $10,000 a year, you'll pay a 40% tax on that excess $1,000 (i.e. you'll pay $400).
● Miscellaneous. As you may have heard, these bills are a bit long. That's because they contain lots and lots and lots of things. Additional money to fight waste, fraud, and abuse in federal health programs. Additional money to encourage medical students (I'm looking at you, Jim!) to go into primary care; this includes things like extra loan forgiveness and resources to create more residency programs, etc. Efforts to improve Medicare, including an end to the practice of subsidizing private companies to do things the government is doing more cheaply. Efforts to emphasis wellness programs to help shift the focus from treating sickness to maintaining health. A focus on collecting and compiling data to encourage comparative effectiveness research that will help doctors choose the most effective (in terms of health and cost) treatments. Numerous delivery system reforms that plant the seeds for the kind of fundamental changes that will ultimately help us control costs by changing the way we deliver care. Even incentive payments to states that come up with novel ways of reforming their medical liability laws (yes, Virginia, that's a flavor of tort reform).
That, in a nutshell, is what's in the Democratic bills that have consumed the national policy debate for the past eight months. These are the bills that were on the verge of being signed into law and which would've, obviously, led to an ultra-liberal dystopia in which freedom as we know it no longer exists and the government is in total control of 1/6 of the U.S. economy. At least, that's what one party told me would happen.
But let's rewind to the last Great Health Care Reform Debate: Bill Clinton's ill-fated 1993 reform effort. As we all know, "HillaryCare" went down in flames. At the time, Senate Republicans took the initiative in drawing up a bipartisan, centrist plan to counter President Clinton's proposal. In addition to having several Democratic co-sponsors, this bill (introduced by Republican John Chafee) counted Republican Senate Minority leader Bob Dole among its co-sponsors, as well as several Republican Senators who still serve today (Kit Bond, Bob Bennett, Orrin Hatch, Dick Lugar, and Chuck Grassley). I want to list some of the key provisions of this bill, the Health Equity and Access Reform Today Act of 1993:
● Universal access to health insurance coverage, in part through premium assistance to low-income individuals who don't quality for Medicaid (ultimately up to 240% of the federal poverty line)
● An individual mandate requiring all citizens to be covered by a health plan
● A mandate on employers to provide health insurance plans to employees
● Requirements for qualified heath plans to meet standards of: guaranteed eligibility, availability, and renewability of health insurance coverage; nondiscrimination based on health status (i.e. eliminating pre-existing conditions); benefits offered; insurer financial solvency; enrollment process; premium rating limitations (allowing variation in premiums based only on age and family); risk adjustment; and consumer protection
● The formation of individual and small employer purchasing groups
● Requirements that the Secretary of Health and Human Services, in consultation with the Secretary of Labor, establish standards for large employer plans similar to requirements applicable to small employer plans
● Formation of a Benefits Commission to develop a standard (minimum) benefits package that any qualified health benefits plan must offer
● Enumeration of state responsibilities in implementing state insurance market reforms
● Certain alterations to tax law, including an excise tax for excess contributions to medical care savings accounts and a tax on employee contributions to health care plans in excess of a certain "applicable dollar amount"
● Quality assurance programs, including the creation of a national health data system
● Medical liability reform, including a requirement that states adopt an alternative dispute resolution method for the resolution of health care malpractice claims
● Efforts to fight fraud and abuse in federal health programs
● Efforts to bolster the primary care workforce
Sound like any other proposals you've heard recently? Maybe some other one described in this very post? Premium assistance to the poor, insurance market reforms, new purchasing groups for individuals and small employers (a pre-cursor to the idea of the health insurance exchange), individual and employer mandates, even a tax on excess spending on health plans (think of it as a tax on Cadillac plans, except with a much lower threshold).
For ideological purposes, it's the same fucking plan. Proposed by Republicans 15 years ago and co-sponsored by 5 Republicans who are still sitting in the Senate and who all voted against the Democratic bills last year. An idea that Republicans now attack so viciously that President Obama correctly pointed out: "But if you were to listen to the debate, and, frankly, how some of you went after this bill, you'd think that this thing was some Bolshevik plot."
This, boys and girls, is political nihilism.
