Posted by Rojas @ 1:30 pm on December 16th 2009

The chief lesson of the health care meltdown

Conor Friedersdorf gets it:

The Senate is, to borrow a famous description, a saucer where legislation is cooled — that is its design. Thus it is extremely difficult to comprehensively reform anything. But that hardly means that problems cannot be addressed by chipping away at them a bit at a time. It merely means that they cannot be addressed in a way that is emotionally satisfying to wonks who aspire to write a white paper that comprehensively solves a problem, or presidents who want a legacy like FDR’s, or Congressional reps who want to pass landmark legislation with their names on it, or a political press that loves covering things that are “historic” or “the biggest in a generation.”

Indeed. There remains a very substantial constituency that wants some form of health care reform, because the existing system, taken as a whole, doesn’t make a lot of sense. Yet most polls show that a majority of Americans are satisfied with their own health care. So we are left with people who are 1. amenable to change in order to help those who are less satisfied, but 2. unwilling to rip the guts out of the existing system and risk losing that with which they themselves are satisfied.

This will come as no suprise to any ideological conservative. Social institutions–even imperfect ones–create a set of expectations that people adapt to, and live their lives under. The undermining of institutional arrangements is, therefore, painful in and of itself–and that pain expresses itself in unpredictable ways. This is the intrinsic peril of social engineering–and the larger the project, the greater the peril.

America is not impossible to govern. It is impossible to engineer. We need to recognize and respect the difference between the two. People can and will be influenced, but they will not be herded or remade. Neither will they easily tolerate having the rug pulled out from under them as regards the arrangements of their daily lives.

It is not necessary to disembowl the American health care system, or to pass gargantuan pseudo-comprehensible bills, in order to provide the uninsured with viable medical care. That is a goal worth pursuing. So let’s do so. But we need to beware of legislative hubris in the process. An effective doctor, first and foremost, does no harm.

15 Comments »

  1. Nice post, but I didn’t see the bit where this is all Joe Lieberman’s fault and he should be publicly disembowelled and eaten by wild dogs who were then themselves eaten by wild dogs before the whole area was nuked from orbit.

    You might want to edit that bit in.

    Comment by Adam — 12/16/2009 @ 2:53 pm

  2. America is not impossible to govern. It is impossible to engineer. We need to recognize and respect the difference between the two. People can and will be influenced, but they will not be herded or remade. Neither will they easily tolerate having the rug pulled out from under them as regards the arrangements of their daily lives.

    Tell that to the people who haven’t seen torture photographs and have never had their communications filtered thorough.
    Mandates that force people to buy insurance from uncost contained insurance providers and let regulation that lets banks rape their customers in whatever way suits their liking are easy to engineer since the politicians are paid for.
    Secret programs which violate law and constitution are easy to implement since no one will prosecute you if you get caught.

    Progressive change is hard to engineer because the public doesn’t have lobbyists and the programs they propose are for the public, which makes it counter productive to keep the details from the public.

    Comment by thimbles — 12/16/2009 @ 3:20 pm

  3. But as he says on the matter in hand, most Americans are happy with their healthcare. So persuade them or try to further undemocratise the country, I guess.

    Calling them stupid or misguided or fooled or trying some variant of No True Scotsman to invalidate their opinion won’t do much good, either.

    Comment by Adam — 12/16/2009 @ 4:09 pm

  4. Just a point of clarification, most Americans are happy with their health care. Most Americans are not happy with their health insurance. Not just a pedantic distinction. And, of course, the most germane number here would be how Americans think of the specific reforms being proposed, when explained to them. Medicare buy-in usually polls in the 60th percentile, competitive public option all over the place, but usually in the 50-70% range.

    Health care polling (more broadly, the “opinions of America” on health care) is one of those things that varies wildly depending on what you’re asking and how you ask it. The gist, that I can glean: most Americans, in terms of abstract values, are very skeptical of government tinkering with health care (when you ask big generalized questions, in other words, they’ll split). But almost all of the specific reforms being bandied about are, themselves, very popular (when you ask specific questions, in other words, they’ll go Democrat). Which strikes me as a perfectly sane outlook. So I would expect that the same poll would find many people agreeing with the notion that “government should stay out of health care”, but a significant number of those people, when presented with a specific intervention, will say “Well yeah though, that’s a good idea. I would support that.” Which is interesting in its own right (and the lesson is, the more Republicans keep things general and ideological, the better they’ll do; the more Americans are actually given policy options, the worse they’ll fare.). I bet every one of the major policy planks of the current health care reform package is supported by a significant majority of Americans. I bet that number is significantly less when asked if “they support the current health care reform package”.

    We’ll see where you stand on the “calling them stupid or misguided or fooled or trying some variant” if it comes to pass that the public is clamoring for a public option or some variant of socialized medicine down the road. I think a very real operable fear from the right here is Congress passing a very liberal health care reform package, and Americans liking it, which I strongly suspect they would. In any case, 20 years down the line when Americans are demanding a single-payer system, and I say to you “it’s what the people want”, I’m going to have that quote in my back pocket waiting for your reply. :)

    Comment by Brad — 12/16/2009 @ 6:40 pm

  5. Just a point of clarification, most Americans are happy with their health care. Most Americans are not happy with their health insurance. Not just a pedantic distinction. And, of course, the most germane number here would be how Americans think of the specific reforms being proposed, when explained to them. Medicare buy-in usually polls in the 60th percentile, competitive public option all over the place, but usually in the 50-70% range.

    I said “healthcare”, as did Rojas, although insurance is going to be a significant element of that in most people’s minds (because it’s cost and quality and for most people, cost relates to insurance). Of course Medicare buy-in would be popular; the issue is surely whether the nation can afford it (or the existing Medicare)? I mean, free money and hookers and blow for all would also be pretty popular, right?

    We’ll see where you stand on the “calling them stupid or misguided or fooled or trying some variant” if it comes to pass that the public is clamoring for a public option or some variant of socialized medicine down the road. I think a very real operable fear from the right here is Congress passing a very liberal health care reform package, and Americans liking it, which I strongly suspect they would.

    I think that the public are often stupid or fooled, but I wouldn’t attempt to change their minds by making those claims. That’d be stupid and foolish for myself. As for whether they like what comes out this process, I think that many may well do even if the cost is clear and moreso if some or much of the cost is hidden; it’s comforting to think someone else is taking care of stuff (indeed, I imagine that’s much of the appeal of the current system, for those that have decent insurance). But weren’t you a Ron Paul fan not so long ago, a believer in the hidden masses wanting to be free from government interference and significant government taxation, making their own way, their own decisions and their own mistakes?

    Comment by Adam — 12/16/2009 @ 7:59 pm

  6. Of course Medicare buy-in would be popular; the issue is surely whether the nation can afford it (or the existing Medicare)? I mean, free money and hookers and blow for all would also be pretty popular, right?

    So persuade them or try to further undemocratise the country, I guess.

    Calling them stupid or misguided or fooled or trying some variant of No True Scotsman to invalidate their opinion won’t do much good, either.

    Man that was fast. :)

    I said “healthcare”, as did Rojas

    Yes, which is very relevant, I admit. In fact, it is second in relevance only to that which is most relevant: their opinions on health insurance, which is the direct action and intervention mechanism of this reform package.

    Comment by Brad — 12/16/2009 @ 8:04 pm

  7. Do you seriously think that when people are asked if they’re happy with their healthcare they’re not thinking about how much it costs them? Really?

    And as I said above, I wouldn’t try to change the minds of people I felt were being foolish by telling them they were being foolish, which is the context of the comment you’ve quoted twice (“it won’t do much good, either”; that’s a comment about achieving persuasion or change).

    Comment by Adam — 12/16/2009 @ 8:06 pm

  8. Do you seriously think that when people are asked if they’re happy with their healthcare they’re not thinking about how much it costs them? Really?

    No, of course I do. I said so. But there is a reason that the two wordings, “health care” vs. “health insurance”, produce significantly different results. People like the care they get; they like less the mechanisms they have to negotiate in order to receive that care. Any reform of either effects the other, absolutely, but the Democrats are directly reforming not the kind of care received by people, but how they get it. The direct action of this reform is health insurance, so surely you’d agree that, given the choice of the two, health insurance is the more relevant. Do you disagree?

    Comment by Brad — 12/16/2009 @ 8:21 pm

  9. People might prefer any number of individual reforms to the status quo. They might, in fact, prefer two mutually exclusive reforms. I wonder how much of the “favorable” polling on the issue offers either/or choices between reforms.

    That’s kind of beside the point, though. What I was getting at was that individual reforms might be popular, and even enactable on their own merits. The more individual popular reforms you try to wrap up in a humongous convoluted package, the more people jump off the bandwagon, because their reform of choice is suddenly coupled with a big bucket of suck which jeopardizes that which they DON’T want changed.

    Comment by Rojas — 12/16/2009 @ 8:28 pm

  10. Let me go on record as saying I’m happy with my health insurance and the care it purchases for me. However, if we were going to split the two — which we should for purposes of considering where reform is needed — it’s actually the healthcare side that has bigger problems, because costs just aren’t out of control, the bill doesn’t really have any clear language to control them (there are some elements which will reduce those costs — insured people will be less likely to use the Emergency Room for non-emergencies, for example — but it’s hard to estimate how much in advance, it seems to me). Obama made a strategic decision to focus his rhetoric on coverage rather than costs, and unsurprisingly (although Obama didn’t write the bill himself) we get a bill that is focussed on coverage rather than costs. Alas, costs are the bigger problem.

    I would imagine that most people are concerned about the consequences of losing their jobs and their health insurance, getting sick and never being able to get affordable insurance, and possibly even a job with insurance, again. That’s why the removal of pre-existing conditions from reasons insurance can be refused will be popular but also, of course, why a mandate is required.

    Comment by Adam — 12/16/2009 @ 8:33 pm

  11. Fair points both. I can’t find much in the previous two posts that I disagree with. And I’m not disinclined to the point Conor is making in the original post, save on this one specific issue, I have a nagging fear that a bunch of little compromises is worse than one giant overhaul. Nobody really passed legislation that created the health insurance system we have now, after all; it’s come from a million little compromises and allowances and exemptions and end-runs, all cobbled together over decades resulting in the tangled mess we have today. One big law affecting say six main facets is sometimes preferable to thousands of smaller laws affecting tens of thousands. I’m at the point with the health care system that I fear more the never-ending sausage grind that seems to keep things headed in the wrong direction. There are, occasionally, moments when the stars align and the wind is at the sails and you ought to take advantage because it’s the one shot you have of a significant overhaul. Now that the house is crumbling for the Dems, I fear inertia takes back over, and it’s going to be another generation or more before the political capital is there again regardless of how the system holds up. And I’m not sure we have another generation or two to spare here before the system controls us versus the other way around.

    Comment by Brad — 12/16/2009 @ 8:54 pm

  12. Sanders is gone.
    So now you have two votes against.

    Progressives are damn angry. And not at Lieberman, but at Rahm and Obama.

    http://digbysblog.blogspot.com/2009/12/inventing-joe-by-digby-reader-jon-s.html

    At this point, it’s simply not possible for me to believe that the Dems are actually falling for this “I’m so very sorry…” act. The only explanation for why he keeps getting let back in is that they actually /want/ him around to play “bad cop,” so that they can say to progressives “we tried, but we just couldn’t get that black sheep Joe on board.”

    I mean, is it possible that, despite public appearances, Holy Joe really is a genuine Democratic team player–it’s just that the Dems aren’t on our team, here? Think about it: if it wouldn’t be for Joe, the Dems wouldn’t have an excuse to not pass progressive reforms. If he didn’t exist, The Village would have to invent him.

    I think there’s something to this. With Republicans almost entirely laying out the Democrats needed some of their own to ensure that the liberals didn’t get out of hand. It wasn’t a problem finding them. And Lieberman was more than happy to take the blame. Indeed, he revels in it. He’s a very useful fellow.

    Comment by thimbles — 12/17/2009 @ 1:51 am

  13. I reckon Sanders will vote for whatever he needs to in order for something to pass, if he were the deciding vote. He might be holding his nose and complaining about it, but I doubt he wants to be the guy that killed healthcare reform for a decade or more.

    Comment by Adam — 12/17/2009 @ 9:52 am

  14. I don’t think so this time. The progressives have been pushed to the wall with compromise and Sanders just had his 700 page single payer amendment forced to be read aloud by republicans for 3 hours as a delaying tactic.
    No one on the left is in the mood to negotiate anymore. It got us nothing, and when that happens over and over, it radicalizes people.
    In other news, an Olbermann rant:
    http://videocafe.crooksandliars.com/heather/special-comment-not-health-not-care-not-re

    Comment by thimbles — 12/17/2009 @ 1:49 pm

  15. Well, I don’t have any reason to oppose a Leftist rebellion against the more political elements of the Democratic Party, but I don’t think it’ll work out to either their good or that of the Democratic Party itself. There are some things that activists can expect of their party — GOP activists can get, for example, fiscal restraint from their GOP representatives and that they didn’t is part of the reason they’re burning now — but too fair remains too far.

    Comment by Adam — 12/18/2009 @ 3:29 pm

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