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Monday, August 31, 2009
The current state of the health care debate has been analyzed from any number of perspectives. One thing that hasn't been commented on enough, however, is what the difficulties that Obama's health care plan is facing can tell us about the weaknesses in wonkish solutions to policy problems.

First, let's define our terms. When I speak of wonks, I speak of the type of people who turn aspirations into concrete proposals. For instance, people may be demanding action on global warming. The wonks turn that desire for action into something that could be sold to the public, and could be the basis for legislation. Note that wonks don't necessarily write actual legislative text-- rather they are the class of strategists, commentators, and political and policy advisors who come up with the outlines rather than the details.

Wonks often upset ideologues, because wonks are often the people who say that an idea can't sell in its pure form, watering it down in ways that are designed to increase public popularity and the chances of passage of a policy proposal. Wonks exist on both sides of the aisle-- for instance, on the Republican side, it was wonks who repackaged conservatives' desires to dismantle Social Security as the George W. Bush personal accounts / privitization proposal. They specifically took actions to attempt to make the proposal more palatable to the public, such as ensuring that current benefits to current retirees would not be touched.

As you can see, what wonks propose doesn't always make the proposal saleable, and therein lies the tale....

In the case of health care, the initial goal was universal coverage. There were a couple of reasons why this was so important to liberals. First, most liberals believe that decent health care is a right of every person in a wealthy, advanced country. This is how they do it in the European countries that many liberals admire. People shouldn't be dying or suffering debilitating illnesses and medical conditions because they aren't wealthy. Many forms of inequality can be tolerated when it comes to mere money or material possessions, but medical treatment should be available to all when they need it.

Second, and related, liberals believe that government-provided health care has instrumental economic benefits. The most important of these is middle-class security. This is the point that conservative Democrat Mickey Kaus, who has long been a vociferous supporter of universal health care, repeatedly makes. Health insurance, for middle-class Americans, is as important as Social Security. It provides them with the assurance that they will not face financial ruin in the case of a medical emergency or a serious illness or condition. Just as Social Security protected Americans from poverty caused by old age, universal health care protects Americans from poverty caused by a medical condition or illness. Another instrumental benefit of universal health care is to remove a competitive disadvantage that is imposed on American businesses, who have to pay for their employees' health care to keep their workers healthy whereas businessess in other countries do not have to face this cost. A third instrumental benefit is that health insurance that is provided by the government and which does not depend on one's job allows workers to be more mobile, which is an important benefit in a dynamic economy. Workers can leave one job for another, or to start a small business, knowing that they won't lose their health insurance. A society where there is no universal health care and where health insurance is tied to one's job is a society where people feel they must stay in their current job no matter what to keep their health care. That becomes a less efficient society.

So those are the basic outlines of the liberal case for universal health care. The obvious models for how to achieve it are to create a National Health Service (which is what the UK does, and which is provided for Veterans and for active duty servicemembers in the US through government programs) which employs doctors and builds hospitals and clinics to treat every American, or to create a governmental, public insurance company (which is what Canada does,and which is provided for all senior citizens in the US through Medicare) which pays private hospitals and doctors for care.

The problem that wonks faced is that these models are thought to be unenactable in the US. They are easily demonized as "socialized medicine" and they impinge on the vested interests of too many players in the current system-- doctors, pharmaceutical companies, and insurance companies, as well as the politicians who fund their campaigns with contributions from those sectors. They are also seen as requiring new taxes and spending, which many political insiders have come to believe cannot be enacted unless disguised.

So the wonks felt they had to design a proposal that bought off some of the stakeholders and disguised the taxes and spending. This is how we got to the "mandate, subsidies, and regulation" approach that is at the heart of the Democrats' current health reform efforts. The "mandate" is a requirement that everyone buys health insurance. It is essentially a tax, but it is disguised as a regulation, and the money raised goes directly to health insurance companies rather than to the government. The subsidies, along with the mandate, buy off health insurance companies by providing them with millions of new paying customers. And the regulations are what is extracted in return-- promises to cover everyone, not to cancel policies or impose pre-existing condition exclusions, and to allow for community rating so that people such as small business owners who buy on the individual market do not pay exorbitant premiums.

So what, then, is the problem with what the wonks did? Well, there are two.

The first problem is that the wonks' approach dragged health care off message. You may have heard Obama drone on and on about bending the cost curve, and I have certainly seen more than a few liberal as well as conservative writers articulate that the health care crisis is that costs are so high. This is, of course, not the crisis at all, at least not in the way that liberals initially conceived it. Sure, health care costs are a major, mid- to long-term problem. Medicare costs are shooting up faster than inflation, and as more expensive treatments continue to be developed, there are serious rationing issues that are materializing.

But the problem that health care reform was meant to solve is not that costs are too high, but that millions of Americans lack health insurance. You know, health care is a right, middle class security, dynamic economy and competitiveness, etc. If the proposal that was on the table was single payer or an NHS, it wouldn't have been dragged off message. But because the proposal did not straightforwardly provide insurance for every American, it was easy for it to be dragged off message.

Why is this? Well, let's think about this. The structure of the mandate/subsidies/regulation proposal is built on the individual mandate, under which all Americans are required to buy their own health insurance. The problem with this is this structure doesn't create an entitlement, it creates an obligation. If someone were proposing that a state enact a mandatory auto insurance law, it would be very hard to sell it as a matter of security, i.e., that under the proposal every state resident would be able to feel secure as he or she moved from car to car that he or she would have auto insurance. Do you see why?

Now this doesn't mean that such mandatory auto insurance laws are a bad idea. They aren't. It simply shows you that if you want to talk about middle-class security and health care as a right, a proposal to simply force everyone to buy a health insurance policy does not further that message.

Of course, proponents of the mandate/subsidies/regulation approach would say this isn't fair-- that the subsidies will provide the requisite security. And maybe they will. But this is a hard sell to the public. Without getting into wonky details, it's very hard to convince someone that the subsidy will really be sufficient to buy them a health insurance policy. And the subsidies are also very much subject to the vicissitudes of politics-- it's much easier politically to cut a subsidy or tighten an eligibility requirement for one than it would be to eliminate Medicare, for instance. And I suspect the public understands this. What is being presented to them is a certain requirement that they buy their own health insurance, and a speculative possibility that the government might cover the cost. Is it any wonder that it is tough to sell this program as providing cradle-to-grave medical security or a right to health care that can never be taken away.

This is why the messaging shift to cost control is no accident. Because while mandate / subsidies / regulation doesn't provide health security in a convincing way, it might very well control costs to some extent by bringing the medical profession and insurance industry under stricter regulation. The problem is, the public doesn't care about health care costs. Indeed, as Kaus points out, there's no reason to think that the public, if presented honestly with the choice between spending more money on health care and controlling costs, wouldn't want to spend more money on health care.

Thus, by creating a plan that was designed to buy off stakeholders and neutralize political attacks, the wonks destroyed the central message, indeed, the moral imperative for health care reform. People who might man the barricades for actual guaranteed health coverage for every American (even if provided through the private sector) have little interest in fighting for a requirement that everyone buy their own insurance, coupled with some iffy subsidies and regulations.

This isn't all that the wonks have wrought, however. The premise of the wonks' work is that single payer or NHS can't pass. Indeed, not even something along the lines of buying everyone a private-sector policy can pass (too much taxation!). But what happens if what the wonks propose can't pass either? Or if it can pass but only in a form so watered down (with reduced subsidies, more ineffective regulations, and no public option) that it will not constitute a positive reform? (I do not need to tell you that this result is a distinct possibility given the state of the health care debate at the present time.)

It seems to me that the argument for wonkish watering down of aspirations and proposals is precisely that the wonks' version can pass. Indeed, this is especially true when the watering down process inserts potentially unpopular measures, such as individual mandates and Medicare cuts. If it can't pass, why do it?

Indeed, there are several benefits to the left in rejecting wonkish approaches to health care if they cannot pass. For one thing, the wonks have moved the Overton Window (the scope of acceptable, "non-extreme" political discourse) to the right. Now, the "left" proposal on health care is mandate / subsidies / regulation. (For point of reference, before the current health care debate, this proposal was more associated with three Republicans, John Chafee (who proposed it in 1994), Mitt Romney (who enacted a version of it in Massachusetts), and Arnold Shwarzenegger (who proposed it in California).) There are many plans that liberals like better than this one. If we are going to have to wait to the next health care crisis to enact a reform, shouldn't we be able to start from a point farther left than this?

Second, the left is now associated with many of the problems in both the messaging and substance of the plan. There's no reason liberals should want themselves associated with the aspiration of cutting health care costs, nor with the concrete policy proposals of individual mandates or Medicare cuts. Rather, liberals want to be associated with the clean messaging of health care for all.

None of this is to condemn wonks in toto. Wonks are necessary to move from aspiration to policy. But the wonks should work in the service of the aspiration, and what they come up with should never replace or supplant it. That mistake has been made in the health care debate, and if liberals don't realize it and correct it, it could be with us for a long time.


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