Have Republicans Forgotten the Purpose of a Political Party?
Leave aside the broader health care reform debate and what the Democrats want out of this process. Why are the Republicans not using their elected offices to advance policies that serve their own supporters?
Their main voting constituency is middle class (or higher) white families in the suburbs, particularly the husbands and fathers in that constituency. They don't face the raft of problems that others do in our society. But one big problem that they do face is that something beyond their control happens to someone in their family. Medical catastrophes have to rank high on that list -- they certainly do for me. If a member of my family were to be afflicted with an expensive medical condition, then I am financialy viable only for as long as I stay insured with my current employer. Put simply, there are gaps in private insurance markets that leave such families exposed. This is plain to see and should be the focus of Republican efforts on health care reform, along the lines that I have discussed over the past six months (most recently here).
Paul Krugman sums it up pretty well:
What really struck me about the meeting, however, was the inability of Republicans to explain how they propose dealing with the issue that, rightly, is at the emotional center of much health care debate: the plight of Americans who suffer from pre-existing medical conditions. In other advanced countries, everyone gets essential care whatever their medical history. But in America, a bout of cancer, an inherited genetic disorder, or even, in some states, having been a victim of domestic violence can make you uninsurable, and thus make adequate health care unaffordable.
You don't succeed as a political party by denying other political parties the opportunity to craft policy that serves their constituents. You succeed as a political party when you craft policy that serves your constituents. Even naked self-interest by the two political parties should be generating better results than what we are seeing.
Self interest
It just goes to show that the GOP (and, frankly, most of its supporters) are no longer operating based on self interest (let alone the greater good). They're operating almost exclusively on the basis of reactionary dogma that ultimately leads to simple obstructionism.
I think one of your premises is mistaken
In the US system, it seems at least plausible that you can succeed as a political party by denying other political parties the opportunity to craft policy. That's certainly what the Republicans believe is the key to electorial gains -- and although I'd like to think they're wrong, I don't see any evidence that they're wrong.
The reason is simple
The consequences of HCR will increase costs for most of the Republicans core constituency. Krugman doesn't care about this because for him, health insurance is or should be a right.
Winners under HCR -- those unable to be insured and those nearly poor
Losers under HCR -- healthy people, voluntarily uninsured, people who make more than 200k
Group 2 is larger than group 1 in the core R constituency.
The best solution for Rs which they have proposed is a high risk pool guaranteed by the govt to deal with those unable to be insured. Dems argue this isn't "enough" to constitute reform.
Andrew, perhaps you should talk to some Republicans and not take Krugman's word for it.
Thank you Mr. Samwick
"You succeed as a political party when you craft policy that serves your constituents. "
Bingo. We it that "doing the people's business". They think they can win with this strategy? It's delusional, and more evidence that they've jumped the shark.
Democrats in the mid-terms will be running with this "they aren't doing anything AND they are obstructing progress" theme. A good example is Tarryl Clark, and she is getting a LOT of traction with the "incompetent and ineffective incumbent" theme:
http://www.tarrylclark.com/node/313
Are Republicans really so irrational?
Their main voting constituency is middle class (or higher) white families in the suburbs, particularly the husbands and fathers in that constituency. They don't face the raft of problems that others do in our society. But one big problem that they do face is that something beyond their control happens to someone in their family. Medical catastrophes have to rank high on that list...
Voters grossly underestimate the risk that any calamity will happen to them. (As fully documented by market surveys regarding the great under-purchasing of private long term care insurance.)
And do not believe that any party's politicians would fix this private-sector insurance gap until you look at Medicare: It provides first-dollar coverage for all kinds of routine procedures -- but not for catastrophically expensive long-term nursing home care, so if you need that in your old age your life savings, home, everything can go *poof* gone.
I went through this personally with my father, who suffered a series of strokes in his Medicare years. If he'd lingered as the doctors expected, everything he'd saved during a successful career would've been wiped out and my mother would've been left with nothing for the rest of her life (absent a major amount of costly legal maneuvering).
Imagine auto insurance working this way, paid for by the govt: It pays entirely for gas, oil, tires, all normal repairs (maybe even buys your car for you) all "free" to you -- but if you have a head-on and go through the windshield with the car destroyed, you get nothing.
What would the result be? Well, over-demand for all kinds of routine auto services, destruction of free market provision of routine items, government-set pricing for them, "gate keepers" administratively trying to restrict ever-rising consumption costs, pending rationing ... all while auto calamities go completely uncovered! ... Sound familiar?
Economically that would be ludicrous, make no sense at all. And it is every bit as ludicrous and senseless for Medicare care as for "Autocare" - only more so, for so much more is at stake.
But politically this arrangement makes perfect sense.
Voters know that after they retire they are going to have all kind of routine medical costs, exams, prescription drugs, and everything else. They don't believe that they will spend years in a nursing home. So they want their out-of-pocket bills covered, "give us that!" And that's what the politicians give them.
This is the problem with politician-designed health care. It doesn't provide what efficient health care requires, it provides what gets politicians votes even if it is destructive to their health care system. Politicians enacting health insurance rules aren't any more responsive to sound health care economics than politicians enacting rent control rules are responsive to sound housing policy or politicians enacting tariffs and protectionist quotas are responsive to sound trade economics. They are responsive to votes . That is all.
If Krugman really is so concerned about lack of catastrophic care, why doesn't he complain about Medicare -- which is already 100% run by the govt (and mostly designed and run by his party too)?
At "the summit" Obama was incredulous when some Republican said he wanted catastrophic care instead of routine costs covered. Obama's reply basically was: "Well you're rich, so routine costs don't matter to you.". Now that was a politician thinking! "Hey, millions of voters want their routine costs covered! What's wrong with you?"
Yet it is exactly because my father wasn't rich that he and my mother needed catastrophic care insurance -- instead of first-dollar coverage, which they could easily have afforded out-of-pocket.
But the politicians weren't going to give him what he needed, they were going to give only what gets them votes.
You succeed as a political party when you craft policy that serves your constituents.
No. You succeed as a political party by getting votes. Have the politicians of NYC served their constituents well via 65 years of rent control rules? (See: market rents, new housing construction, South Bronx). But renewing those rules always gets them re-elected! Is that not political success?
So, why would politicians be any more concerned about catastrophic care in the private market than in Medicare -- which has been the politician's own responsibility for 40 years?
Look, for anyone for whom "pre-existing conditions" is the big issue there is an easy fix: make health insurance portable so once you have it you can keep it if you leave your employer. That would cover 90% of cases, once a person has insurance pre-existing conditions are never a problem again. The US is the only nation that doesn't have portable health insurance. You keep your auto insurance if you change employers. It would require some changes, but nothing radical -- compared to restructuring one-sixth of the entire economy it would be as nothing. Simple and sensible enough so that in the polls all the masses would understand it and support it (so different from today).
Why didn't they propose that? Guess.
Health care politics is just like rent control politics, about getting votes, not sound policy.
We tried providing a government subsidized nursing care program
I clearly remember the Medicare Catestrophic Health Care debacle of 1988. Congress recognized that long term (usually end-of-life) catastrophic health care costs would eventually bankrupt Medicare. They also realized that many relatively affluent seniors were deliberately tranferring assests to younger family members or trust funds in order to become “indigent” which qualified them for Medicaid as well as Medicare. So Congress passed and President Reagan signed legislation to close this loophole; but do so in a way that allowed seniors to protect themselves by purchasing subsidized catastrophic health care insurance. The premiums were about $160 per month but heavily subsidized for all but the wealthiest seniors. I recall the average premium being less than $50 a month. The firestorm from the public was off the charts! You would have thought Congress had passed a bill requiring seniors to live in hovels and eat dog food. In one famous film clip, a group of seniors surrounded a congressman’s car waving their premium notices and demanding his resignation. BTW some of them were wearing jewlery worth more than the price of the car. Several members of Congress were defeated for reelection over this issue and the legislation was repealed the following year. A major triumph for populist democracy and a major defeat for fiscal disipline.
Devil in the details
"Look, for anyone for whom "pre-existing conditions" is the big issue there is an easy fix: make health insurance portable so once you have it you can keep it if you leave your employer. That would cover 90% of cases, once a person has insurance pre-existing conditions are never a problem again"
Does this mean that any employer that hires me is responsible for my health insurance coverage, until I reach age 65 (Medicare)? If I leave (voluntarily or involuntarily) this means I have the right to purchase insurance in their subsidized pool forever? What happens if the company goes belly up? Will there be a government safety net program, similar to the pension thingy? This appears to be a never-ending COBRA plan (COBRA is now limited to up to 36 months).
Most employers won't like this idea, not at all. They don't like COBRA as it is. Seems to me that this is government messing with the free market and corporate interests.
The other issue is that many pre-existing conditions are now diagnosed during childhood, and this category is growing rapidly (asthma, ADHD, autism, genetic defects, vision and hearing problems, juvenile diabetes, and even heart conditions). These are all diagnosed BEFORE a person has their first paying job. My child falls into this category, and I can walk down the street of my neighborhood and count at least 10 kids who wouldn't make it to their first job under such a rule (three of them are obese). Discrimination against hiring these people (it already exists even though it is supposed to be illegal) would be rampant. We need to do something to protect this class of people, not further punish them for a condition they have no control over.
Your idea sounds nice on paper, but it presents insurmountable implementation problems. It would NOT take care of 90% of the pre-existing condition problem (where did you get that number?), not even close.
And there's this
"You keep your auto insurance if you change employers."
Zero relevance to the issue here, unless you are suggesting that everyone pay health insurance themselves and it is made mandatory (like auto insurance).
I pay 100% of my auto insurance regardless of employment status. Unlike health insurance, it has never been subsidized by my employer.
Sigh
This is simply another variation on the typical liberal-elitist theme: "we know what's good for the American people and we'll cram it down their throats and demonize anyone who dares disagree."
Evidence of this? You're completely ignoring proposals coming from the Republican side to decouple insurance from employment by *removing* regulations that have driven the insurance market to the current status quo: such as the tax break given to employer-provided insurance, and getting rid of coverage mandates that limit the variety of policies that people can buy.
The Main Problem Is Pre-Existing Conditions
I would mention those proposals if they addressed the issue of pre-existing conditions, but they don't. If pre-existing conditions can be excluded, then any family is vulnerable to medical risk of the sort I described. Fixing that is going to require regulation that changes the nature of the insurance that is provided. It could be as I have outlined it here (or here), or it could be as John Cochrane has described it here, but it has to be there.
In some cases, we do know what's good for the American people -- like an insurance system that actually provides insurance. In this post, nothing has been crammed down their throat, except perhaps for the minimal requirement that everyone buy some form of insurance, and no one has been demonized.
Pre-existing conditons, and good ideas unheeded
I would mention those proposals if they addressed the issue of pre-existing conditions, but they don't
Wyden-Bennett created portability, that takes care of pre-existing conditions -- because once you have insurance you can keep it forever -- it had 10 Republican and 9 Democratic sponsors in the Senate.
As David Brooks reported in spite of a stream of ecomomists from political left-to-right testifying for its principles, Baucus buried it immediately at the heed of Democratic interest groups. (The unions definitely were *not* going to give up their tax preference merely to insure the uninsured! As we have since well seen.)
So Democratic interest group politics buries *two* excellent Republican (bi-partisan!) ideas ... so deep they are not worth a mention. They don't exist.
I'll repeat what I said before: Parties do not succeed by well-serving their constituents -- they succeed by getting votes, and if they use policies to do that which are in fact against their constituents' interests, that's what they'll do. And they will succeed politically.
I could start with rent control politics ... move on to politicians creating $50 trillion of unfunded entitlement liabilities -- how well are they serving their constituents with that? Not as well as they've been serving themselves! I could make a list down my arm.
CBO scored Wyden-Bennett as actually "bend the cost curve" revenue-neutral while insuring the uninsured, fixing the pre-existing condition problem, eliminating the gross inefficiencies that result the employer-tie, and creating real pro-market reforms -- there was stuff in it for left, right, and middle to like.
Even Ezra Klein said Wyden-Bennett was better than what the Democratic committee chairs were going to produce (and boy was he right).
So if we were going to enter a bipartisan (post-partisan!) political world with health care reform, why wasn't it the starting point of negotiations? Why was it killed in its cradle by Baucus and Co instead? Never given the slightest consideration. It's ideas forgotten today.
Because it offended the wrong Democratic interest groups, right at the starting gun. And when it comes to getting elected, first things first, that is first. Well-serving the nation of voting constituents is not the first thing.
Double standard for govt health programs?
BTW, I question the logic of those who think the big issue with private health care is lack of "catastrophic" coverage via pre-existing condition problems -- when the govt's own health program, Medicare, lacks coverage for "catastrophic" long-term care *period*, pre-existing condition or not!
I've lived through that.
And if one looks at the data, risk of this catastrophy during Medicare years is a heck of a lot higher than than during one's much younger years coincident upon a job change.
So where's the outrage about the govt's lack of catastrophic coverage? If we are pushing govt and politicians' plans as being the remedy for everything, shouldn't the govt and politicians take care of their own current responsibilities first? Take care of their own house?
End of life care vs. "catastrophic"
"Medicare, lacks coverage for "catastrophic" long-term care *period*, pre-existing condition or not!"
A government-paid system DOES exist for long-term "catastrophic" (as you call it) care, and this is covered under state programs (in Minnesota, we are paying for thousands of elderly in long term care when they run down their assets -- see Medicaid Managed Care -- it is the largest part of our state Health and Human Services budget).
Medicaid is *not* Medicare's long-term care insurance
A government-paid system DOES exist for long-term "catastrophic" (as you call it) care ... see Medicaid Managed Care ...
Medicaid is a poverty program. Basic eligibility for Medicaid in NYS is an income limit of $785 per month, plus assets not exceeding $13,800.
For a married couple the income limit is $1,087 per month and the assets limit is $19,200. (Plus each spouse can have up to $1,500 in a separate burial account).
By the time your nursing home bills -- not covered by Medicare -- have reduced your finances to that level, where are your home and lifetime savings?
Try to imagine if Medicare wasn't available to you unless your income was that low and your assets had been spent down to that level. Would you be admiring it? This *is* the long term care coverage for catastrophic events that the govt provides to you.
BTW, New York State spends more on Medicaid than anyone.
But you made my point for me, precisely. Thank you.
People grossly underestimate their exposure to financially catastrophic long-term care costs. And of course they imagine they are protected from them by the government somehow.
So they want first-dollar coverage for routine expenses to protect the cash in their pocket -- while what they need is protection against catastrophic long-term care costs.
And, of course, politicians prosper by giving voters what they want -- *not* what they need -- and that's exactly what's provided here and all throughout our politician-directed health care system.
It's no different than the process that has politicians give us rent controls, $40 trillion of unfunded entitlement liabilities, protectionist tariffs and quotas, hundreds of billions of dollars annually in tax loopholes and expenditures and corporate welfare and all the rest.
The politics of "health care reform" is no different at all. What gets votes will win out. What's good policy won't.
Hey, what happened to the "Cadillac tax"? The *one* real "cost bender" that economists agreed was in the reform plan was that (albeit as a poor substitute for getting rid of the grossly distortionate tax exemption for health benefits clear and upright -- and perhaps using the savings to insure the uninsured, as per Wyden-Bennett). Oh, but the unions said, "not with our votes!". And then everyone else said, "not with our votes if the unions are getting favored treatment" -- so the whole thing went overboard, kerplunk. Yet again, politicians sink sound policy for votes.
And as to catastrophic care -- any politician who damns private insurance for not covering it *if* a person changes jobs, due to the pre-existing condition issue, *should* be required to explain why Medicare doesn't cover it at all! And why he hasn't made a "peep" about it not doing so.
But he won't have to, because the voters won't ask him to.
Medicaid is a good option
for end of life care. These people are going to die anyway (most never make it back out of the nursing home), and as the saying goes, "you can't take it with you". In this stage these folks won't live to suffer the consequences of poverty. It's end-of-life care (as in they are going to die fairly soon).
There is no such government program forr people with pre-existing conditions who can't afford insurance (at least not yet). Their plan is called "bankruptcy", and because they don't have the advantage of dying (in most cases) quickly the consequences can follow them for years. I worked for a time at a collection agency, and nearly all the people we called were impoverished due to health care costs (at least 80% of them). Some were chronically ill. None of them were on Medicaid. They were constantly being harassed, and they spoke of making choices between paying the electric bill and buying drugs they needed. Some cried on the phone.
These people were dealing with extreme financial stress on top of their medical conditions. The elderly on Medicaid are taken care of . . . no harassment, no bad credit rating to deal with that means anything in their lives.
I'm just sayin', you can't compare end-of-life care (and yes, there is a government program to take care of those people) with pre-existing condition struggles for those who are younger. Totally different animals.
Incorrect
"And as to catastrophic care -- any politician who damns private insurance for not covering it *if* a person changes jobs, due to the pre-existing condition issue, *should* be required to explain why Medicare doesn't cover it at all!"
Medicare DOES cover pre-existing conditions, and most catastrophic care (heart attacks, strokes, you name it). Nearly everyone (at age 65) who enters the Medicare program has some pre-existing condition, ranging from high blood pressure to bad knees.
What Medicare does not cover is long-term care (nursing home). Nearly all elderly who need nursing home care are eligible to receive it under a government program (Medicaid), but yes, they do have to use their own resources first. This is a safety net program that prevents the family from bankruptcy . . . younger people who can't get insurance due to pre-existing condition don't get this level of support. Their program is called "bankruptcy", and it has long-lasting toxic after effects.
Andrew, You can solve
Andrew,
You can solve pre-existing conditions with a high risk pool, guaranteed at the pool level to insurers, with them acting as a utility for the government. It would work like this. Insurers would be guaranteed a rate of return for insuring high risk people (the funny part is, you'd probably have to put a price floor in to keep them from maximizing the subsidy).
And to be clear, you've not just forced people to buy insurance in this bill, you've also forced them to buy a particular type of insurance that covers things that the politically connected think must me a minimum. As an example, should prostate screening tests be in the minimum policy. In my view, no because a whole host of people (read probably 75% of them) don't need prostate screening but they still pay for it if it's in the minimum.
This discussion about minimums is silly. Nobody has to buy a minimum plan. That's the point about catastrophic insurance. It's actually a great deal if you are and remain healthy but we couldn't give those poor fools in the public the option to purchase it. They might get it wrong.
???
"In this post, nothing has been crammed down their throat, except perhaps for the minimal requirement that everyone buy some form of insurance, and no one has been demonized."
Please define some sort of insurance.
"You don't succeed as a
"You don't succeed as a political party by denying other political parties the opportunity to craft policy that serves their constituents. "
And who are the constuents? Voters, or major donors?
Look at the Bush-Cheney behavior for their 8 years (which the GOP Senate and House continue, as best they can).
They quite deliberately screwed over the majority of their constituents, in return for large sums of money. All that they had to do was to keep a large enough share either fooled or dstracted, and they were home free.
Whatever Barry
"They quite deliberately screwed over the majority of their constituents..."
Not a fact in that statement is there? Either you are spewing talking points or it was just too much work for you to provide any facts.
NY TIMES: The Cost of Doing Nothing on Health Care
good article at: http://www.nytimes.com/2010/02/28/weekinreview/28abelson.html
snip...
... Even those families that enjoy generous insurance now are likely to see the cost of those benefits escalate. The typical price of family coverage now runs about $13,000 a year, but premiums are expected to nearly double, to $24,000, by 2020, according to the Commonwealth Fund. That equals nearly a quarter of the median family income today.
... “It’s also cramping our economic growth,” said Frank McArdle, a consultant with Hewitt Associates, which advises large employers and reported on the need for change for the Business Roundtable, an association of C.E.O.’s at major companies. Spending so much on health care is “really a waste of people’s money,” Mr. McArdle said.
*SIGH*
And the Medicare actuaries say that exactly the same thing will happen as when HCR is passed.