Health Care Reform?

This is an interesting piece from McClatchy about the apparent arrangement between some of the major stakeholders in the current health care economy to voluntarily attempt to reduce costs and to presumably pass the savings on to the consumer. Certainly this is a laudable goal, but I don’t see how it can make much of a difference, nor how it can be enforced in any meaningful way. One is reminded here of the rejoinders of the now disgraced John Edwards who poked fun at the other candidates’ health care approaches, noting that those with overwhelming power do not generally give it away, no matter how kindly they are petitioned.

Among the groups behind the pledge are the American Hospital Association, the American Medical Association, Pharmaceutical Research and Manufacturers of America, America's Health Insurance Plans, and the Service Employees International Union.

This should tell us something right there. With the exception of SEIU, these are the guys who own the system, and they are the same guys who pretty much own Congress, along with the banks and the energy companies. And note that we are talking about reducing the cost of the growth rate of health care costs, not the actual costs themselves, which will presumably rise at their current unacceptable rates less the proposed reduction of 1.5%.

This is another exercise in marketing, really a preemptive gesture by the major stakeholders to maintain the status quo in terms of how economic and political power is distributed within the system. Right now health care costs account for roughly 15% of GNP, a significantly larger proportion than other industrialized nations. The growth rate is generally thought to be around 4%. The only way to really affect these numbers is to interfere in the market in a very significant way, both in terms of administrative costs and actual reimbursement for services.

What I don’t get is why the mainstream Democrats and the Obama administration and substantial numbers of real people are going along with this. Well, I do actually sort of get it. In the one case, Congressional Democrats, they are owned by the special interests, and in the case of the administration, they are convinced that real, substantive change that alters the balance of power between the oligarchy and the population at large is impossible and probably undesirable. But I still don’t get why the ordinary people buy this stuff.

Look, nobody really complains about Medicare, do they? And what the advocates of single-payer universal health care are really talking about is an extension of that system to the population at large. Nevertheless we cannot seem to get this proposition on the table even as a competitive alternative to private insurance.

Medicare and other universal single-payer systems work because they drastically reduce administrative costs – there is one source of reimbursement to medical providers and one set of rules and entitlements – and because the single-payer has dominant market leverage, so as to be able to virtually dictate reimbursements, far in excess of the savings available through preferred networks that insurance providers typically negotiate. And yet hospitals and doctors and clinics are not refusing Medicare payments, are they?

What I am getting at is that that this whole health care issue is being framed in a manner that is detrimental to the public at large, and really also to the economy as well. It is being discussed as something uniquely American, filled with all the illusions that, for example, people now have the unfettered choice of who provides services and that medical care is not rationed under the current system simply because there are a lot of people who do not have insurance or who have inadequate coverage and so simply do not seek it. Whereas we should be starting out from the premise that medical care is a social cost and that competent medical care is an inherent right for everyone.

Weekend Readings

There were three rather interesting pieces posted at Salon over the weekend, all in one way or another related to the torture issue, which, I confess, has become something of an obsession with me lately, a kind of litmus test of being politically serious in this country.

In one, Glenn Greenwald, contrasts the absurd positions of nut jobs like Charles Krauthammer with the surprisingly forthright rejection of torture by no less a nut job than Ronald Reagan, especially in the matter of the need to prosecute torturers no matter what the circumstances. Of course, in Krauthammer’s view, torture is unacceptable unless there is a ticking time bomb (amazing, isn’t it, how the TV melodrama 24 has penetrated the American psyche?) or if you have captured a high value prisoner whom you need to knock silly in order to reveal the plot that threatens all civilization. Which is to say, torture is always permitted because, in these times, either or both of the above scenarios might be true, and you will never know for sure unless you are willing to do what it takes to find out.

In the second, Norman Kelley takes journalists to task for their reluctance to even use the word torture, preferring the bromides of enhanced interrogation techniques, etc. I especially like his conclusion:

Let's face it: the United States has become a politically depraved society masquerading as a democratic republic. It's easy to cite people like Charles Krauthammer's demented justification for torture, but what else would one expect from someone whose profession is a willing executioner of such a policy. However, average Americans also think it's okay to torture people. Now you have reporters too afraid to call engage in truthful reporting.

This does not bode well for the democratic process. It's Orwellian, which makes the process of self-correction difficult. This kind of mindset may well represent the insidious nazification of American society.

The country may have tried to save its soul by voting for Obama, but it has shown that it has opted to do the devil's work by being so casual about torture, rationalizing it, and refusing to call it by its true name.

Which brings up the subject of Obama’s press conference, especially his statements on torture. There is an inherent contradiction in the apparent recognition that the United States did engage in torture and the reluctance to do anything about it. When I listened to Obama’s answers, I was really uncomfortable. I must be one of a handful of people who find them deeply disturbing. And yes, I went back and read them and on reading rather than hearing they are not that bad. But, for my money, what’s the point of all this hemming and hawing and soul-searching and nuance. In a way, it is just as bad as the journalists Mr. Kelley criticized above.

Why can’t our politicians just answer a simple question simply, that is, yes, water-boarding is torture and yes, it was authorized at a high, if not the highest, level of government. And another problem is that in framing the issue, the President came perilously close to the kind of perception of the world that is implicit in the Krauthammer framing. If you reject torture of these individuals because you could have obtained useful information in other ways, doesn’t that imply that if it is possible to obtain useful information by torture and that if it were not possible to gain that information lawfully and morally, then unlawful and immoral means might be justified? Obama’s response lacks clarity and unnecessarily weakens his case. Once more, the 24 mindset is revealed.

Which brings me to the third article, America’s Necessary Dark Night of the Soul, by Gary Kamiya. Kamiya argues eloquently for the need to have a kind of national blood-letting over the Bush years. I’m not sure that some sort of truth commission will provide that, or whether the sort of blunt recognition of guilt will ever take place, but the Kamiya article does provide a serious start to thinking about it.

The kinds of prosecutions or even truth-telling being suggested on the left are political acts, and sometimes political acts of this nature are necessary, particularly in a democracy. It is not the punishment that matters so much - whether Bush or Cheney or Bybee or Rumsfeld or any of a host of lesser thugs get sent up the river – but the act itself and the shame and disgrace it brings to the figures indicted. I don’t think societies can look forward unless they have pretty squarely faced the past, what happened in the past, and resolved not to let it happen again.

Nudge, Nudge. Change Nobody Wants

I saw an interesting article in the New Republic the other day, Nudge-ocracy, by Franklin Foer and Noam Scheiber. It is long and wonky as New Republic articles often are, but it is informative and probably historically accurate.

The basic idea is that Obama and his team prefer policies of incremental change based on subtle interventions rather than grand strokes of policy. The authors conclude that

Obama has set out to synthesize the New Democratic faith in the utility of markets with the Old Democratic emphasis on reducing inequality. In Obama's state, government never supplants the market or stifles its inner workings--the old forms of statism that didn't wash economically, and certainly not politically. But government does aggressively prod markets--by planting incentives, by stirring new competition--to achieve the results he prefers. With health care, for instance, he would make it easier for employees to tote their insurance from job to job, eliminating the disincentive for insurers to invest in preventive care. Or take his bank plan, which helps banks dispose of their toxic assets, reducing uncertainty and making the banks more attractive to private investors--a far less drastic step than nationalization. Rather than force markets to conform to his wishes, he shapes their calculus so they conclude (on their own) that their interests coincide with his wishes.

The authors correctly trace this way of thinking back to the Carter presidency and the ideas of Charles Schultze. I think the roots of the situation go back a little deeper, though. The mainstream Democratic Party really hit a wall in the aftermath of the sixties. It came apart because of the Vietnam War and the civil rights movement and the splits these events introduced into its coalition. In the aftermath of the Nixon/Watergate debacle, there was a missed opportunity to put things back together. Since then, it has been all downhill.

What we have to ask ourselves as people of the left, people who want to see real structural change in the way America works, is whether there is a real progressive program, and beyond that whether there is a progressive constituency. OK, there ought certainly to be one given the serious problems that exist in this society. But if you think about it there isn’t much there, or at least not much that percolates to the mainstream.

There are a lot of reasons for this, reasons that are pretty complex to be sure, but, in all honesty, recognition of this situation has to be the point of departure for progressives. There is a massive disconnection between the real situation of the country and the majority of its citizens and the political and media elite, really of both parties, but my own concern and preoccupation is with the Democrats or actually the progressive or left Democrats.

So in this context, one wonders exactly what this wonky ideology has to do with political and social reality. I hate to get down on Obama and his team. They are certainly better than the right-wing alternatives. But you have got to wonder whether people are going to take to the barricades over the portability of health insurance or presumptive 401-K participation. Not that these are not laudable or harmless initiatives, but are these the lessons we have learned from the past three decades of American history?

The question here, and the real objection to this kind of back-door social engineering is who is going to drive it, what class or interest carries this agenda? If we are honest, there is no significant social group behind it beyond a segment of the political and academic elite.

After seven pages of beating about the bush, the New Republic authors finally reach a sense of uneasiness with the program.

The health care plan suffers from a similar Rube Goldberg quality. For example, the "public option" sounds like an elegant way to improve quality by promoting competition. If only it were so simple. The problem is that private insurers have every opportunity to game the system: By skimming off the youngest, healthiest patients and leaving the rest for the government to cover, they drive down their own costs and make the public option look outrageously expensive by comparison. To prevent this, the government would have to restrict the way private insurers woo patients--something that's not impossible, but definitely tricky, given the variety of subtle techniques for screening out the sick. At a certain point, it seems far less complicated to just expand Medicare to everyone. The irony here is hard to miss: In order to keep its hands mostly off the free market, the Obama administration sometimes has to hatch schemes so convoluted they'd make an ambitious social planner blush.

Which raises a final objection: What's so great about private insurers or the people who currently run our banks? We are, after all, talking about a banking industry that tred a global financial meltdown and which, according to the IMF, may be sitting on trillions in losses to show for it. We're talking about a private health insurance industry that leaves almost one-sixth of the U.S. population without coverage and is a major reason we pay more for health care on average than any other country and get only mediocre results in return.

Bingo! It took these guys a long time to figure this out, although in the last paragraph they successfully pull all their punches and then some. But heh, here’s why this stuff is some much baloney. It is a rehash of the old complaint about the Fabians. It is, at bottom, change that nobody wants.

That’s the first objection. The second is perhaps even more cogent. These schemes are by and large dependent on congressional action. To the extent that they affect significant sectors of the economy, like banks and insurance companies, for example, the sectors affected have a disproportionate power to mitigate or resist reform, whatever subtlety or intellectual trickery is involved. They know what is really in their interests and they have an army of lawyers and lobbyists to figure it out and communicate it to our representatives. Most of Congress is there in some measure due to their contributions. So when things get serious, they have the consolation of pretty much owning most of the media and most of Congress.

Now Obama is uniquely suited to the role of tribune of the people, but until he gets a stomach for it, we are unlikely to see much of real significance happen.

Mixed Messages

“The first thing we do, let's kill all the lawyers.”
Dick the Butcher, Henry VI

I was appalled to note that President Obama went out of his way to address the CIA and to assure them they were doing a bang-up job in a hard world, blah, blah, blah. One wonders what sort of change we are dealing with when it is necessary to reassure historically dysfunctional agencies that everything is really OK.

But then it is rather becoming a habit for the Obama administration, despite possessing a considerable mandate for a program of change, however nebulous, to govern as if that mandate did not exist, as if, in fact, the Democrats had lost the election. I don’t want to get into some kind of psychological explanation of all this, but leaving aside the personal experiences of Obama himself, a great many of the men and women who have come to power with him are veterans of the Clinton administration or have had their ideas formed by the experience of the Clinton years. And, of course, that was the case then.

It is good to see that the left and the blogoshere, with the exception of a few lawyers who insist on reducing the debate to the issue of whether Obama is legally compelled to prosecute the torturers or whether he just ought to, has come down, after the obligatory soul-searching, pretty much on the side of virtue. This is a start, a step for us in the right direction.

Speaking of lawyers, it would appear that the President has inched closer to the Shakespearean solution alluded to above by implying he would be amenable to throwing Bush’s lawyers under the bus. It’s a start, and an indication that pressure from the left can have at least a minimal result.

But reading through his remarks both at the CIA and in his later amendatory news conference, one still sees evidence of the kind of delusional thinking that has got us into so many impossible situations as a nation, the idea that we live in a world surrounded by enemies, powerful enemies, and that we are engaged in some sort of dark struggle and that, moreover, the guys who fight it are not thugs but unsung heroes.

Every now and again, as in his discussion of the real threat that Chavez poses to American interests, that is, none, we get a glimmer that somehow this man and his administration have a deeper connection to reality than the average Republican, which, of course, is none, but these flashes of reason need to become a good deal more commonplace before any of us can rest easy.

Whose Side Are We On?

I was heartened to see good and forthright and informative posts from David Bromwich at Huffington Post and Digby and dday at Hullabaloo, among others, but on the whole the reaction from the blogosphere to Obama’s torture memo speech has been disappointing.

Why are decent men and women still looking for excuses and exculpatory arguments when it comes down to core values and issues that used to define this country and its way of life in contradistinction to the rest of the world?

When we talk about moving forward and reconciliation, what Obama seems to be talking about is not something even remotely resembling the processes that took place, for example, in the aftermath in South America or South Africa. These were genuine attempts at healing and reconstruction within the polity itself, within the sovereign nation. They were based on the recognition of guilt and error.

No, this stuff is just empty rhetoric, as is so much of what passes as national dialogue these days. The reconciliation that our politicians speak of is simply an agreement among the political class to let bygones be bygones.

I don’t think enough of a point has been made of what really happened during the whole fiasco of the Bush torture years, and what is really being revealed in its aftermath. Not to put too fine a point on it, these memos were solicited by a group of practitioners within the CIA for the express purpose of obtaining a legal cover for actions of dubious legality.

Lots of people in the intelligence and law enforcement and military establishments opposed this stuff, most notably, in this context, the FBI operatives at Guantanamo, hardly a source one might expect to be staffed by softhearted liberals. So by giving these guys a pass, aren’t we simply completely the circle? We are not talking about innocent conscripts here. We’re talking about people whose primary concern was not the moral dilemma that besets everyone who wields power, but was rather to find a legal cover for illegal and immoral acts, a cover kindly provided by the tortuous reasoning of Bush’s legal team.

Putting aside the issue of prosecution, what no one has suggested is how ripe these organizations are for what amounts to a purge. Far from letting the past stay in the past, at a minimum, these people should be kicked out, separated from the service just like that. There is a culture within the CIA that is just so wrong it cannot be tolerated in a democratic state. I don’t want to be reconciled to that culture, and I suspect anyone who does.

There is a fundamental obscenity at the heart of the exercise of power. All the great literatures and all the great political thinkers have somehow had to grapple with its inherent contradictions. Those of us on the left in America need to start getting back to basics, to start thinking straight.

I read a speech recently by the Japanese novelist Haruki Mirukami. He basically said that he was always on the side of the weak and the powerless, on the side of the egg, no matter how flawed, against the system, against the wall. That’s how I feel now. Those of us who want real change should never give in. We should never be reconciled. We should never make excuses. We should avoid being practical. We should never give comfort or faith to those whose fingers are on the trigger. We should never feel comfortable behind the gun. And we should not permit those who hold the guns to ever feel complacent.