health care reform

Unsolicited Advice on the Health Care Summit

Voters hate to be played for suckers, and we will act against our own self-interests to punish someone we think is acting unfairly. (Footnote fans can see for example here and Stealth Democracy, both by Prof. John Hibbing).

These instincts are on display in the current health care debate – some of the most successful Republican attacks are those that complain of back room deals and closed-door meetings. It is worth recalling that Senator Brown (R-MA) effectively killed health care reform the day he was sworn in – yet as a state legislator he voted for a health care reform bill that was more liberal than the legislation his election tanked. Senator Brown’s election had little to do with the substance of legislation and a lot to do with how Washington is seen as producing that substance.

With this in mind, I offer some unsolicited advice for those participating in Thursday’s health care meeting with the President.

Don’t Rant. Ranting makes you look like you’re more interested in making a point than in solving a problem. Americans hire elected officials to solve problems, we hire pundits to rant. If you want to rant get a TV or radio show, if you want to lead stop ranting.

Agree. Surely there are points of agreement – agree to them. A handful of professional ranters and their fans aside, no one thinks that Democrats or Republicans have a monopoly on good ideas or that the other side is pure evil, plain and simple.

Admit to Agreement. As a corollary to the previous suggestion, if you’ve supported something in the past, support it now or provide a rational explanation as to why you changed your mind. The numbers of ideas that both sides have embraced and disowned is stunning. Senator Lieberman was for expanding Medicare before he was against it, Senator Grassley supported an individual mandate to buy health insurance before he opposed it.

Don’t Aha!. As a corollary to the previous suggestion(s), don’t engage in Aha! politics. The President and Democratic leaders should not waive around transcripts of Fox News interviews and scream “but aren’t these your words, on your network, didn’t we just trap you like a fox in a box?!” That looks, and is, petty. It also doesn’t make anyone confess and result in a Pauline Conversion – it makes them defensive and push back. Instead, ask good questions and listen respectfully to the answers. Keep handing the opposition rope, they’ll do the rest.

Americans want health care reform. Survey after survey finds they (we) like most of the elements of even the liberal Democratic bills. Americans also want leadership that appears to be, and is, honest and forthright. And they (we) will punish elected officials who are seen as school-boy bullies, cheaters, or weak followers. Anyone who wants to win in November will increase their chances by supporting health care reform and behaving like adults. Abandoning either reform or adult behavior will lower the odds of re-election.

Unsolicited Advice for Democrats on Health Care Reform Based on Unsolicited Advice for Republicans

The Democrats best strategic decision on health care is to immediately pass a scaled-back package of health care reforms. If Democrats don’t move quickly, Republicans will. This will hand Republicans a big win, will result in policies that Democrats in the House like even less than the Senate bill and make the losses in November even greater.

Assuming no feedback, the Democrat’s options on health care reform are limited to ‘worse’, ‘worser’ and ‘worstest.’ The House could pass the Senate bill – unlikely and it would look like Democrats were cheating to get around the Brown victory (which accurate). They could cram as much as possible through reconciliation – extremely tricky, which is why it wasn’t done last fall and it would look like Democrats were cheating. Or Democrats could give up on reform which would fail to address a major economic and social problem, fail to deal with an issue important to voters, and prove that Democrats are incapable of governing.

But of course Democrats are not the only players in this game. If one takes into account possible Republican actions the best course of action becomes obvious.

If I were a Republican I would modify my advice from several weeks ago (here) and introduce a series of smaller health care reform bills that would be popular with the American people and that are already part of the Democratic package such as barring rescissions, lifting the anti-trust exemption for insurance companies, allowing people to buy health insurance across state lines, and so forth. I would do it a bill at a time which wouldn’t require full agreement on the massive package (different Republicans could defect on different bills as long as the overall vote on each were large) wouldn’t look like massive over reach, and would rack up a series of wins. It would also force Democrats to support reforms they have already voted for and that the American people like or vote against health care reform because they don’t want to be bi-partisan. The Republicans would go into November saying (correctly) they led the charge on health care reform, they forced bi-partisanship and changed the tone in Washington, and they are better equipped to run the country. As a policy matter the bills probably wouldn’t provide long-term solutions to health care and would almost certainly be worse (from the perspective of Democrats) than similar individual bills that Democrats would write

Given this obvious strategy, if I were a Democratic I would start introducing small packages of fixes immediately. These fixes would put Republicans in a tricky spot (supporting reform or being obstructionists), would demonstrate momentum and prove the Democrats can govern. Republicans, in response, would declare victory because it was only their hectoring and the Massachusetts Senate race that led to these changes – but they would be following Democrats, and Democrats would deliver reform. And, not insignificantly, the reforms would be better (from the perspective of Democrats) than the Republican versions. If Democrats do nothing they will likely lose to an obvious Republican strategy. If Democrats act immediately they can still claim victory and get the health care debate moving in a good direction for the first time in decades.

The choice is easy: play and win, don’t play and lose.

On the Impossibility of Debating the Health Care System

On Christmas Eve I was a guest on POTUS, a political news station on XM/Sirius satellite radio, talking about the just-passed Senate health care reform legislation. My job was to offer political analysis of the bill, to talk about what happened in the Senate, what is likely to happen next, and what might happen after that. My job was not to promote or deride it. In an effort to steal ideas from friends and simultaneously plug myself, I posted my upcoming appearance on Facebook and asked for input.

The responses reminded me that that we are not having a debate about health care reform in this country; we are shouting our biases, anecdotes, fears, and hopes at each other.

None of my Facebook friends (who are also “real” friends) offered process thoughts. There was no, “the Kremlinesque line that the public option was just sick has finally given way to what everyone has known for months: it’s dead.” Instead there were a couple of suggestions on how to argue to make the bill more liberal, one suggestion on how to promote the bill, and one scathing attack. I mentioned “health care reform” and people immediately reached for their talking points and assumptions.

What makes this especially interesting is that other than one Facebook plug of a Paul Krugman column I don’t think I have publicly said what I think about the legislation (for the record, I agree with Krugman and Dionne).

A couple of observations based on this episode strike me as worth mentioning:

No one who has used the health care system likes it (the most vitriolic attacker in my Facebook page “discussion” and I exchanged a series of private emails that grew increasingly more balanced and respectful – he agrees the current government run systems, from which he benefits, are a mess and thinks that increased government attempts at solutions will only make it worse). People may like their doctor or hospital but the paperwork and bureaucracy involved in getting well are awful.

We don’t encounter or have opinions about the “health care system.” We see parts of it and extrapolate from those parts to the whole. The back and forth on my Facebook page covered a lot of ground and still left out Medicare Advantage, durable medical devices, the VA and Tri-Care, Indian Health, and countless other issues. Attempts to talk about the “system” are heard in the context of the piece or pieces the discussant knows about or is invested in. Those who rely on Medicare view system reform through the lens of impact on Medicare. Seen in this light, we are not having a debate about health care reform, we are instead throwing our personal interactions with small pieces of the massive pie at each other. The “system” is not discussed; the parts with which we individually interact are discussed, generally without consideration of the other parts. The individual or immediate element stands in for the whole. Immediate elements sail past each other, and a conversation about the whole is essentially impossible.

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