Categories
National

No Public Option, No Mandate

Over at Fire Dog Lake, Jon Walker challenges those with the “we can fix it later” mentality (which may or may not include enough senators to pass this bill) to hold the individual mandate out of the bill as a hostage to ensure that Congress will have leverage to come back and replace all the things they have compromised away in this bill already.

Progressives should make the rallying cry of “no public option, no mandate” an unmovable demand, now and in the future. Progressives in Congress should refuse to support the individual mandate until it is accompanied by the government guarantee of a decent, cost-effective public health insurance option.

To me that sounds like killing two birds with one stone – we could get a bill without a public option as the Republicans have worked so hard to remove already and we could get a bill without an individual mandate which is the most serious infraction contained in the bill (more serious than the public option ever was).

I would be perfectly content, if the bill passes now without either of those provisions, to never come back and “fix the bill” (at least the way he is thinking of it). But I’d rather gain a temporary victory against the individual mandate and have to come fight against it again in the future, than have the individual mandate pass and face the prospect of having to try and reverse it later.

Categories
General

Questions of Legitimacy

I found Power, Authority, Legitimacy at Electric Politics to be a very interesting article. It talks about these three important elements to effectively government and how they interact with each other. The focus is on legitimacy, but George Kenney also explains how power and authority can be in place without bestowing any legitimacy.

As I started reading, before Kenney began speaking about the United States government, my thought was that our government is suffering from issues of legitimacy not unlike Mexico or Iran. There is no doubt about the authority or the power associated with our government, but legitimacy is definitely a question.

Nowhere do we see intelligent discussion regarding whether the government of the United States is legitimate or, if not, to what degree it is not, how it got that way, and what should be done about it.

Despite that claim in the article I think that the discussion has been happening on a small scale for some time although I’m not sure the discussion has been framed with the term “legitimacy.” I also think that it is being discussed more broadly and more openly. Kenney also makes this claim which might explain why I see the discussion differently than he does:

American voters have done their job: they’ve elected politicians who promised to satisfy their preferences. But politicians haven’t delivered. Should we blame the voters? That’s one approach . . . Another approach is to blame our leaders. . . All such complaints, though, have to do with either power or authority.

I am among those who has talked about whether the federal government has the authority to do what they are doing and what they propose to do going forward. When Mr. Kenney talks about authority he is not talking about theoretical authority, which is what I am questioning. Instead he is talking about functional authority, which is not in doubt. As the only government operating in the entire United States and with no state governments putting up any real challenge to their mandates, the federal government unquestionably has the functional authority to do what it is doing.

Categories
General

The Health Care Issue as a Catalyst for Debate


photo credit: the queen of subtle

When I saw that Jim DeMint had written an article titled Our Health Care Mess Is a Symptom of a Much Bigger Problem my interest was piqued partly because I like DeMint as a senator and partly because I had just been saying the same thing in a series of comments with a reader from New York. It was exactly as DeMint predicted in his final paragraph:

The current debate over health care reform is a symptom of a bigger problem in Washington. But it can be the catalyst for a wider debate about the proper role of government in our lives.

The comments I was receiving demonstrated exactly what DeMint was talking about when he said:

All of these things have happened because we’ve stopped asking, “Should government attempt to solve this problem?” Instead, we start by asking, “How should government fix the problem?” It’s now considered a sign of admirable restraint to occasionally ask, “How much should we spend?” And somehow we started thinking that anything less than a trillion dollars is a bargain. (emphasis mine)

We can’t expect to come up with the right answer when we start by asking the wrong question. For too long we have been asking only how the government should fix our problems and not if the government has any business fixing those problems. Obviously there are some problems that the government should fix, but there are many that it should not address.

Because er have been asking ourselves the wrong question we find ourselves as a nation in this situation:

There’s not a word in the Constitution about the government deciding what medical tests private health insurers should pay for. Nothing about the government deciding how much executives on Wall Street should earn, or what kind of light bulbs and cars we should buy. There’s nothing about the thousands of parochial earmarks that fund local bridges to nowhere, golf courses, bike paths, sewer plants, and tea pot museums.

There’s nothing about these or many other things in the Constitution because they have nothing to do with the proper role of a federal government in a free society. But these are exactly the kinds of things our government spends its time and money on, and we don’t even question anymore why that is.

As the length of that list indicates we have had many opportunities to ask the right question. Hopefully health care will be the issue where we finally step back and ask the right question. Once we ask the right question we will begin to understand the truth that:

It matters because every time we give a job to the government, we take away some control that people have over their lives, and we take away a little bit more of their freedom. In return for letting government try its hand at solving a problem, we as citizens cede our ability to try for ourselves to find a better way.

It’s awkward to admit it, but my colleagues in Congress have led this country into the woods despite our oath of office. We swore to protect and defend the Constitution of the United States and to bear true faith and allegiance to it. The Constitution prescribes a very limited role for the federal government. There is not a word in our oath, or in the Constitution, about most of what we do. As we’ve wandered off the path of liberty, there are few crumbs left of the Constitution in the halls of Congress to lead us out of the woods. (emphasis mine)

If we honestly ask the right question we will undoubtedly reach some uncomfortable conclusions such as the fact that the government has already overstepped its bounds with things we would rather not alter, like Social Security and Medicaid/Medicare, but if we continue to shut our eyes to that primary question there will be no way to reverse our downward spiral, the best we could ever manage to do is quit digging the hole deeper.

Categories
culture National

Medical Cultures

[quote]I have called David Goldhill’s How American Health Care Killed My Father a must-read for anyone who wants to speak up in the health care debate. The New Yorker also has a must-read article on the issue called The Cost Conundrum. In that article we are introduced to the town of McAllen, Texas where Medicare spends much higher than average amounts per capita than the national average ($15000 vs $8000) in an area with much lower than average per capita income($12000 vs $21500) and cost of living. Atul Gawande, himself an associate professor of surgery at Harvard Medical School, introduces us to the town and begins an attempt to discover why the costs of health care are so high in McAllen.

Are the people there less healthy? No, they have higher rates of some health conditions than average and lower rates than average of other conditions. Overall health fails to explain the cost differential.

Was the quality of health care being provided higher than average? While they were not lacking for available medical technology or facilities the quality of care was, once again, nothing unusual.

McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

Gawande went to dinner with some McAllen doctors and showed them the data on health care costs in McAllen:

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

He then asked them why they thought the care was so costly there. One suggested the cost of malpractice insurance but then they admitted that since Texas had passed caps on malpractice lawsuits they had virtually no lawsuits to drive up the cost of care.

Finally a general surgeon among the dinner party declared that the issue in McAllen was overutilization.

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

Anecdotal evidence and agreement is fine, but Gawande went in search of more concrete evidence.

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice . . . I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

Having identified the cause of the high costs the search was on for an explanation of why there was so much overutilization. The answer was in the culture of the medical practitioners in McAllen – they were very profit oriented rather than results oriented. I believe the one place that Gawande’s article falls short is that he stopped with exploring the cultures among the medical community and failed to examine whether the general community culture in McAllen helped to foster that inefficient mindset among the medical practitioners in the area. I’m willing to bet that such a short-sighted culture in the medical community might not need encouragement from the local culture, but could not survive if the local culture were one that actively discouraged a similar outlook in the community at large.

Talking to a surgeon from McAllen, Gawande concludes that whether we have a public option, single payer, or private health insurance will not matter if the culture in McAllen continues to become more common as it has been doing.

In contrast to McAllen, Gawande explores the cultures in the Mayo Clinic and the Medical community of Grand Junction, Colorado and finds that both of these low-cost, high-quality health care systems took very different approaches to each arrive at “accountable-care {organizations} . . . {where} leading doctors and the hospital system adopted measures to blunt harmful financial incentives  {and} took collective responsibility for improving the sum total of patient care.” He also lists four other high-quality low-cost health care systems each of which has a culture of accountable care – the Geisinger Health System, the Marshfield Clinic, Intermountain Healthcare, and Kaiser Permanente.

Whatever approach Congress tries to take to reform our health care system they and the American people need to understand that we cannot successfully plant a Health Care tree. The only workable approach will be to plant Health Care seed and help it to grow into a health new health care system.

Categories
State

Return of the Food Tax

Curtis Haring is concerned about the possibility that the state legislature will reinstate the food tax that they repealed all too recently. Considering that the state is facing a budget shortfall in the neighborhood of 3/4 of a Billion dollars, it is a very legitimate concern for Curtis and a very legitimate consideration for the legislature.

I wish that I could provide a link to the poll Curtis cited showing that 68% of Republican political insiders who favor bringing back the tax on unprepared food. (Curtis has now provided the link to that poll – thanks.) On the other hand I can provide a link to a report from Senator John Valentine stating that Governor Herbert has submitted a budget devoid of any tax increases. I hope that budget is also free of numerous fee increases, but either way I recognize that it is the legislature and not the Governor who will ultimately pass a budget bill to deal with the shortfall.

Amazingly, amid his criticism of what he expects out of the Republican legislature, Curtis fails to mention even a hint of disappointment with Democrats despite his acknowledgment that the same poll showed that 81% of Democratic political insiders favored reinstating the food tax. (With the link to the poll Curtis also provided the correction that 81% of Democratic political insiders are against reinstating the food tax.) While I hold out hope that the food tax will stay dead, based on what Senator Valentine said about the Governors proposed budget, I am absolutely confident that if the food tax returns it will be the result of the democratic super-minority in the legislature being unwilling to make necessary cuts along with a good chunk of Republican legislators who do not have strong principles against government control of virtually everything. It will be the Democrats and these semi-principled Republicans who are unwilling to make unpleasant cuts in waste and some not-truly-critical programs who force the return of the food tax if it does come back to life.

Looking forward to the next legislative session I would give at least 50% odds that the food tax returns to Utah. If it does, I hope that final suggestion that Curtis makes – that any tax increases (and I would add fee increases) in the budget have a sunset clause built in so that the legislature is required to revisit those increases as the economy recovers in the next couple of years – is attached to the budget bill that finally passes.

Categories
General

Phony Federalism


photo credit: estherase

Gene Healy wrote about what he called Obama’s phony federalism but what he was really talking about was a relatively universal perspective on federalism:

Not yet a year into his administration, Obama’s record on 10th Amendment issues is already clear: He’ll let the states have their way when their policies please blue team sensibilities and he’ll call in the feds when they don’t. Thus, he’ll grant California a waiver to allow it to raise auto emissions standards, but he’ll bring the hammer down when the state tries to cut payments to unionized health care workers.

. . .

Just a few years back, the Republicans — nominally the party of federalism — were busily wielding federal power to enforce red state values . . . In that odd political climate, you often heard liberals lamenting the decline of states’ rights.

That strange new respect for the 10th Amendment lasted roughly as long as the blue team’s exile from power.

Federalism then, as understood by both major political parties is simply a tool to bash your opponents into conformity and then deflect their power from affecting you when you are on the defensive.

Categories
General

Eight Ideas for Reform

Kyle Mathews shares eight steps he believes would produce a more functional congress at the League of Ordinary Gentlemen. It is an interesting list including ideas I’ve heard before and a few new ideas. There is also some good discussion in the comments. I thought it would be worth sharing here in the order that he presented the ideas.

Resolve the electoral status of D.C.

I’ve made my position on this issue clear in the past. Kyle agrees with me that it is important and that the current legislation is the wrong route.

Limit campaign contributions to those who will be represented in the election.

Again, I’ve already shared my thoughts on that (multiple times) and I agree with this idea. I like the term Kyle uses – electoral carpetbaggery.

Water down the filibuster.

This is one I don’t think I have written about. I agree that the filibuster is overused but I also agree with one of the comments which said that placing a time-limit on filibusters would effectively remove them completely. As one who believes that the filibuster mechanism provides an important check on the system I think I would rather put up with its overuse, than do away with it entirely.

Eliminate anonymous holds.

I had not considered this before either, but as a believer in transparency and accountability I agree that holds should not be anonymous. If I put a hold on a bill I should be willing to admit it and explain my reasons.

Increase the size of both houses.

Once again, I have made my position on this quite clear, and once again I agree. I had never considered increasing the size of the Senate, but the way that he presents it – three senators per state – would be workable and would still allow the Senate to function in the same capacity that it was originally designed to function. I especially like the way the three senators per state idea would give each state a chance to bring a fresh face to the Senate in each cycle.

Increase the capacity and role of the Congressional Research Service.

This was another idea that was new to me, but it sounds like a good one. One comment argues that members of congress only use the CBO information if it benefits them. That argument is fairly weak because whatever hurts one side of the debate will benefit the other so the information will almost always be used. More information is almost never a bad thing for the governing process.

Restructure the committee system.

This is another idea I have never addressed, but I agree that the committee system is broken. Committees tend to turn committee members into industry insiders (if they weren’t already) and thus minimize any objectivity that should exist between government and industry. One other idea I once heard related to this was random committee assignments and regular rotation. I think there are lots of ways the committee system could be altered and most of them would be improvements over the current system.

Make all elections non-partisan.

Once upon a time I might have agreed with this, but I now believe that this would actually make it more difficult for voters to get truly informed about candidates and would further discourage voter participation in the political system. I could be wrong about that, but that is what I would expect to happen.

Out of the eight ideas I had addressed three directly in the past and I agree with six of the ideas in principle – some details would still need to be worked out on some of those. If I had to choose all or nothing I think that making all eight reforms would be a positive change overall in our system despite the drawbacks of the two ideas that I disagree with.

Categories
culture National State

Term Limits for All

One year ago today I pointed out that the subject of term limits becomes popular after an election. Like clockwork it came up again this year. Jim DeMint jumped the gun a bit by announcing three weeks ago that he would introduce a term limit amendment. Yesterday he introduced the bill and today I read an opinion by Mark Tapscott on why he thinks it will actually happen this time.

In previous posts on the subject we have usually had some good discussions, but they tend to be the same from year to year. I’ll summarize the previous discussions in hopes that we can start a step or two down the road and have a more advanced discussion by doing so.

The discussion  that we usually have boils down to the fact that term limits deal more with a symptom of our broken system rather than a cause but that treating that symptom might help to promote the curing of some of the underlying causes. Those who oppose term limits often argue that the people should be free to keep their same representatives as long as they want – but that thinking seems to obscure the fact that the position should always be greater than the person holding it and that society and the political system benefits from regular turnover so that we can’t mistakenly think that the junior senate seat from Utah somehow belongs to Bob Bennett, or that the senior senate seat from Massachusetts was some inalienable right for Ted Kennedy until his death.

Categories
General

Hit Them Where it Hurts

[quote]As Congress finds new and ever more inventive ways to spend money (both real money and imaginary money) more and more voters are waking up to find themselves becoming fiscal conservatives. First off, I must say that there are not nearly enough of us among the voters and secondly I feel compelled to add that we would be in a much better position to be taken seriously if there had been many more converts to the cause while Bush was still in office.

Earlier this week a friend of mine asked for my thoughts on an idea he had to slow and/or reverse the growth in government spending. (I feel compelled to state that said friend was awake to this issue well before Obama was elected – lest anyone mistakenly think that he just woke up to this in the last week.) His idea consists of two parts and boils down to this:

  1. Have states set the wages for their Congressional delegation.
  2. Have each member of Congress pay for 0.00001% of the federal budget out of their own paychecks. (That’s one out of 10 Million dollars for each member of Congress.)

My initial response was to point out the fact that it would take a Constitutional amendment to make the first part legal due to the provisions of Article I Section 6 that their salaries be paid out of the U.S. treasury (not that state money is not already mostly from the U.S. Treasury).

After thinking about the proposal more I recognize that it only works if both parts are enacted because if only the second portion is enacted it would only take about 30 minutes for the House to pass emergency legislation (or simply attach it to that proposal if they want to be efficient) in which the calculation for Congressional salaries is changed from it’s current “$170,000 plus an automatic annual cost of living increase” to “0.000012% of that year’s annual budget plus $169,999.99 plus an automatic annual cost of living increase.”

The real kernel of the idea was to hit Congress in the wallet – where it hurts – for the egregious budgets they pass from year to year like kidney stones in the national economy. For myself I have long believed that we should make congress feel the pain of their overspending by having them be responsible for a portion of their deficit spending – say 3 times whatever portion of their budget is financed by deficits. (In other words,  if 15% of the budget is deficit spending then members of Congress lose 45% of their salaries – and probably the same portion of their budget for staffers etc. for the year – to help offset their budget.) This only works if there are no exceptions (“oops, we had an emergency and had to overspend – but our regular spending didn’t include a deficit so we should not pay a penalty.”) On the other hand they should also receive some incentive for wise management by offering a bonus of one tenth of any percentage surplus they run for their personal salaries. (That would be, if 10% of revenues were in excess of the annual budget they would get a 1% bonus on their salary for the year.)

Theoretically this would have the downside of encouraging them to raise taxes to cover their spending priorities thus causing citizens to bear a greater cost for their government. Personally I think that would be beneficial because people would spend less time clamoring for more government handouts because they would almost universally feel the effects of any spending increases. Such a change should also have the side effect of having people be more engaged in the process of removing representatives who ignore them because they would be more likely to feel the effects of whatever votes their elected officials cast.

Categories
State

You Must Answer These Questions

Jim Matheson voted against the health care bills – that’s old news already. Some Democrats have, with varying degrees of seriousness, questioned whether they should  run or nominate someone else for his seat – that’s not really fresh news either. The news that I am following is that along with the ruminations regarding a new nominee there are some important questions being asked among some 2nd district Democrats:

Do you really think you’ll be better off if you take him down in the convention or a primary?

. . .

Is it more important to have the seat in your camp or feel good about pushing out anyone who doesn’t push the party line?

1) Is there anything that I’m currently getting with Jim Matheson as my “representative” that I couldn’t get with a Republican in his seat?

2) Is there anything Democrats living in the 1st and 3rd Congressional Districts get with Matheson in office that they otherwise wouldn’t get.

While these are specifically being asked about Matheson by these people right now, they are the same questions that the members of any party must ask when they are unhappy with the incumbent of a seat they currently hold. It should be noted that there is no universal right answer. Sometimes it’s more important to keep a Matheson and other times it’s more important to toss a Cannon. (I chose both of those examples because they are choices that have been made in the past – I do not intend to either endorse or refute those actions nor am I trying to suggest that the actions of the past must determine the actions of the future.)

These are the same questions that Republicans all over the nation are trying to answer on a large scale as well as in individual races (just notice that the number of Republican challengers for Bennetts’ seat changes regularly). Sometimes (such as with Bennett) tossing the incumbent does not do much to endanger the chances that the party will continue to hold the seat while other times (such as with Matheson) it could seriously endanger those chances. Regardless of how it alters the outlook for the party those questions can go either way.

The choice of who to support hinges not only on how well you like the incumbent, but also on answering those questions.