Patterico's Pontifications

10/29/2009

ObamaCare: The public option and liberal fascism

Filed under: General — Karl @ 11:06 am

[Posted by Karl]

House Democrats are planning to unveil their version of ObamaCare this morning, without a “robust” government-run insurance plan, which would slash reimbursement rates to some variation on Medicare rates. This has bloggers like OpenLeft’s Chris Bowers wondering whether the House can pass any ObamaCare bill:

This is going to anger quite a few members of the Congressional Progressive Caucus. Some of them might not vote for passage now, because they consider the public option too weak.

This matters because there are around 18-25 Democrats who will vote against the bill from the right, pretty much no matter what at this point. With every Republican likely to vote against the bill, this means that opposition from 15-22 Progressives would sink the entire bill.

And maybe pigs would fly out of my butt. The House proggs will cave in the end, having to settle for a bill that requires insurers to accept all customers and charge all the same price, regulates all aspects of their marketing to make sure they aren’t discriminating, and then redistributes the profits to make sure that no company gets penalized unfairly.

On the flip side, Megan McArdle explains why the “robust” public option would be an economic and political disaster:

[T]he thing about patients whose insurance doesn’t cover the average cost of treating them is that they cannot be 100% of your patient pool. Someone has to cover the cost of that MRI machine. If the public option does manage to crowd out other insurance–as it might well do, with the ability to dictate price controls–then suddenly, the public option won’t be cheap any more. Hello, fiscal crisis.

That’s the financial problem. Here’s the political problem: if you insert a strong public option, the providers will revolt.

You’ve already lost the insurers. Try to reimburse hospitals and doctors at Medicare + 5% for any large segment of the market, and you’ll lose them too. Health care reform is likely to survive the defection of the much-hated health insurance industry. I doubt there is any way at all that it survives negative ads from coalitions of doctors, hospitals, and other assorted healthcare workers. I don’t see Obama having much success getting on the radio one Saturday morning to complain that doctors are all a bunch of lying obstructionists.

McArdle wonders why the fixation with a “robust” public option has persisted. Her commenters correctly note that it makes a nice bargaining chip and distraction from the mandate-driven government takeover of the US healthcare system. And the cheap shot answer is that the nutroots generally lack a nuanced understanding of economics or practical interest group politics.

However, all of that is only a partial answer. The Obama administration has long seen this issue as another in the long tradition of corporatism, a staple feature of what Jonah Goldberg calls liberal fascism since the days when Big Meat co-opted the Teddy Roosevelt adminstration. One of the adminsitration’s main strategies on ObamaCare has been to pay off the “stakeholders”, i.e., the special interests most affected by the bill. Big health insurers, Big Pharma, AARP, doctors, etc. — have all been promised goodies under this approach. The point of friction with the “stakeholders” has been the public option, which is opposed by the insurers and the Business Roundtable (a major player which is otherwise with the SEIU and AARP on ObamaCare). This is implicit in McArdle’s analysis (though it is not entirely clear that the Dems have lost insurers, provided the Dems can fool AHIP into believing the mandates and penalties will be stiffened and enforced).

The history of the 20th century shows that progressives have generally been content to pursue corporatism clothed as “reform.” So why are liberals not content to let health insurance companies become the premium collectors for the welfare state?

Two possible answers leap immediately to mind. The first possibility is that healthcare is different. Socialized medicine has been the Holy Grail for the Left for the better part of a century because they see it as the cornerstone of a proper, Euro-style welfare state. Control over the healthcare system gives the government influence and control over many life-and-death decisions (except abortion, though that issue may be a monkey wrench in the House yet). In this context, corporatism leaves open the possibility that non-state actors would remain dominant, which is simply unacceptable to the true believers of the Left. This is why the Left freely admits they view the public option as a Trojan Horse for socialized medicine when talking among themselves.

The second possibility is that the 21st century Left is different. It may be that last year’s meltdown on Wall Street has actually convinced them that capitalism is a failure. They look at the bailouts, TARP, etc. and see most of the same flaws the Right sees — but concludes that the financial sector should have been nationalized instead. In this view, a version of ObamaCare that is merely corporatist simply does not take enough steps down the road to serfdom.

Of course, those possibilities are not mutually exclusive. I’ll be interested to hear if there are other possibilities I missed. In the meantime, a couple more ObamaCare tidbits. Yuval Levin notes that it looks like Pelosi may again be forcing her vulnerable Dem colleagues to vote before the Senate, which may be bad strategy in the short- and long-term. Sen. Evan Bayh may not be able to support a motion to proceed with the health care debate on the Senate floor, and he is practically daring his Dem colleagues to try getting the public option through budget reconciliation. (A reminder: Bayh’s wife is a director at Indianapolis-based health insurer WellPoint Inc.).

–Karl

25 Responses to “ObamaCare: The public option and liberal fascism”

  1. Awesome analysis, Karl – but what do you think the odds are at this point that no matter what kind of bill gets through the house, the Senate will still fail to pass it? Sure seems like Reid will never get the required 60 votes, and that his gambit regarding cloture is already being exposed as BS by the Blue Dogs (and Lieberman). How hilarious would it be if Lieberman provided the final nail in the coffin? Revenge is a dish best served cold.

    Dmac (5ddc52)

  2. Maybe its just because today’s a Thursday, but the whole thing seems both depressing and inevitable.

    We know what the left wants: a government-run health care system. Not just a public option, not just a single-payer system, but the whole thing. A health care system run by the government paid for by taxes. This would allow the left to do what they’ve always wanted – to reach into every aspect of life. Diet, health, behavior, you name it. This would give them the leverage to make people live the way they’re “supposed” to.

    The depressing thing is that this won’t be the end. If this bill fails, they’ll try again in 10 years. If it passes, they’ll start changing it to be more and more centralized. They won’t even need to pass laws through Congress – the bureaucracy will do it for them.

    Even if the system doesn’t work (and it won’t), it won’t stop “progress”. Every failure will be a “market failure”, and the only solution will be more government. We’d like to think there’s a tipping point where people will rebel, but is there? Or will more and more people go along to get along?

    I don’t see a way out of this.

    JayC (0a3ab7)

  3. There was a theory among doctors back in 1994 that the end game was to eventually pay all doctors a salary. They (We) would all work for the government, or for government sponsored HMOs in a Kaiser-like arrangement. The theory went on to postulate that the for-profit HMOs that have been such a bane to medical care the past decade were intended to soften us up.

    The time may be here when most doctors are ready to sign up. My generation is mostly gone and we were the last to really be small businessmen. And women. It is no accident that medical students are over 50% women. In 1961, admissions committees tended to turn down women applicants (We had the theory that they only accepted homely ones) because they assumed that women doctors would marry and have children and would not spend as much time practicing as their male colleagues.

    They were right. All sorts of work force studies have shown that women spend about 60% of the time men do in active practice. Furthermore, they don’t go to rural areas and set up one person offices. They tend to join groups with fixed hours and vacation schedules. The present “reform” efforts will accelerate that trend and I suspect we will see medical students at 70% women by 2019. One result will be a worsening of the shortage of doctors.

    I suspect we will see more and more primary care by nurse practitioners and PAs. Most workers comp care is done by them now. I talk to them on the phone every day. I don’t think there is a problem with that except the matter of supervision and the sorting out of the occasional zebra from the horses. Since zebra care is to be discouraged by the present reform plan, that is a minor problem. We will end up with something like Canada, where the care of the well proceeds smoothly but god help you if you get sick. The obnoxious Florida Congressman has it backwards.

    The curve of LA Times circulation would probably fit well superimposed on the curve of general surgeon production by residency programs. It will be an interesting time, especially as none of this can be paid for. A lot of women physicians I know are married to cops and firemen and EMTs as the shift work fits well and those men aren’t intimidated by achieving women. It may be also true before too long that their incomes will exceed their wives’. The final question will be, who will pay all those huge student loan balances?

    Mike K (2cf494)

  4. “The present “reform” efforts will accelerate that trend and I suspect we will see medical students at 70% women by 2019.”

    Uh-oh, watch out Mike! You’re treading in dangerously un-PC territory. But I think you’re right; the Soviet Union had a lot of women doctors, didn’t it? And I heard they weren’t paid all that much.

    It would fit the pattern of wages of a profession dropping as women enter it.

    cassandra in MT (5a5d33)

  5. Mike K, isn’t the situation you are describing pretty much the way the Canadian Health System works? Doctors are paid a fixed amount (salary), and in return they only work a fixed number of hours. On the one hand it means for many doctors a better quality of life with more time to spend with their families, but on the other hand it is a key contributor to the long waits for health care in Canada.

    I am trying to be more optimistic than JayC (11:39 am) is, but I see the point he is making. All the Dems have to do here is get the camel’s nose in the tent — which Republicans would help facilitate if the Dems would dial back the most hardcore statist elements of the bill — and from there they can always build upon their health care system year by year. Check out this tidbit from one of the leaders of the Progressive Caucus in the House:

    Not all liberals were ready to sign on. “My inclination is not to support it,” said Rep. Raul Grijalva, D-Ariz., a co-chair of the Congressional Progressive Caucus, but that represented a softening of his opposition.

    Grijalva acknowledged there was an argument for progressives to vote “yes.” “The logic is to keep the ball rolling,” Grijalva said Thursday.

    As Karl points out, liberals won’t pass up the chance to get half a loaf now, knowing they can come back for the other half soon. No society votes in socialism overnight; they just gradually slide down that path over a number of years until one day they wake up to find they have signed away all of their liberties one by one.

    JVW (d32e06)

  6. In the UK and Canada, the shortage of medical professionals is made up by hiring qualified individuals from developing nations.

    DOuglas2 (62fec6)

  7. #6, thereby starting a literal “brain drain” in the Third World.

    But that never seems to bother the usual suspects.

    Techie (482700)

  8. My noon comment wasn’t meant to be as misogynist as it looks. Male students are also far less likely to put in the hours I did and my generation did. One reason is the Libby Zion case that sharply reduced the working hours of residents. Nobody explained to them that the law did not apply once you were in practice but they have figured this out and are avoiding the long hour specialties like general surgery. About 8 years ago, a woman general surgeon I know told me that she did not know a general surgeon in San Francisco, where she practiced, who was under 50.

    Yes, they are filling up spots, especially in rural areas, with foreign graduates. In Central California, large numbers of Indian doctors arrived about 30 years ago, many of them related to each other, and basically drove out the non-Indians except for primary care. They only referred to each other.

    The Canadian system pays fee-for-service but the payment is low and it is very low for specialists. I was in Saskatoon about 15 years ago for a meeting (That is no longer held because all the professors who used to hold it emigrated) and got a chance to compare notes with general surgeons. At that time, a laparoscopic cholecystectomy, for which I charged about $1200, was worth $160 to the Canadian system. One guy I talked to said they only could make it because his wife was an internist and between them they made a living.

    Primary care docs are already voting with their feet by dropping Medicare, let alone Medicaid, and practicing for cash. Surgeons and hospital based specialists can’t do that so their numbers will decline. Eventually, the hospitals will have to put them on salary and then the hospitals will fight the battles. It’s getting close to that now for OB, for example. Hospitals are having to pay OBs to take ER call.

    Mike K (2cf494)

  9. Has anyone asked why we need health insurance to afford health care, but we do not need insurance to afford oil changes, or housing, or food?

    Michael Ejercito (6a1582)

  10. Michael…questions like that will get you labeled as a “disruptive influence”.

    AD - RtR/OS! (c561b5)

  11. We know what the left wants: a government-run health care system. Not just a public option, not just a single-payer system, but the whole thing.

    Aided by some of the most ignorant and biased left-wing MSM reporters around, I am sorry to say. This comment from one recently appeared on Facebook:

    Lieberman’s been wrong on so many issues it’s hard to pick which is the worst, but this certainly has to rank with one of them. The Libertarians prefrer to be enslaved to the most expensive and least effective health insurance system in the world, bar none. With Lieberman’s help, they may get their wish, which will only mean continuing sky-high bills for us as the Europeans, Canadians and Japanese chortle behind our backs.

    That package of bias and ignorance is from a business reporter!

    Brother Bradley J. Fikes, C.O.R. (0ea407)

  12. Lieberman’s been wrong on so many issues it’s hard to pick which is the worst, but this certainly has to rank with one of them. The Libertarians prefrer to be enslaved to the most expensive and least effective health insurance system in the world, bar none. With Lieberman’s help, they may get their wish, which will only mean continuing sky-high bills for us as the Europeans, Canadians and Japanese chortle behind our backs.

    Why do they only use foreign examples?

    Why do they not use Massachussetts, Maine, and Tennessee as examples?

    Nobody has ever explained why the public option can not be provided on a state-by-state basis.

    Michael Ejercito (6a1582)

  13. Dmac,

    I would answer your question with a question:

    When was the last time the Senate raised taxes by $500 Billion and cut Medicare by $400 Billion in the same bill?

    Karl (6aa6ff)

  14. Why do they only use foreign examples?

    Because it’s accepted wisdom for the great majority of MSM reporters that foreigners are wise and wonderful, and the U.S. is stupid and venal. At least it was under the reign of Bush the Younger (The Ignorant).

    After reading numerous fact-free bloviations from MSM journalists and journalism professors on Twitter and Facebook, I now understand why such outlets as the Washington Post are afraid of letting their minions reveal their personal opinions. Their half-baked opinions could not survive the light of day.

    Whatever you think of left-wing media bias, it’s worse than you think.

    Brother Bradley J. Fikes, C.O.R. (0ea407)

  15. Those opinions are not half-baked, Brother Bradley. They are fully baked.

    JD (c87796)

  16. “Those opinions are not half-baked, Brother Bradley. They are fully baked.”

    JD – Are you saying all those reporters are smoking dope like the LA Times folks?

    daleyrocks (718861)

  17. If these MSMtards were smoking dope, they’d at least have an excuse. These are seriously deluded folks — deluded by their own hubris. They think they know everything.

    Brother Bradley J. Fikes, C.O.R. (0ea407)

  18. Sadly, I have yet to meet a reporter that wasn’t full of themselves or willing to be a journalist and only report what they see and can prove, not what fits their preconceived story.

    PCD (1d8b6d)

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