20 questions, 20 answers, 20 defenses–now it’s my turn

Nate Silver posted 20 questions for [health care] bill killers, Markos Moulitsas of the Daily Kos answered and Jon Walker at FireDogLake answered. Silver is thrilled “that this debate seems to be evolving into something a little more civilized on all sides” and has posted his answers to the answers.

But he’s still wrong, on all but one point.

  1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?

    Moulitsas refuses to accept that this is the only bill on the table. Silver answers this essentially claiming that Liberals have tried everything possible to get a robust public option and failed. But he doesn’t answer Moulitsas’ point that “the point of reform isn’t to shovel taxpayer dollars to the insurance companies.” And that is just what the current proposal does. As my 69-year old mother put it, instead of providing insurance for some 47 million people, this provides 29-36 million more customers for health insurance companies. And it does so without any meaningful cost control.

    Walker thinks the threat to use the reconciliation procedure could have forced some obstructionists to back down on a filibuster. I’m inclined to accept Silver’s point here. Yes, reconciliation can be used to pass something with only 51 votes, but as Senator Ron Wyden explained to Rachel Maddow, “with reconciliation, you can‘t get any of the insurance reforms. Reconciliation deals with budget matters. So you can‘t get the protection for folks from preexisting conditions. You can‘t protect them from cancellations. You can‘t even get the exchanges up and running.” Though I see Moulitsas and Walker both think it can be done and that Silver thinks you might be able to do it, I don’t see how you could legally institute a public option under these rules. And even if you can do it, we already have enough problems in this country with hypocrisy about who should abide by rules and who can simply ignore them.

    But the point isn’t how Silver frames it. It isn’t “to provide in excess of $100 billion per year in public subsidies to poor and sick people,” but rather–as Silver acknowledges in his discussion of question 19–to make sure they have access to affordable health care. By failing to institute meaningful cost controls, this bill trusts insurance companies whose abuses have led to the need for reform. That means this isn’t reform. It simply opens a pipeline from the U.S. Treasury to the health insurance companies.

  2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?

    Moulitsas thinks “the insurance industry would simply absorb the new subsidies just like universities have raised tuition to shovel up any increases in financial aid.” Walker doesn’t trust the subsidies to remain adequate. To some degree, Walker’s objection would apply to anything that passed, but Moulitsas’ argument is much harder to answer. Particularly if, like me, you’re a starving student who has been watching tuition rates and fees go up year after year like we’re made of money. And Silver simply punts.

  3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?

    Moulitsas rephrases the question: “Where is the evidence that insurance companies would rig the system to extract record profits? I don’t know. Perhaps the last decade or two might provide the answer.” That’s clever, but Walker points out that “the bill doesn’t need to increase profit margins to make the insurance companies more profitable. It will increase overall profits by expanding their customer base, which has be shrinking for years.”

    Silver argues that insurance company profits are low. Perhaps that’s because they pay their executives so much. Or perhaps it’s because, as Walker wrote, their customer base has been shrinking. Or perhaps it’s because, as Moulitsas suggests, they’re fixing the books.

    But the fact is that it doesn’t matter. The health insurance companies–and their profits–are only one part of a hugely expensive problem, that we have the world’s most expensive health care system but really a rather low standard of care. Simply throwing money and customers at these companies cannot rectify this.

  4. Why are some of the same people who are criticizing the bill’s lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?

    Moulitsas sees it as targeting “blue collar workers in high-risk jobs, or workers that have given concessions on wages to preserve good benefits packages.” Walker writes, “The excise tax is designed horribly. It’s a very weak cost control that will only reduce NHE by $100 billion by 2019. That is a 0.3% reduction. And it will only do that by encouraging employers to provide their employees with worse quality insurance policies that cover fewer procedures and have higher co-pays and deductible.

    Silver’s answer to this, other than flatly denying Moulitsas’ claim, is horribly unclear. He cites the Center on Budget and Policy Priorities who explains that “over 80 percent of the revenue generated would come not from the tax on insurance premiums itself, but from income and payroll tax revenue on the tens of billions of dollars of higher wages that workers would receive — as employers modified their health plans to avoid the excise tax and converted what they had been spending for health coverage in excess of the tax thresholds into higher wages and salaries.” Sorry, but that’s a win for general revenue that does absolutely nothing to contain national health expenditures.

    Moreover, “many of the plans that would be affected apparently are smaller plans with a below-average number of enrollees.” I don’t know but I’m guessing that’s a lot of blue collar workers. Finally, the CBPP confirms Walker’s point, writing “Employers would modify their health plans to stay within the thresholds for the excise tax, and they would convert the resulting savings into higher wages or other fringe benefits for their employees.” Higher wages for that portion of the workforce with these sorts of insurance plans does not make insurance more affordable for everyone else.

    So Silver merely creates the appearance of rebutting the answers on this without actually doing so.

  5. Why are some of the same people who are criticizing the bill’s lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?

    Moulitsas hits this one on the head: “Because without premium caps or a public-run competitive option, there is no incentive for them to lower their premiums.” Because there is no more competition than we already have. And we’ve seen what that does. As Walker writes,

    This bill fails to guaranty either quality or affordable health insurance. There is no ban on annual limits, meaning the insurance companies can now put a cap on how much they will pay out. They will still be allowed to drop their sick customers and deny claims if they decide their customers need an “unreasonable” amount of health care. And the maximum out-of-pocket limit is far too high. It will not stop medical bankruptcy if you get really sick, which makes a mockery of the whole idea of insurance.

    Silver answers that the individual mandate is necessary if you’re going to require companies to accept people with pre-existing conditions. And he’s right. But Walker is right too, and Silver doesn’t actually answer him.

    Silver insists, “The bill on the floor fact does create a somewhat more competitive insurance market — through the exchanges.” That’s laughable. While exchanges might facilitate price comparisons for some people, they will still have essentially the same choices they have now. Silver is flatly wrong.

  6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: “forcing you to buy government-run insurance?”

    This alleged Republican talking point contradicts itself. Silver explains it better in his defense:

    I just think it’s liable to have more to do with the extent to which insurance is perceived as affordable, rather than who you’re buying it from — someone who gets deeply subsidized insurance from Aetna is not likely to complain, whereas someone who gets “unaffordable” insurance from the government probably will. (And for what it’s worth, the CBO has estimated that premiums for the public option would actually be higher than those for private plans, although in exchange for much better coverage.)

    But it is important to remember why the “premiums for the public option would actually be higher than those for private plans.” This issue arose when it was revealed that insurance companies would essentially be able to cherry pick their customers, perhaps through unaffordable rates. That made the public option into a dumping ground for the people needing the most coverage. Because these costs would not be spread among that healthier portion of the population whose money the companies deign to accept, of course the public option’s costs would be higher, and so its premiums would be higher.

    In the absence of a public option, however, an individual mandate leaves individuals at the mercy of a very few companies who have established a record for abusive practices. So if you’re going to have an individual mandate, you must do something to curb these practices. And the present bill goes nowhere near far enough to do this.

  7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?

    Moulitsas responds: “Is this argument that the mandate doesn’t matter because too few people will be subject to it? If so, then strip it out. It shouldn’t matter.” Actually, Silver concedes this: “The point is that not that very many people will fall into the category of feeling like they’re ‘forced’ to buy insurance because most of them will continue to get policies through their employers, or will think they’re getting a pretty good deal.” But if we say there is a problem with an individual mandate, it is reasonable to ask how many people are affected by it. Walker effectively points out the difference between the 47 million uninsured and the 29-36 million who would be forced in:

    If people are “exempt” from the individual mandate because the private insurance companies made insurance too expensive for them to buy (which thanks to the 1:3 age rating would be the older sicker people most in need of insurance) what is the point of the individual mandate? This sounds like a recipe to price out the old (nonprofitable) and force only the young (profitable) to buy insurance. The individual mandate should only be used for an “everyone in” system. This is “everyone in” except those whom the private insurance companies price out of the market.

    Walker’s point is that the people who most need insurance will be among the 11 to 18 million who won’t get it under this plan. Silver doesn’t answer that.

  8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?

    Moulitsas writes that “if anything, this argues for pushing for the most progressive bill possible.” But another question to ask is, if the public correctly perceives this so-called reform to be a sham, how much longer will it be before they ever again vote in Democrats? Silver effectively concedes this when he writes, “There’s almost no way that Democrats will end up with more votes for a public option at any point in the near future.”

  9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?

    Moulitsas correctly treats this as a straw person:

    No, the idea is to get the best possible legislation today. We may not be able to get something with reconciliation before Obama’s State of the Union Address, but I don’t think something this important should be beholden to something as trivial as a speech, even one as important as the SOTU.

    As Walker writes, “The meltdown is coming either way. This Senate bill is at best a very expensive band aid, and at worst a way to quicken the meltdown.” Silver acknowledges the straw person but writes, “If you examine the collective response to recent cataclysms such as 9/11, the financial meltdown, and global warming, it has been a little scary for progressives.” The truth is that it’s been scary for a lot of people. The responses to these events have been poorly thought through. But what we’re getting now has also been poorly thought through. This is an indictment of the political system rather than an argument for a flawed health care plan.

  10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?

    This question is laughable. In August, “support for a public option [was] at a robust 77 percent, one percentage point higher than where it stood in June.” Now, “fifty-one percent of poll respondents said they oppose the proposed changes for the health-care system.” Moulitsas writes (relying on a different poll):

    Given that the current bill only has 32 percent support, I don’t think this turd of a bill in the Senate has much support of anyone, much less party activists. And the voter intensity numbers are clear — base Democratic voters are planning to sit out 2010. And I doubt 18-29 year olds — a key part of the Democratic base — are going to be thrilled with a mandate. In fact, it may be the single least popular item in the bill.

    What we’re looking at here is a plan to leave the most vulnerable uninsured while sticking younger, healthier people with a tab for enhancing insurance company profits. I’m guessing 18-29 year olds just aren’t that stupid. Silver tries to answer this by citing a column that doesn’t even mention the public option, let alone rebut polls indicating its importance.

  11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?

    Moulitsas thinks the Democrats damage themselves by “caving in to Lieberman, Republicans, and corporate interests,” that doing so “sends the message that the Democratic super majorities are irrelevant, and all the hard work from the last four years in electing them was a wasted effort.” That’s pretty apparent. Silver admits this, saying he’s “actually coming around to the view that Democrats are about equally screwed either way, in large part because of the vehemently negative reaction that we’ve seen from the left over the past 72 hours.”

    I would point out that this isn’t a “reasonable plan.”

  12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?

    Both Moulitsas and Walker discount the objections to reconciliation, but when I see the actual arguments against it, they don’t sound like bullshit. I think they’re coming from people who are intimately familiar with the process. This is the one point I’ll concede to Silver.

  13. What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?

    Both Moulitsas and Walker say essentially the same thing, but Moulitsas is a much more colorful writer:

    Fallout with the DC press corps? They didn’t mind when Republicans used it to pass their tax cuts under Bush, but that’s a different time. I’m sure they’ll hyperventilate about it now. The voters? I’ve seen no data that suggests they care about process. Just results. Democrats would cheer, Republicans would bitch, but those guys will bitch anyway.

    Silver essentially answers by writing, “The Bush tax cuts were popular; health care is not.” I would ask whom “the Bush tax cuts were popular” with, but I’m guessing they did manage to convince the working class that the cuts would be to their benefit. But to claim that “health care is not” popular flies in the face of those poll results showing 77 percent support for the public option.

  14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?

    Walker actually has the pithier answer here: “First you only need 50 votes plus the vice president to break the tie. Second, are you really asking progressive to not stand up for better policy because there are possibly 11 Democrats who will bring down the reconciliation bill to protect their absurd Senate clubhouse feel?”

    Silver estimates the votes aren’t there. And he might be right. But what’s in question right now is whether the Democrats can even muster 60 votes for the plan they’re advancing. If that falls through, and I’m thinking it very well might, well, here’s Walker again: “The Democrats in the Senate seem were willing to give Joe Lieberman anything he wanted to get a bill labeled ‘health care reform’ passed. If they will swallow their pride for Lieberman, they will do it for reconciliation if that is the only way the can get the ‘win.'”

  15. Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?

    Moulitsas suggests, “Expand medicaid, add a national exchange instead of the state one, get rid of mandate, etc.” Then he wonders what New York Democrat Representative Anthony Weiner wonders when he points out that “Some of us have compromised our compromised compromise.” Moulitsas asks “how many concessions has the other side made? Maybe it’s time for a ‘compromise’ that actually includes a compromise.” Walker writes, “Progressive have zero power in Washington if they can not draw a line in the sand and say enough is a enough. Only by being willing to bring down a bad bill will they force those in power to listen to them instead of Joe Lieberman.”

    Silver accuses both of using the public option as a proxy for progressive influence. But he starts from a presumption that this is an essentially good bill that still deserves passage. It’s pretty clear, however, that this simply isn’t true.

  16. What are the chances that improvements can be made around the margins of the plan — possibly including a public option — between 2011 and the bill’s implementation in 2014?

    Moulitsas writes, “[If] everyone surrenders now, the impetus for such tinkering will be gone. If people are angry and campaign on these key issues, then political pressure will be maintained for further action. The ‘surrender now’ crowd actually makes further tinkering less likely, not more.” Walker writes, “If Obama does not feel a need to listen to progressive on the issue of health care reform at this moment, I don’t see how that will change between now and 2014. If anything, when people are not looking the lobbyists will go to work slowly crippling all the new regulations this bill will add.”

    Silver is trying to advocate a “split-the-bill” strategy. This is to pass what can be passed now and work on it further later on. But for a whole bunch of reasons in addition to health care, I really don’t think that’s happening. I wrote earlier:

    [Obama’s] escalation of the war in Afghanistan is simply bone-headed. His acceptance of the Nobel Peace Prize unmasks a bipartisan warmongering. His administration is acting to cover up war crimes.

    Obama’s rhetorical harshness towards bankers is belied by the fact he undermined his own negotiating position with them, the fact that he believes in them, and the fact he relies on them for economic advice even though they have only profited themselves (UPDATE: harshly phrased corrections to linked article here) and have no real plans to reduce unemployment. His handling of the economy is subject to withering criticism from both left and right.

    Obama’s plans to address climate change (as well as those of Western countries generally) are a fraud. His record on civil rights is deplorable. He can’t even get it right with marijuana.

    With all that and more going on, it is easy to overlook poll results showing that people are so unhappy that some 44 percent in the U.S. want George W. Bush back. Bush was heavily criticized for being “a divider, not a uniter,” but polarization seems only to have become even more extreme under Obama.

    Poll results show people are increasingly unhappy with Obama; his public approval rating is down to 47 percent. I don’t have any idea how this plays out. The same poll shows that “the entire Republican Party . . . continues to maintain a net-negative favorable/unfavorable rating, 28 percent to 43 percent.” Democrats are only a little better, but who knows for how long: “For the first time in more than two years, the Democratic Party also now holds a net-negative rating, 35 percent to 45 percent.” It’s hard to see who is going to vote for whom with these kinds of numbers. And it’s simply nuts to bank on further health care reform after this. I return to Moulitsas’ point that “if anything, this argues for pushing for the most progressive bill possible.”

  17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a ‘mandate’ for a public option that could be inserted via reconciliation?

    I don’t know where Silver comes up with this question. There is no national referendum process. People are going to vote for candidates based on their expectations of those candidates, which will largely be based on their experience with those candidates. Moulitsas writes, “The public option remains popular, despite the year-long demonization process by insurance interests, Republicans, teabaggers, and even some Democrats. . . . But if 2010 is a referendum on that current Senate bill, we’re in deep trouble.” Silver refers to his earlier answer, writing “that the fight over the public option, to the extent that people regard it as a gratifying organizing exercise, will not end just because a bill has been adopted that doesn’t include one.” I hate to break this to you, but 2010 is now two weeks away. A public option would probably help the Democrats but as Moulitsas also wrote, “2010 will be all about Democratic ‘socialists’, and HCR will be Exhibit A in the wingnut playbook.”

    It’s not even one year into his first of two possible four-year terms, but I’m seeing Obama as a lame duck. Even if he isn’t a lame duck, he might as well be for all the good he and the Democrats are doing progressives. We need a third party to bring some real pressure to bear.

  18. Was the public option ever an attainable near-term political goal?

    Moulitsas answers:

    Yes. But even if it wasn’t, perhaps we would’ve been better off starting with a Medicare For All approach, or at least an expansion (back when Lieberman was for it). I’m sure someone will write a book about all the tactical mistakes made during this battle. There’s no doubt the Democrats blew it big time, but that’s not the same as saying a desired policy outcome was not attainable.

    Moulitsas is arguing for a single-payer plan. And he’s right. Democrats didn’t start with their strongest bargaining position. They already conceded the Republicans’ “socialism” argument by starting down a slippery slope with the public option. Now we have again what we always have, socialism for the rich, capitalism for everybody else.

    Silver pats himself on the back, saying that health care reform was always going to be a tough battle: “To use [the public option] as a litmus test for progressive efficacy was rather risky, in the same way that it’s risky to declare your training regime a failure because you collapsed on the last stage of the Ironman Triathalon.” Silver starts from a position that the public option was not that popular an idea; as I wrote above, he cites as column as evidence for this that actually says absolutely nothing about the public option and he ignores the polls that say the public option was a whole lot more popular than the present plan.

    So unsurprisingly, this amounts to the fact that politicians do not represent the people. If Silver criticizes the framing of the public option as a proxy for progressive influence, we might instead view the failure to pass meaningful health care reform as a failure of a system which is naïvely claimed to represent the people. There are many reasons why this is the case. But it cannot help that we have a deeply polarized country that no longer makes sense as a single country, where politicians are so remote from the people that they are clearly no longer accountable to the people in any meaningful way.

    That isn’t an argument against pushing for a public option. It’s an argument for breaking up the country into manageable chunks.

  19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?

    Silver misses the importance of a public option as meaningful competition in an otherwise oligarchic industry and “find[s] more disingenuous . . . the people who have suddenly decided that the bill was really about cost control after all, and that the coverage aspects of the bill are merely incidental.” Walker writes that he has “always said the individual mandate is only acceptable if the government provide everyone with access to decent cost effective health insurance.” And indeed the criticism of the U.S. health care system that has long compelled reform has long been that it is the most expensive system in the world while delivering mediocre results and that it left an increasing number of people unprotected. People are dying because of this but the best this political system can manage is a system that abandons the most vulnerable while compelling the young and healthy to fatten insurance company profits.

  20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?

    Moulitsas shifts blame to Montana Senator Max Baucus. Walker says he made his arguments “long before Joe Lieberman was empowered by Harry Reid to remove the public option.” Silver, while avoiding attacking Moulitsas and Walker directly, insists he’s never seen so many personal attacks. I think perhaps that what Silver is really seeing is a different origin for these attacks.

    In supporting Democrats, progressives have hitched their wagon to a horse that’s going the wrong way. Now we had a popular promise of health care reform that has evaporated for the most venal reasons. A lot of people are feeling betrayed. But what can we say about the right wing’s attacks on its opponents? We’ve been labeled as “terrorist sympathizers,” as “unpatriotic,” and as “betraying the troops.” Communism–technically a notion that we all owe something to society and that society owes something to each of us–has been demonized. Socialism–technically an idea that distribution of goods must be fair–has been demonized.

    Meanwhile, capitalism remains beyond challenge even as the gap between rich and poor widens, people die for lack of health care–and will continue to do so whether or not this plan passes–and war criminals walk free. It’s about damned time that some invectives hurl the other way. But Silver only notices progressives’ howls of protest.

Silver’s arguments are in many cases simply wrong and in some cases disingenuous. Citing a source for support that doesn’t even mention the topic does not win points with me. But all these interlocutors retain an investment in a failed political system in a failed country. We need to start talking about change that goes far beyond health care. And the sooner, the better.

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