Saturday, December 26, 2009

Realism Triumphs Again

Well, it looks as if health care reform is going to pass. As you know, the Senate version was approved early on December 24, and one way or another the Senate and House versions will likely be harmonized, maybe even in time for the President’s signature before his State of the Union address late next month.

This is not an ideal health care bill. For the Republicans, of course, every health care bill is fatally flawed and to be strenuously opposed. Many Democrats, included the President, it seems, wanted things included in the health care bill that are not there. Many compromises were made, but such compromises had to be made in order to get the necessary votes to pass the bill.

The current issue of The Economist opines, “Every time someone tells you to ‘be realistic’ they are asking you to compromise your ideals” (pp. 38, 40). That is probably true. But the President and many senators had to be realistic and compromise their ideals to some degree in order to get a health care bill passed.

We have to realize that “politics is the art of compromise.” (I have been unable to find a source for that adage.) Also, “politics is the art of the possible” (Otto von Bismarck). As I wrote earlier, in spite of his fine Nobel Lecture, President Obama’s deployment of troops to Afghanistan showed the triumph of realism over idealism. And now with the health care bill, we see realism triumphing again.

While the health care bill leaves a lot to be desired, it is not a bad bill. Although it still leaves out millions, this reform will extend coverage to more than 30,000,000 Americans who don't have it now. This is no small matter, for that number represents nearly 10% of the nation’s population.

The health care reform bill is one example of democratic socialism at work. It is democratic in that it will be enacted by Congress, the democratically elected leaders of the nation. It is socialistic in that the government guarantees health care for at least most of the citizens of the nation.

The health care reform bill is socialistic in the same way that Social Security and Medicare are socialistic. There are problems, mostly financial, with both of those programs. But would any except the wealthiest among us want to do away with Social Security and Medicare? (I challenge those of you who might be opposed to the health care bill because it is socialistic to voluntarily forfeit your Medicare coverage.)

I would like to have had an “ideal” health care reform bill. But I am glad that realism triumphed over idealism, for in this case something is far better than nothing.


  1. Thanks for the good posting about this important moment in U.S. history. I know people who desperately need affordable health care now, and I hope this plan will help them soon.

    You might enjoy this NY Times Op-Ed piece by the Nobel-prize-winning economist Paul Krugman (if you haven't read it already), in which he also comments on the current health care bill:

  2. We just finished watching the George C. Scott version of Scrooge in "The Christmas Carol." It makes me happy that a Health care bill has passed both Houses, and it feels good that it passed just before Christmas. The timing might even make it more palatable to the "Scrooges" still with us in December, 2009. J.T.S. (A longtime admirer ;-)

  3. One of my Thinking Friends, predictably, sent me the following comments. I think he points out some legitimate concerns, so I want other TFs to consider these comments. I will make a brief response in a separate comment below.

    "This first step toward universal health care creates the exact problems that you pointed out about In-As-Much and the Salvation Army a few blogs ago. This health care legislation creates dependency to and on the Federal Treasury, just as Medicare and Social Security has created. It is a dependency that the Federal Treasury cannot afford and is being used by politians to get re-elected and feel morally good about themselves. It is, as politicians have discovered, easy to be genereous with other peoples money. Dependency is anonther form of addiction and slavery and I will never compromise on anything that creates dependency, addiction or slavery. The very question you pose about 'who would give up Medicare or Social Security' proves my point about the addiction. Safety nets create irresponsible living and eliminate the motivation to change. I, like most conservatives, believe that reasonable health care can be established with changes in Federal regulations, with no long term commitment of Federal, State or Local dollars and without creating an addiction to a federal program. 'Atlas' will eventually 'shrug' and this new federal 'freebie' is unsustainable and will not be free; I hope and pray it does not cost us our freedom. In the words of Margaret Thatcher, 'The problem with socialism is that you eventually run out of other people’s money.'"

  4. This is a response to just part of the previous comments, but I would like for you to consider the following:

    In Great Britain, the National Health Service was established in 1948 in order to “provide healthcare for all citizens, based on need, not the ability to pay.” Today it is the world’s largest publicly funded health service. (The NHS was in operation, of course, all the time that Margaret Thatcher was PM of UK.)

    And note this: in 2007, the UK spent 8.4% of its gross domestic product on health care. The United States spent 16% of its GDP for health care in 2007, and the Congressional Budget Office predicted that that figure would be 25% by 2025.

    The U.S. health care bill due to be passed next month not only provides coverage for nearly 10% of the population who do not have it now, it is also designed to curb the spiraling cost of health care in this country.

  5. Good word Leroy. I want to give a person like Obama some more time also. He was trained as a faith based community organizer back when that was not a positive to many including the church. Karen and i had some of the same trining a bit later. The focus is on self interest of the community. I see him trying to listen and hearing the self interest in each situation. That is new for us and hard for some to take. Yes, the health bill sucks in many ways, but it is better than we have and more folks wil have a chance. I stilll live in silly as that might sound. I worry more about how we let Israel continue their killing fields in Palestine. With Obama's chief of staff a dual citizen and former Israel Army man, one ownders the advise he is getting. Free Palestine! Also at the Parliament we lasck leadership in East Timor and other places as well as the oppression and killing continues. Please take your shoes off at the airport! Merry CChristmas folks, and a Blessed New Year. Thanks Leroy Hi June!

  6. To the points made by the person whose comments, Leroy, you provide above, I note from the book I'm currently reading --- "Consumed --- How Markests Corrupt Children, Infantilize Adults and Swallow Citizens Whole," the argument that it is not the government that has created dependency, enslavement and addiction, but, rather an ideology (or ethos, as the author puts it) of consumerism that claims that all matters can be privatized -- that, in fact, according to Margaret Thatcher, there is no society, only individuals. The author asserts that we have become slaves to consumerism and free market liberalism. Interestingly, the author cites Hannah Arendt, who wrote famously about the "Origins of Totalitarianism" and who reminds us that political freedom is defined by participartion in government rather than freedom from its reach. The author argues that "privatization has not only diminished our capacity to shape our common lives and determine the character of the civilization in which we want to live; it has made us less free."

    Like the author, and like Hannah Arendt, I believe it is not freedom that seems chosen by us in our circumstance of rampant consumerism and privatization, but, rather, a slavery of a different sort. Slaves to an ideology that we must consume for the benefit of the corporation because "what is good for GM [or United Healthcare, or Aetna] is good for America..."

  7. These are serious matters. I've been reading the thoughtful remarks for several days, now. I don't have much to contribute other than noting in one TF's comment the allusion to Ayn Rand's "objectivist" philosophy (through her work 'Atlas Shrugged') while also appealing to Federal Regulations of (now mute) current health care systems and the economy seems to capture well the contradicting forces at work in our thinking about these issues.

    I have yet to meet a reader of Atlas Shrugged who did not think him or herself one of the ones carrying the burden of the economy for the enjoyment of the rest of the civilization's slackers (it's kind of like Calvinists who never have a doubt about themselves being among the elect). And in only a few cases have I met a reader of that book who would not find Rand's objectivist assumptions diabolical if he or she were not already living in such prosperity.

    I myself find them simplistic in their analysis of the complexities of human beings and human society. Frankly, I have serious doubts about the notion of being "self-made" at anything. Humans are social beings; they rely on community for their species to survive. Individualism is an interesting social experiment and necessary for human well-being in small doses. But in the end, humans cannot survive, grow, prosper, and find happiness without the interrelationships in which we help each other.

  8. The belief that inequality (in resources, income, etc.), based on assumptions of self-made success, is good for society is not supported by recent research. I've just completed a fascinating book called "The Spirit Level: Why Greater Equality Makes Societies Stronger" wherein the authors (two epidemiologists) have shown the relationship between high inequality nations (the U.S. being one of them) and social dysfunction (based on literacy rates, incarceration rates, mental health, physical health, obesity, education performance, teenage births, social mobility and violence). There is a strong relationship between high rates of violence, high levels of incarceration, high levels of obesity, low social mobility, lower education performance, high rates of heart disease, etc., and greater societal inequality (based on income). Importantly, high average or absolute income (the ol' rising tide raises all ships theory) has very little impact on societal dysfunction, rather greater equality (based on the variety of studies --- I think the authors reference their review of over 200 studies in addition to their own studies) seems to be the greatest determinant of societal dysfunction. Interestingly, the research shows that the same relationship(s) can be shown at the state level in the United States (with states higher in inequality showing greater societal dysfunction).

    I recommend this book to anyone interested in social justice, inequality, and societal dysfunction.

  9. I just hope everyone is ready for the unintended (unplanned) consequences of this well intentioned social engineering.

  10. By the way, I am interested in how many of the commentators actually provide health care of any sort to others in a professional sense. It is my livelihood, and as a result the changes will personally affect my practice and the patients who seek care from me. As long as I am able I will provide care to the level that I would expect for myself and with the personal interaction that I would also expect. However, in time with additional people in the system and fewer providers (see Canada and the UK), the waiting times for basic care will increase with shorter times allocated to each patient encounter. From interacting with colleagues, the promised efficiency increases from electronic medical records actually slow down the the availability of care but dramatically increase the efficiency of insurance audits.

    One of the problems with the near financial collapse last year was that the large Wall Street banking firms had their risks socialized but their potential rewards privatized (which leads to excessive speculative behavior--no consequences for poor decisions). The opposite situation is happening in health care where the rewards are socialized but the risks (i.e. malpractice) remain privatized. As a result, many of the brightest will enter into fields where the rewards are greater and the risks are lower (e.g. politics, law, investment banking, etc.).

    These are just a few of the unintended consequences which will follow. The challenge I have with this is that health care inflation did not come into being until the late 1960's when the federal government became involved in health care through medicare and medicaid. The government with the AMA set prices (see the history of price controls and the unintended results from well meaning policies of the past--e.g. 1973 gas crisis, etc.) and to this day continue to set prices through the CMS. If someone is a private pay individual, the provider must charge that patient the same amount as the provider charges patients covered by insurance. The insurance companies frequently pay the provider as little as 40 to 50 cents on the dollar for the entire bill while the private pay individual has to pay the entire bill or be handed over to collection. If the provider charges the private pay patient less, then the provider is committing insurance fraud. It is quite a system developed by the government with the willing aid of private insurance companies to force everyone into "needing" insurance. I liken this behavior and action to the mob vandalizing a business and then returning to the same business with the offer of providing protection from such actions. The ones responsible for health care inflation are now the ones who are going to protect us from the high cost of health care. Wow, we are sheep--BAH, BAH.

  11. Just rereading the string of thoughtful comments I cannot help but muse that anyone doubting such a thing as "socially constructed reality" would find evidence to the contrary here. Living in fear of unintended consequences and being shaped by a system of our own creation seems to be the definitive evidence. Ayn Rand is wrong again: ideas are a (non-material) defining aspect of reality. What is more, I wonder whether one of the hermeneutical keys to understanding this string of comments does not lie in the social location of each of the contributors. I would predict that the participants are highly educated, upwardly mobile, middle-aged (sorry CT), securely employed, possibly white, with the exception of one, KS, male, and reasonably well-financed. Is this conversation evidence of the conflict between or just within the social classes in America? Is there a voice out there from anyone not a member of that demographic?

  12. Paraphrasing one of the Indian representatives to the recent UN sponsored Global Warming Conference in Copenhagen, this debate appears to be what the idle rich do while we (the Indians of the subcontinent) are more interested in developing and taking care of the citizens of our country. Thanks MPH for highlighting the lack of diversity in the comments. However, it is interesting that a non-diverse group like the founders(i.e religious, economic, racial, and gender) of the US could develop documents like the US Constitution and the Bill of Rights. It is not a fear of unintended consequences that I write these comments, but rather that all actions and policies have consequences which should be explored, debated, and thoughtfully analyzed before making a blind leap of faith. From such an academic group of responders, this lack of exploration of the consequences of the actions is fascinating.

  13. If I could just presume to offer one more respectful comment in response to DHJ, I will shut up and press on to LKS's next fascinating post. Without denegrating either the work of the framers or their documents (by which we are still governed), I would just point out that the US Constitution and Bill of Rights may serve equally as examples of the narrowness and presumption of privilege. Neither document had the forethought to include sizeable proportions of the population, namely women and African slaves (let alone other minorities such as native Americans not regarded as falling under their ruling purview). Neither of those were regarded as persons whose rights needed protecting, we can safely assume. Like the Bible, the Constitution and Bill of Rights must be interpreted (a whole other conversation) and reinterpreted in order to find relevance to each successive generation. This process makes all the more imperative an awareness of the role power, privilege and the resulting presumption of influence play in the formulation of policy.

  14. Capitalism is like fire, which can be very useful when under control, but capable of burning down your house when it is not. Socialism is like a fireplace, which can control fire, but not replace it. This is why all successful modern economies are stuck with the label "mixed."

    We have a fair amount of socialism in our society, think of police, fire departments, schools, libraries, roads, and so forth. We have a lot of capitalism in our society. Where there are efficient markets delivering sufficient affordable goods, we encourage capitalism. Unfortunately, some markets are notoriously inefficient in one way or another, so we have public schools and police.

    Health care has been debated, explored, and tested on this boundary line for a century. Today America ranks number 1 in cost and number 37 in quality of health care. We already have a large portion of health care provided by and/or paid for by the government. An efficient market would not get this kind of intense scrutiny. No other leading economy has such a chaotic health care system. Frontline on PBS recently rebroadcast a report based on a survey of several major world health systems, namely, England, Germany, Switzerland, Japan and Taiwan. None spent more than half the amount of GDP on health care that the US does. While they varied in how much capitalism they used in their systems, all had strict price controls. Or, for a perhaps more entertaining list, check out Michael Moore's Sicko tour of Canada, England, France and Cuba. He has an interesting side trip to Norway in the DVD extras.

    Let me end with the caveat, for those who might not know, that I work for the government. But then, most people will work for either private enterprise or the government, so it is hard to imagine what a neutral observer might look like!