Commentary Magazine


Topic: health care

Don’t Underestimate Gruber’s OCare Impact

Liberals are in retreat this week as they recover not only from the historic defeat suffered by Democrats in last week’s midterms but also from the fallout from Jonathan Gruber’s confessions about the deceit at the heart of the effort to pass ObamaCare. The three videos that have surfaced in which Gruber strips away the veil of lies from the campaign to pass the misnamed Affordable Care Act is a major embarrassment for the administration. But while many on the right are treating this as a smoking gun that should doom President Obama’s health-care legislation to repeal, liberals are confident that this storm will pass and that the law will survive. But while they are right that nothing—not even a similar admission from the president himself—could wipe it away, they are wrong to think Gruber’s statements haven’t significantly altered the debate and may yet play a crucial role in its destruction.

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Liberals are in retreat this week as they recover not only from the historic defeat suffered by Democrats in last week’s midterms but also from the fallout from Jonathan Gruber’s confessions about the deceit at the heart of the effort to pass ObamaCare. The three videos that have surfaced in which Gruber strips away the veil of lies from the campaign to pass the misnamed Affordable Care Act is a major embarrassment for the administration. But while many on the right are treating this as a smoking gun that should doom President Obama’s health-care legislation to repeal, liberals are confident that this storm will pass and that the law will survive. But while they are right that nothing—not even a similar admission from the president himself—could wipe it away, they are wrong to think Gruber’s statements haven’t significantly altered the debate and may yet play a crucial role in its destruction.

Writing for the Washington Post’s The Fix column, Aaron Blake writes to claim that no matter how much they scream about the videos of Gruber in which he acknowledges that the law was drafted so as to deceive members of Congress, the Congressional Budget Office, and the American people (whose “stupidity” ensured its passage), it won’t have an impact of the future of ObamaCare.

Blake is probably right when he says the debate about the law is already so polarized that nothing will alter the opinions of those who are for or against it. However, in citing the consistency of the polling on the legislation, he should also note that a majority of Americans have always opposed it. This runs contrary to the expectation of both hopeful liberals and fearful conservatives that once implemented, the ACA would become as popular as Social Security or Medicare.

That didn’t happen because unlike those government programs, which were controversial when first suggested but ultimately accepted by everyone, not everyone benefits from ObamaCare. Indeed, there may ultimately be as many, if not more Americans who are net losers from the law than there are winners who now have health insurance. While the disastrous rollout of the law and the exposure of President Obama’s lies about allowing consumers to keep their insurance and doctors if they liked them has already done damage to its reputation, once the more unpopular individual mandates are imposed in 2015 (they were postponed by the president in order to avoid more damage to Democrats in the midterms) and insurance rates start to skyrocket, ObamaCare isn’t going to be winning more fans.

Blake’s also right that this isn’t the first evidence of deceit on the part of the Democrats who passed the law in a party-line vote. Then House Speaker Nancy Pelosi’s infamous line about the law having to be passed in order “to find out what’s in it” is probably just as bad as anything Gruber said.

Moreover, his conclusion that the law will, in one form or another, remain on the books until 2017 at the earliest, is also inarguable. Repeal or a complete restructuring of the scheme will require a Republican-controlled Congress and a Republican in the White House, something that can’t happen until President Obama’s term in office is over.

But, even if we acknowledge all of this, it must be understood that Gruber’s comments illustrate one basic fact of American political life that liberals have a hard time accepting: the debate about ObamaCare is not only not over, it’s just getting started.

The president and other Democrats have been fond of mocking the GOP-controlled House of Representatives’ repeated votes on repeal. Each such vote was a futile exercise in symbolism since the Democrats still had the Senate and the White House. Further, such votes won’t be any more useful as long as Obama remains in office and Republicans lack a veto-proof majority.

But the impact of the law’s full implementation will, like it or not, generate plenty of debate about how to fix a scheme that is bound to cause more damage in the next two years. This will keep the ObamaCare debate alive and well. And anyone who thinks the Gruber comments won’t be endlessly thrown in the faces of the law’s defenders isn’t paying attention. That matters because whatever the American people think about the law, and most have always rightly disliked it, they don’t like being played for saps by elitist liberals. That means the Gruber admissions will be a gift that keeps on giving for Republicans right through the 2016 elections.

However, the greatest impact of this may be, as Blake acknowledges in passing, on the Supreme Court’s decision in King v. Burwell, the lawsuit that alleges that federal subsidies given in states that don’t have their own insurance exchanges as mandated by the law are illegal. Gruber’s comments illustrate that the insistence on each state having one isn’t, as Paul Krugman alleged earlier this week, a mere “typo” but a glaring flaw in the law that could sink the whole scheme.

In 2012, Chief Justice John Roberts sided with the court’s liberals and ruled ObamaCare constitutional in an opinion that led many to believe he thought it best to keep the Supremes out of a health-care debate that should be decided by the voters and Congress. What the White House should be most worried about is not the way Gruber’s candor is playing on the cable news channels but in Roberts’ mind. The open talk about the lies that led to the legislation’s passage might be enough to convince the chief justice to go along with conservatives who rule against the government and bring the ACA crashing down long before the GOP is able to finish the job.

If so, Gruber will have earned himself a place in American political history as the man whose honesty about his lies took down Obama’s greatest accomplishment.

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Obama Is Destroying Traditional Democratic Issue Advantages

Here’s an interesting, and potentially significant, effect of the Obama presidency. Issues that have traditionally been very strong Democratic ones no longer are.

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Here’s an interesting, and potentially significant, effect of the Obama presidency. Issues that have traditionally been very strong Democratic ones no longer are.

Health care is one obvious example. Historically it’s been an issue on which Democrats have dominated Republicans. No more. While the public still trusts Democrats more than Republicans on health care, the margin is single digits. And a recent poll shows that nearly 60 percent (58) of Americans disapprove of Obama’s handling of health care. Health care was a central issue in the GOP landslide in the 2010 mid-term elections, and it’s a key subject in this year’s mid-term elections as well. In almost every instance, Democrats are playing defense on health care.

Then there’s immigration, another issue that until now has been a potent one for Democrats. No more. A poll last week by AP-GfK shows that immigration is now President Obama’s worst issue. More than two-thirds of Americans (68 percent) disapprove of Obama’s handling of the immigration issue in general. Just 31 percent approve. Aaron Blake of the Washington Post points out, “when you separate those most passionate about the issue, the difference is even more stark, with 57 percent opposed and just 18 percent in favor. That’s more than three-to-one.” A CNN/Opinion Research poll from June showed Obama’s worst two issues were gun policy and illegal immigration.

What’s happened, it appears, is that the public is holding the Democratic Party accountable for the failures of Mr. Obama. Americans have for the most part cast aside the airy rhetoric and promises; they’re now judging the president and his party against reality. Their propositions and policies have been tested in real time, in real circumstances, and the results have been by and large a disaster.

This hardly means Republicans are home free on these matters. But it does mean there are enormous cracks in the foundation and Republicans have a historic opportunity to make inroads on issues that were once owned by Democrats.

Barack Obama may turn out to be a historic president, but not for the reasons Democrats were hoping for.

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Report Shows Veterans Affairs in Crisis

When Paul Krugman says a government health-care scandal is being blown out of proportion by conservatives, you can be sure the opposite is true. Such was the case when Krugman told his readers to be suspicious of cancer patients suffering under ObamaCare, and it is the case with the scandal at the Department of Veterans Affairs, as a new report makes clear.

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When Paul Krugman says a government health-care scandal is being blown out of proportion by conservatives, you can be sure the opposite is true. Such was the case when Krugman told his readers to be suspicious of cancer patients suffering under ObamaCare, and it is the case with the scandal at the Department of Veterans Affairs, as a new report makes clear.

To be fair, Krugman does not dismiss the VA entirely: “It’s a real scandal; some heads have already rolled, but there’s surely more to clean up,” he writes. But he understands the philosophical stakes here. Liberals (like Krugman) have used the VA as an example of the success of what he calls “an island of socialized medicine, a miniature version of Britain’s National Health Service, in a privatized sea.” If the VA were really in much, much worse shape, the island of socialized medicine would be best avoided. And now, thanks to a yearlong congressional investigation spearheaded by Tom Coburn, we know that the VA is indeed in much, much worse shape.

The key for leftist proponents of centralized health-care bureaucracy is to somehow disentangle the scandals from the policy. There’s no denying the corruption of the VA system; the PR strategy, then, is to claim that one is not the cause of the other. For the VA, this means showing that veterans are still getting good, even superior care from the VA system so there’s a scandal but no crisis. Unfortunately for the Obama administration’s dedicated spinners, that just isn’t the case.

Politico summarizes the key findings:

Delinquent doctors and nurses and lagging medical treatment at the Department of Veterans Affairs may have caused the deaths of more than 1,000 veterans and cost the U.S. $845 million in medical malpractice suits, Sen. Tom Coburn charged in a report released on Tuesday.

The deaths, which occurred over a 10-year period, resulted from VA officials prescribing unneeded and unmonitored painkillers to veterans, delayed treatment that caused cancer to go undetected and veterans waiting at times for months for procedures, the report found.

“More than 1,000 veterans needlessly died under the VA’s watch, and the Department in turn paid these veterans’ families $200 million in wrongful death settlements — the median payment per victim was $150,000,” the report states.

The investigation into ongoing issues at the VA also found that a doctor was able to perform “unnecessary pelvic and breast exams” on female patients, that minority employees faced racial discrimination and that illegal drugs were prevalent in VA facilities.

The report “shows the problems at the VA are worse than anyone imagined. The scope of the VA’s incompetence — and Congress’ indifferent oversight — is breathtaking and disturbing,” said Coburn, an Oklahoma Republican and physician who once worked in the VA system.

Wrongful death, systemic racism, sexual abuse, corruption–according to the report, the VA isn’t a model of care with some bad apples. And the allegations about how the VA handled–or didn’t handle–the infractions are disturbing:

A male doctor in Kansas was forced to register as a sex offender after five female patients accused him of performing inappropriate breast and pelvic exams, while a social worker in Oregon was placed on administrative leave after her affair with a veteran under her care was discovered. In both instances, the VA officials continued to receive pay while on leave.

A doctor’s pattern of sexual abuse got him on the sex-offender registry but still collected a salary? Could that be right? According to the investigation, it is; here’s the relevant paragraph from Coburn’s report:

While a Kansas VA official stated sexual abuse allegations are taken seriously by the Department, the doctor continued to collect a salary for nearly two years, although he was not permitted to see patients. He was placed on paid administrative leave in 2011, arrested by Topeka police in May 2012, suspended without pay in July 2012, and finally fired in May 2013. Coincidentally, this doctor’s “employment at Colmery-O’Neil overlapped briefly with that of another physician “who was hired within two years of acquittal on Florida charges he sexually abused multiple patients by performing breast and pelvis examinations unrelated to their medical needs. Prosecutors there said 16 patients filed complaints against” him, “but the doctor was welcome at Colmery-O’Neal in 2011 and 2012 before taking a job in Texas.”

As I wrote yesterday, and as this report confirms, the issue isn’t money: the VA wastes it. The real issue is that government health care lacks accountability and has certain constraints, and that even working with a more limited scope of care, as the VA does, it cannot reconcile the care it is supposed to provide with the reality of central planning.

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Solving the GOP’s Middle Class Problem

Yesterday the YGNetwork released a new book, Room To Grow: Conservative Reforms for Limited Government and a Thriving Middle Class. It includes essays by some of the top thinkers and policy experts in the conservative world, offering reforms in the areas of health care, K-12 and higher education, energy, taxes, job creation, the social safety net, regulations and finances, and the family. Yuval Levin articulated a conservative governing vision while Ramesh Ponnuru wrote a chapter on recovering the wisdom of the Constitution.  

(The New York Times story on the release of the book can be found here, a related event held at the American Enterprise Institute can be viewed here, and the book itself and chapter summaries can be found here.) 

For my part, I contributed an opening chapter to Room To Grow, the purpose of which is to define the middle class and summarize the attitudes of those who comprise it. Here’s what I found. 

When speaking of the middle class, there’s both a technical and a practical definition. The technical definition is households with annual incomes ranging from roughly $39,400 to $118,200. The practical definition is the broad base of Americans. Fully 85 percent of Americans consider themselves as part of an expanded definition of middle class (lower, upper, and simply middle class). It’s people who don’t consider themselves rich or poor and who can imagine their fortunes going either way. 

Any successful political movement and party need to be seen as addressing their concerns.

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Yesterday the YGNetwork released a new book, Room To Grow: Conservative Reforms for Limited Government and a Thriving Middle Class. It includes essays by some of the top thinkers and policy experts in the conservative world, offering reforms in the areas of health care, K-12 and higher education, energy, taxes, job creation, the social safety net, regulations and finances, and the family. Yuval Levin articulated a conservative governing vision while Ramesh Ponnuru wrote a chapter on recovering the wisdom of the Constitution.  

(The New York Times story on the release of the book can be found here, a related event held at the American Enterprise Institute can be viewed here, and the book itself and chapter summaries can be found here.) 

For my part, I contributed an opening chapter to Room To Grow, the purpose of which is to define the middle class and summarize the attitudes of those who comprise it. Here’s what I found. 

When speaking of the middle class, there’s both a technical and a practical definition. The technical definition is households with annual incomes ranging from roughly $39,400 to $118,200. The practical definition is the broad base of Americans. Fully 85 percent of Americans consider themselves as part of an expanded definition of middle class (lower, upper, and simply middle class). It’s people who don’t consider themselves rich or poor and who can imagine their fortunes going either way. 

Any successful political movement and party need to be seen as addressing their concerns.

As for what I discovered in my analysis of the middle class, let me start with their mood, which is anxious, insecure, and uneasy. National Journal‘s Ronald Brownstein, in analyzing the data from an April 2013 Heartland Monitor Poll, said, “The overall message is of pervasive, entrenched vulnerability–a sense that many financial milestones once assumed as cornerstones of middle-class life are now beyond reach for all but the rich.” 

These concerns are largely justified. Since the turn of the century, middle class Americans have been working harder yet losing ground. Wages are stagnant. (The typical household is making roughly the same as the typical household made a quarter of a century ago.) Meanwhile, the cost of living–especially health-care and higher education costs–has gone way up. For example, health-care spending per person, adjusted for inflation, has roughly doubled since 1988, to about $8,500. The average student debt in 2011 was $23,300. (For middle class families, the cost of one year of tuition equals about half of household income.)   

The middle class is also increasingly pessimistic, with two-thirds of Americans thinking it’s harder to reach the American Dream today than it was for their parents and three-quarters believing it will be harder for their children and grandchildren to succeed.

The middle class holds the political class largely responsible for the problems they face. Sixty-two percent place “a lot” of blame on Congress, followed by banks/financial institutions and corporations. 

If Congress in general is held in low esteem, the situation facing the GOP is particularly problematic. Middle class Americans are more likely to say that Democrats rather than the Republicans favor their interests. Polls indicate 62 percent of those in the middle class say the Republican Party favors the rich while 16 percent say the Democratic Party favors the rich; 37 percent of those in the middle class say the Democratic Party favors the middle class while only 26 percent say the GOP does. When asked which groups are helping the middle class, 17 percent had a positive response to Republican elected officials; 46 percent were negative. (For Democrats, the numbers were 28 percent positive v. 40 percent negative.) 

The challenge of the GOP, then, is to explain how a conservative vision of government can speak to today’s public concerns; and to explain how such a vision should translate into concrete policy reforms in important areas of our national life. 

“Policy is problem solving,” I wrote in the introduction:

It answers to principles and ideals, to a vision of the human good and the nature of society, to priorities and preferences; but at the end of the day it must also answer to real needs and concerns. And public policy today is clearly failing to address the problems that most trouble the American people.

Room To Grow suggests some ways forward, with special emphasis on what can be done to assist and empower those who are, and those who want to be, in the middle class.

Reactionary liberalism is intellectually exhausted and politically vulnerable. There is therefore an opening for conservatism to offer a different way of thinking about government, to move from administering large systems of service provision to empowering people to address the problems they confront on their own terms; to provide people with the resources and skills they need to address the challenges they face rather than to try to manage their decisions from on high. The task of the right isn’t simply to offer new policies, as vital as they are, but to explain the approach, the organizing principle, behind them. It is, as my Ethics and Public Policy Center colleague Yuval Levin puts it, replacing a failing liberal welfare state with a lean and responsive 21st century government worthy of a free, diverse and innovative society. It’s time we get on with it.

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We’re Still Talking About ObamaCare Because Obama Designed It That Way

A reliable indicator of the troubled start to the age of ObamaCare is how much President Obama complains about the attention paid to his signature achievement. He is proud of it, supposedly, and thinks Democrats should be as well. Yet, puzzlingly, he’d really wish people would stop talking about it.

There are many reasons for this. To know ObamaCare is to despise ObamaCare, so to talk about ObamaCare is usually to criticize ObamaCare. Additionally, the president has been selectively implementing the health-care reform law as well as adding regulations to it, and he’d prefer the lawlessness and inherent cronyism of ObamaCare not be exposed to too much sunlight.

But complaining about people talking about ObamaCare is hypocritical for another reason: this is precisely how the president designed it. I don’t just mean his embracing of the ObamaCare moniker. Here’s the president in his own words, displaying the bitterness and resentment that has come to define his rhetoric:

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A reliable indicator of the troubled start to the age of ObamaCare is how much President Obama complains about the attention paid to his signature achievement. He is proud of it, supposedly, and thinks Democrats should be as well. Yet, puzzlingly, he’d really wish people would stop talking about it.

There are many reasons for this. To know ObamaCare is to despise ObamaCare, so to talk about ObamaCare is usually to criticize ObamaCare. Additionally, the president has been selectively implementing the health-care reform law as well as adding regulations to it, and he’d prefer the lawlessness and inherent cronyism of ObamaCare not be exposed to too much sunlight.

But complaining about people talking about ObamaCare is hypocritical for another reason: this is precisely how the president designed it. I don’t just mean his embracing of the ObamaCare moniker. Here’s the president in his own words, displaying the bitterness and resentment that has come to define his rhetoric:

Appearing at a Democratic Congressional Campaign Committee event at a Potomac, Maryland, residence on Monday evening, the president said he wanted a national conversation between the two parties on the efficacy of government programs.

“But that’s not the debate that’s taking place right now,” Obama said. “The debate we’re having right now is about, what, Benghazi? Obamacare? And it becomes this endless loop. It’s not serious. It’s not speaking to the real concerns that people have.”

Americans, of course, still disagree. Here’s the takeaway from Gallup’s latest polling, with a particularly revealing phrasing:

American voters have a clearly differentiated sense of which issues will or will not be important to their vote for Congress this year. They give economy-related issues, including the distribution of income and wealth, along with the Affordable Care Act, above-average importance. Hot-button issues such as immigration and global warming, and issues that have been much in the news recently, such as foreign affairs and immigration, have below-average importance.

Not health care, but ObamaCare specifically–a change Conn Carroll noticed and pointed out on Twitter this morning. Indeed, in the poll, there is no result for health care, only ObamaCare. The category is called “The Affordable Care Act, also known as ‘Obamacare’.”

As strange as it may sound, this makes a fair amount of sense–but Democrats should be the last ones complaining about it. That’s because the whole point of ObamaCare was to upend the entire health-care system, regardless of the fact that Democrats had to lie about it repeatedly and brazenly in order to get the bill passed. We’re long since passed the point where liberals can claim this is not government control of the insurance market and not be laughed out of the room.

ObamaCare’s coverage expansion rested on two pillars. The first was an explicit government program, Medicaid. It’s a failed and expensive program that in many cases is actually worse for the patient than having no insurance at all. It’s insurance, in other words, but often not really health care. The second pillar was to kick millions of Americans off their insurance policies and mandate by law that they buy a new policy. This aspect of ObamaCare is not designed to insure the uninsured. It’s designed to enable the government to control the health-insurance market by greatly restricting legal health-care plans, raising the prices for those the government thinks can pay and offering subsidies to those who can’t. Those who are permitted to keep their insurance plans will see their access to doctors restricted under ObamaCare and their premiums, in many cases, skyrocket.

It’s a scam, sure, but it’s a government scam. In reality, this means that even those who don’t buy insurance from the government will have their insurance impacted by the government in all sorts of ways. It becomes nearly impossible to avoid ObamaCare, even if you don’t depend directly on the federal government for your insurance under ObamaCare.

This was always the point, and it’s one of the great many reasons the law was so ill-conceived and had to be sold on false advertising. One of the central claims of ObamaCare’s backers was, as Sarah Kliff and Ezra Klein hilariously asserted in January: “Here’s the biggest thing to know about Obamacare: Most people will never notice it.”

No one who understood the law or the basics of the health-care sector could possibly have written such a thing with a straight face. And the crafters of ObamaCare certainly didn’t plan it that way–however it was sold. So it’s not terribly surprising that Gallup has incorporated the reality of ObamaCare into its polling instead of relying on the administration’s propaganda. And it shouldn’t be surprising to the president that, now that the law has been passed, Americans are finding out what’s in it.

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Obama’s Staggering Record of Failure

 In advance of President Obama’s four-nation Asian tour this week, the Washington Post published an article saying this:

President Obama’s bid to focus U.S. attention on Asia has failed to meet the lofty expectations he set three years ago in a grand pronouncement that the new emphasis would become a pillar of his foreign policy.

The result, as Obama prepares to travel to the region… has been a loss of confidence among some U.S. allies about the administration’s commitment at a time of escalating regional tensions. Relations between Japan and South Korea are at one of the lowest points since World War II, and China has provoked both with aggressive actions at sea despite a personal plea to Beijing from Vice President Biden in December.

The same story could be said of the Obama presidency on issue after issue, in foreign policy and on domestic matters. The lofty expectations and grand pronouncements of Obama–unmatched by any presidential candidate in my lifetime–have crashed against reality time and time again.

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 In advance of President Obama’s four-nation Asian tour this week, the Washington Post published an article saying this:

President Obama’s bid to focus U.S. attention on Asia has failed to meet the lofty expectations he set three years ago in a grand pronouncement that the new emphasis would become a pillar of his foreign policy.

The result, as Obama prepares to travel to the region… has been a loss of confidence among some U.S. allies about the administration’s commitment at a time of escalating regional tensions. Relations between Japan and South Korea are at one of the lowest points since World War II, and China has provoked both with aggressive actions at sea despite a personal plea to Beijing from Vice President Biden in December.

The same story could be said of the Obama presidency on issue after issue, in foreign policy and on domestic matters. The lofty expectations and grand pronouncements of Obama–unmatched by any presidential candidate in my lifetime–have crashed against reality time and time again.

It’s not simply that Mr. Obama has fallen short of what he promised; it’s that he has been, in so many respects, a failure. Choose your metrics. Better yet, choose Mr. Obama’s metrics: Job creation. Economic growth. Improving our health-care system. Reducing the debt. Reducing poverty. Reducing income inequality. Slowing the rise of the oceans. Healing the planet. Repairing the world. The Russian “reset.” Peace in the Middle East. Red lines in Syria. Renewed focus on Afghanistan. A new beginning with the Arab world. Better relations with our allies. Depolarizing our politics. Putting an end to the type of politics that “breeds division and conflict and cynicism.” Working with the other party. Transparency. No lobbyists working in his administration. His commitment to seek public financing in the general election. The list goes on and on.

By now, nearly five and a half years into the Obama presidency, objective people can draw reasonable conclusions, among which are these: Barack Obama was among the least prepared men to ever serve as presidency. It shows. He has been overmatched by events right from the start. He is an excellent campaigner but unusually inept when it comes to governing.

By temperament and experience, based on skill set and ability, Mr. Obama is much better equipped to be a community organizer than to be president of the United States. 

For the sake of our nation and much of the world, I wish he had stayed on Chicago’s South Side.

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OCare’s Milestone and Jindal’s Opportunity

Today’s Washington Post article on Bobby Jindal, by Robert Costa and Amy Goldstein, is a great example of how a newspaper’s reporting can be vastly improved by actually embracing ideological diversity. Costa was recently hired by the Post from National Review, where his access to the right side of the political isle had him running circles around other reporters when it came to conservative politics.

And today’s article is refreshingly free of condescension and peppered with actual information and verifiable claims, unlike the treatment Republican rising stars are used to getting in, say, the Washington Post. For example, the article centers on Jindal’s new health-care reform proposal, and rather than parrot DNC talking points that Republicans have no plans or ideas on offer, we read this:

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Today’s Washington Post article on Bobby Jindal, by Robert Costa and Amy Goldstein, is a great example of how a newspaper’s reporting can be vastly improved by actually embracing ideological diversity. Costa was recently hired by the Post from National Review, where his access to the right side of the political isle had him running circles around other reporters when it came to conservative politics.

And today’s article is refreshingly free of condescension and peppered with actual information and verifiable claims, unlike the treatment Republican rising stars are used to getting in, say, the Washington Post. For example, the article centers on Jindal’s new health-care reform proposal, and rather than parrot DNC talking points that Republicans have no plans or ideas on offer, we read this:

In his 26-page plan, Jindal lays out a lengthy critique of the health law — which he refers to throughout as “Obamacare” — and reiterates his belief that it needs to be entirely done away with. In its place, he sets forth a bevy of ideas that have run through conservative thought for years, in some cases renaming them and in other cases suggesting new variations on old themes.

Indeed, conservatives have been offering ideas–most of them better than the bureaucratic mess and extralegal application of ObamaCare–for years. The article is also interesting for its framing of Jindal within the 2016 presidential landscape. Jindal has long been a favorite of GOP policy wonks and proponents of education reform, but it’s an open question as to whether he could translate that into broader, television-friendly appeal.

The biggest setback to that possibility came when an overly-folksy Jindal delivered the GOP’s response to Obama’s 2009 national address. He was written off, unfairly; after all, Bill Clinton famously cratered at the 1988 Democratic nominating convention only to be nominated himself four years later. But the weakness in Jindal’s delivery was real: he had committed the modern age’s cardinal sin of discarding authenticity in an attempt to be memorable. (He was, but not for the right reasons.)

Jindal seems now to be more comfortable in his own skin:

Putting an emphasis on Jindal’s policy chops has become the latest project for his kitchen cabinet, which includes Curt Anderson, a former political director at the Republican National Committee, and political adviser Timmy Teepell. So is highlighting Jindal’s willingness to articulate an agenda — all while other hopefuls, from Christie to Paul, are making their own strides on the pre-primary stage.

“It’s early, but this is a good time for him to show how he belongs with the rest of those names,” said Charlie Black, a former campaign adviser to Sen. John McCain of Arizona, the GOP’s 2008 presidential nominee.

Jindal has been steeped in the world of health policy since early in his career. In his mid-20s he became secretary of Louisiana’s Department of Health and Hospitals, and then he was named the staff director of a bipartisan commission on the future of Medicare. A few years later, he became an assistant secretary in the Department of Health and Human Services during the presidency of George W. Bush.

Is this a winning strategy? It always depends on the competition, of course, but Jindal is one of the few conservative leaders who could benefit from the enrollment numbers ObamaCare racked up thus far. ObamaCare is far from a success–indeed, even late-night host Jimmy Fallon greeted the “mission accomplished” ObamaCare announcement by noting that “it’s amazing what you can achieve when you make something mandatory, and fine people if they don’t do it — and keep extending the deadline for months.”

But the president’s celebration was telling. The point of the frantic enrollment rush was to try to mitigate what had made the enrollment rush possible in the first place–Obama’s cancellation of Americans’ insurance policies they actually liked–and get them in some way dependent on the state. At the outset, ObamaCare was weakest before it created millions of dependents. That’s the mark Obama was aiming for, not a more serious definition of “success,” which might be well beyond ObamaCare’s reach anyway.

Now the narrative has shifted, and Republicans who want to undo the damage ObamaCare has already done and prevent the damage it threatens to do must concentrate as much or more on the “replace” side of their “repeal and replace” slogan. It’s the first moment, in other words, in the post-2012 election drama that calls specifically for a wonk to step forward, and Jindal has done so. Whether that can enable him to compete with Republicans’ prospective first-tier candidates remains to be seen, but it’s clear he’s at least improved his sense of timing.

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Perry’s Deconstructive Governing Agenda

In his speech at CPAC, Texas Governor Rick Perry brought the crowd to its feet by saying this:

Nowhere does the Constitution say we should federalize classrooms. Nowhere does it give federal officials primary responsibility over the air we breathe, the land we farm, the water we drink. And nowhere does it say Congress has the right to federalize health care… It is time for Washington to focus on the few things the Constitution establishes as the federal government’s role: defend our country, provide a cogent foreign policy, and – what the heck – deliver the mail, preferably on time and on Saturdays. Get out of the health care business! Get out of the education business!

This points to a concern of mine and which Michael Gerson and I wrote about recently in an essay for National Affairs. For starters, Governor Perry’s interpretation of enumerated powers is more restrictive than what many of the Federalist Founders believed. (See the essay and here  for more.) As for Governor Perry’s line of argument: He says the Constitution doesn’t give “primary” responsibility over the air we breathe, the land we farm and the water we drink. But in fact, the Constitution doesn’t affirm even a secondary role for the areas mentioned by Perry. Is it really his position, then, that the federal government should have no role in education, health care, and clean air and water? What about child immunization? Support for the National Institutes of Health? Pell grants? The GI Bill? All of the New Deal? Bans on child labor? The Second National Bank (signed into law by the “father” of the Constitution, James Madison)? After all, the Constitution says nothing about establishing a national bank.

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In his speech at CPAC, Texas Governor Rick Perry brought the crowd to its feet by saying this:

Nowhere does the Constitution say we should federalize classrooms. Nowhere does it give federal officials primary responsibility over the air we breathe, the land we farm, the water we drink. And nowhere does it say Congress has the right to federalize health care… It is time for Washington to focus on the few things the Constitution establishes as the federal government’s role: defend our country, provide a cogent foreign policy, and – what the heck – deliver the mail, preferably on time and on Saturdays. Get out of the health care business! Get out of the education business!

This points to a concern of mine and which Michael Gerson and I wrote about recently in an essay for National Affairs. For starters, Governor Perry’s interpretation of enumerated powers is more restrictive than what many of the Federalist Founders believed. (See the essay and here  for more.) As for Governor Perry’s line of argument: He says the Constitution doesn’t give “primary” responsibility over the air we breathe, the land we farm and the water we drink. But in fact, the Constitution doesn’t affirm even a secondary role for the areas mentioned by Perry. Is it really his position, then, that the federal government should have no role in education, health care, and clean air and water? What about child immunization? Support for the National Institutes of Health? Pell grants? The GI Bill? All of the New Deal? Bans on child labor? The Second National Bank (signed into law by the “father” of the Constitution, James Madison)? After all, the Constitution says nothing about establishing a national bank.

It’s worth quoting here, as I have before, Senator Daniel Patrick Moynihan, who made this observation:

Perhaps the most important act of the Continental Congress was the Northwest Ordinance which provided a direct federal subsidy for education. Almost the first act of the Congress established by the present Constitution was to reaffirm this grant. A plaque on the Sub-Treasury on Wall Street commemorates both actions. This does not invalidate the view that the federal government ought not to exercise any responsibility, but it does make nonsense of the view that the Constitution – presumably because it does not mention the subject – somehow bars such an exercise.

It is one thing – and I think very much the right thing – to argue for a more limited role for the federal government and conservative reforms of everything from entitlement programs to education, from our tax code to our immigration system to much else. It’s quite another when we have the kind of loose talk from the governor of the second most populous state in America.

I realize that some people will argue that what Perry is offering up is simply “red meat” for a conservative audience. It’s a (lazy) default language those on the right sometimes resort to in order to express their unhappiness with the size of the federal government. But words matter, Governor Perry is actually putting forth (albeit in a simplified version) a governing philosophy, and most Americans who hear it will be alarmed by it.

As a political matter, running under the banner of “Get out of the health care business! Get out of the education business!” hardly strikes me as the best way to rally people who are not now voting for the GOP in presidential elections. I’m reminded of the words of the distinguished political scientist James Q. Wilson: “Telling people who want clean air, a safe environment, fewer drug dealers, a decent retirement, and protection against catastrophic medical bills that the government ought not to do these things is wishful or suicidal politics.”

According to a CBS News/New York Times poll, only 33 percent of respondents had a favorable view of the Republican Party while 61 percent had an unfavorable view. Having a prominent GOP figure give a speech in which he insists that virtually the entire modern state is unconstitutional and therefore illegitimate probably won’t help matters. Then again, neither does having the 2008 vice presidential nominee give a speech in which she takes great delight in re-writing Dr. Seuss.

This is not what the Republican Party or the conservative cause needs just now.

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Obama’s Priorities v. Those of the American People

President Obama has recently said that the trend of growing inequality is “certainly my highest priority.” He might be interested to know that it’s not the highest priority for the people he was voted to represent.

Not even close.

A new Gallup poll found the 10 most important issues facing the American people to be, in order, (1) unemployment/jobs; (2) economy in general; (3) government; (4) health care; (5) federal budget deficit/federal debt; (6) immigration/illegal aliens; (7) ethical/moral decline; (8) education; (9) lack of money; and (10) poverty/hunger/homelessness. Even among Democrats, income inequality doesn’t rate. Neither, by the way, does raising the minimum wage, climate change, and gun control–three other issues Mr. Obama has made central to his second-term agenda.

So why is the president talking about issues that the public has so little concern about?

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President Obama has recently said that the trend of growing inequality is “certainly my highest priority.” He might be interested to know that it’s not the highest priority for the people he was voted to represent.

Not even close.

A new Gallup poll found the 10 most important issues facing the American people to be, in order, (1) unemployment/jobs; (2) economy in general; (3) government; (4) health care; (5) federal budget deficit/federal debt; (6) immigration/illegal aliens; (7) ethical/moral decline; (8) education; (9) lack of money; and (10) poverty/hunger/homelessness. Even among Democrats, income inequality doesn’t rate. Neither, by the way, does raising the minimum wage, climate change, and gun control–three other issues Mr. Obama has made central to his second-term agenda.

So why is the president talking about issues that the public has so little concern about?

Part of the explanation, I suspect, is that Mr. Obama really believes in his (progressive) agenda and feels more liberated in his second term to pursue it. But I also imagine that the president has very little to say that’s helpful to him or his party about unemployment and jobs, the economy in general, health care, and the debt. So Mr. Obama is turning to other issues, hoping to shift the American people’s focus from what they care about to what he cares about.

This effort is turning out to be a bust. The public is tuning the president out and turning him off. His words are like white noise, and he increasingly looks to be a lame duck–one day impotent, the next day irrelevant, drifting along in a world of his own. 

Mr. Obama seems to think that as a second-term president, he can talk about what he darn well pleases. Maybe. We’ll see what the voters think about that in November, when they get their chance to render their judgment on his second term. 

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Congress Is Loving the Army to Death

Bipartisanship is a much-lauded ideal in Washington, but sometimes the worst legislation can pass by the biggest margins. Witness Congress’s decision a few days ago to repeal a small cut–just 1 percent a year–in the cost-of-living adjustment for working-age military retirees below the age of 62. The House voted to rescind the cut by 326-90, the Senate by 95-3, after vigorous lobbying from military retirees and their official associations.

The money involved was fairly trivial by Washington standards–a 1 percent cut in cost-of-living allowances would have produced a savings of $7 billion. But the fact that Congress is not willing to make even such a small, symbolic trim is bad news on two levels.

First, it suggests a lack of will to deal with the much more serious fiscal problems caused by runaway entitlement spending. Second, it suggests a lack of will to do what is necessary to maintain military readiness.

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Bipartisanship is a much-lauded ideal in Washington, but sometimes the worst legislation can pass by the biggest margins. Witness Congress’s decision a few days ago to repeal a small cut–just 1 percent a year–in the cost-of-living adjustment for working-age military retirees below the age of 62. The House voted to rescind the cut by 326-90, the Senate by 95-3, after vigorous lobbying from military retirees and their official associations.

The money involved was fairly trivial by Washington standards–a 1 percent cut in cost-of-living allowances would have produced a savings of $7 billion. But the fact that Congress is not willing to make even such a small, symbolic trim is bad news on two levels.

First, it suggests a lack of will to deal with the much more serious fiscal problems caused by runaway entitlement spending. Second, it suggests a lack of will to do what is necessary to maintain military readiness.

As things stand now, the military budget is declining and an ever-growing share of it is going to personnel costs–salaries and benefits for current and retired personnel, with health-care costs rising especially rapidly. A succession of military leaders, uniformed and civilian, have warned Congress that the Pentagon is in danger, essentially, of becoming a giant HMO that occasionally fires a missile. The Defense Department needs to maintain or even increase its current budget, but, failing that, it needs the leeway to redistribute money away from personnel and toward operations, procurement, training–in short, to all of the things needed to project military power.

The problem is Congress. Lawmakers are so supportive of our service personnel–for perfectly understandable reasons–that they are loving the armed forces to death. Benefits and salaries and pensions have risen so dramatically over the past decade that military personnel are now, by any measure, more generously compensated than their civilian counterparts.

Given the risks and hardships that uniformed personnel can endure (even if most of them never see combat), this may be right and fair–but only in an ideal world in which we can afford to pay retirees generously while not compromising the ability of those currently on active duty to carry out their assigned missions. Unfortunately we don’t live in such a world. We live in a world where difficult budget trade-offs have to be made, and regrettably Congress is dictating that those trade-offs be made based on politics, not on the merits.

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Why Have Health-Care Costs Been Rising so Much More Slowly of Late?

On a par with President Obama’s oft-repeated masterpiece of mendacity that “If you like your insurance plan you can keep your insurance plan,” is his claim that the Affordable Care Act has already begun to slow down the rise in medical costs.

There’s only one problem with that. The ACA came into effect (well, at least those parts Obama did not decide to waive on his own, non-existent authority) on October 1, 2013, and medical cost increases have been slowing for more than a decade. So what did cause the slow down?

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On a par with President Obama’s oft-repeated masterpiece of mendacity that “If you like your insurance plan you can keep your insurance plan,” is his claim that the Affordable Care Act has already begun to slow down the rise in medical costs.

There’s only one problem with that. The ACA came into effect (well, at least those parts Obama did not decide to waive on his own, non-existent authority) on October 1, 2013, and medical cost increases have been slowing for more than a decade. So what did cause the slow down?

John C. Goodman, head of the National Center for Policy Analysis, makes the argument that the causative agent has been the Health Savings Account, which first became legally possible in 2003. The HSA and its close cousin Health Reimbursement Arrangements (HRA) provide company employees with a high-deductible insurance plan to cover catastrophic events and a savings account that can be used to cover routine medical expenses. If the money in the savings account is not needed, it usually is added to the employee’s retirement account.

HSAs have grown by leaps and bounds since 2003. In 2005 there were about 1 million people covered by them. At the end of 2012, about 15 million were.

This structure has great economic advantages. For one thing, health insurance becomes health insurance, covering unexpected costs that would be financially calamitous, just like car and house insurance does. It does not cover routine expenses, such as the infamous birth-control pills, that are much more expensive to cover in what amounts to a pre-payment plan, as I have explained before.

But most important, it gets health-care consumers to ask the magic question: How much is this going to cost? When consumers have to ask that question, costs are kept under control much more easily. As Milton Friedman explained, no one spends other people’s money as carefully as they spend their own. When it becomes in a person’s self-interest to find the cheapest way to get a job done, he will find the cheapest way. If it makes no difference to him, why bother? Life is short enough.

This has had supply-side effects as well. As Goodman explains, “The emergence of so many people paying for care with their own money is also changing the supply side of the market, leading to walk-in clinics that post their prices and provide timely care, and places like Walmart that offer $4 generic drugs financed by cash, not costly insurance.”

Altogether, HSAs cost about 25 percent less than traditional health insurance.

HSAs were not legally possible before 2003 because Senator Ted Kennedy, who favored a single-payer system, used all of his very considerable legislative skill to keep them off the market. He feared, correctly, that they would work effectively to keep down costs and thus pose a threat to the socialization of health care he so wanted, so he fought them tooth-and-nail.

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Both Obama and the GOP Badly Damaged

The most recent NBC News/Wall Street Journal survey is filled with ominous news for the president.

It’s not simply that the president’s approval ratings are near all-time lows for him in this particular poll (43 approve v. 51 disapprove). Or that for the third-straight survey those who view Obama negatively (44 percent) outnumber those who view him positively (42 percent). It’s also the sour and anxious mood of the nation.

Nearly 70 percent of those surveyed (68 percent) believe the country has either gotten worse or stayed stagnant during the Obama era. Fifty-nine percent say they are either “pessimistic and worried” or “uncertain and wondering” about Obama’s remaining time in office. By a 39 percent to 31 percent margin, Americans believe the country is currently worse off compared with where it was when Obama first took office (29 percent say it’s in the same place). And when asked what one or two words best describes the state of the union, here are the top three responses: “divided” (37 percent), “troubled” (23 percent), and “deteriorating” (21 percent). Only 28 percent of those surveyed say we’re on the right track. And the president’s instantly forgettable State of the Union address won’t change any of that.

But before Republicans rejoice too much, they should consider this finding: Only 24 percent of the public has a very or somewhat positive view of the GOP, whereas 47 percent have a very or somewhat negative view of the Republican Party (28 percent are neutral). So nearly twice as many Americans now hold negative views about the Republican Party as positive ones. (As a point of comparison, 37 percent have a very or somewhat positive view of the Democratic Party v. 40 percent a very or somewhat negative view of the Democratic Party, with 22 percent neutral.)

There are, I suspect, several different things going on at once. There’s clearly a deep disenchantment with American politics today, and it’s directed at both parties, most politicians, and many of our political institutions. There is a great deal of frustration that things aren’t working as they should, and the entire political class has been implicated.

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The most recent NBC News/Wall Street Journal survey is filled with ominous news for the president.

It’s not simply that the president’s approval ratings are near all-time lows for him in this particular poll (43 approve v. 51 disapprove). Or that for the third-straight survey those who view Obama negatively (44 percent) outnumber those who view him positively (42 percent). It’s also the sour and anxious mood of the nation.

Nearly 70 percent of those surveyed (68 percent) believe the country has either gotten worse or stayed stagnant during the Obama era. Fifty-nine percent say they are either “pessimistic and worried” or “uncertain and wondering” about Obama’s remaining time in office. By a 39 percent to 31 percent margin, Americans believe the country is currently worse off compared with where it was when Obama first took office (29 percent say it’s in the same place). And when asked what one or two words best describes the state of the union, here are the top three responses: “divided” (37 percent), “troubled” (23 percent), and “deteriorating” (21 percent). Only 28 percent of those surveyed say we’re on the right track. And the president’s instantly forgettable State of the Union address won’t change any of that.

But before Republicans rejoice too much, they should consider this finding: Only 24 percent of the public has a very or somewhat positive view of the GOP, whereas 47 percent have a very or somewhat negative view of the Republican Party (28 percent are neutral). So nearly twice as many Americans now hold negative views about the Republican Party as positive ones. (As a point of comparison, 37 percent have a very or somewhat positive view of the Democratic Party v. 40 percent a very or somewhat negative view of the Democratic Party, with 22 percent neutral.)

There are, I suspect, several different things going on at once. There’s clearly a deep disenchantment with American politics today, and it’s directed at both parties, most politicians, and many of our political institutions. There is a great deal of frustration that things aren’t working as they should, and the entire political class has been implicated.

Yet there’s no getting around the fact that the Republican Party is in a very precarious situation. In the fall of 2013, for example, in the wake of the government shutdown, the GOP recorded the lowest favorable rating measured for either party since Gallup began asking this question in 1992. Which means Republicans have a tremendous amount of work to do in order to win back the confidence of most Americans.

Different people recommend different solutions. Some will argue that the GOP has been too easy on the president and that its rhetoric hasn’t been sufficiently anti-government. They will argue that those on the right need to amp up their declamations against Mr. Obama, invoking words like “Marxist,” “coup,” and “tyranny” to describe him. The key to making the GOP more popular is for it to become more strident, the language more apocalyptic. People in this camp think the government shutdown was an impressive victory for the conservative cause and backfired only because of a failure of nerve by Republicans. They believe the contemporary politicians whom Republicans should pattern themselves after are Sarah Palin and Ted Cruz. 

Readers of this site know that I’m of a different view, that the leaders of the GOP and the conservative movement, while leveling very tough criticisms at the president, also need to carry themselves with a degree of grace and winsomeness. They need to be less agitated and more agreeable, in possession of strong convictions and moderate temperaments. They need to demonstrate a genuine interest in justice and those living in the shadows of society. And they need to propose far-reaching conservative reforms that constitute an actual governing vision, one that matches the challenges of this moment.

Which is why the recent health-care plan put forward by Senators Burr, Coburn, and Hatch is so encouraging. An alternative to the Affordable Care Act, It would cover pre-existing conditions, provide universal coverage, reform Medicaid, and promote medical liability reform and market-oriented policies. (Among the specific proposals is to extend a tax credit for the purchase of health insurance to all Americans below 300 percent of the poverty level who don’t have health coverage from a large employer.) No piece of legislation is perfect, and neither is this one. But I agree with those who consider it to be the most impressive conservative health-care plan yet put forward by Republican lawmakers.

There are, then, several currents of thought that exist in the modern GOP. The debate isn’t between those who are conservative and those who are not so much as it’s between those who have some important disagreements over what constitutes authentic conservatism. The debate involves differences in tone and style and divergent interpretations of the federalist Founders and the Constitution, the role of government, and the conservative tradition. 

It’s a fascinating debate, really, and at times quite a spirited one. Whichever side prevails will go some distance toward determining the future of conservatism and the country.

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Study: “Basic Economic Principle” Debunks ObamaCare Claim

“If you’ve got insurance, then … preventive care is going to be covered, and that should make a difference,” President Obama said in 2010, describing ways his unpopular health-care reform law “should save us all a lot of money. I mean, one of the toughest things about this health care debate was—and sometimes I fault myself for not having been able to make the case more clearly to the country—we spend—each of us who have health insurance spend about a thousand dollars of our premiums on somebody else’s care.”

How were we all spending that money on other patients’ care? “What happens is, you don’t have health insurance, you go to the emergency room,” and the costs for those expensive ER visits get passed along. “And that’s why,” Obama boldly declared, “we feel pretty confident that over the long term, as a consequence of the Affordable Care Act, premiums are going to be lower than they would be otherwise; health care costs overall are going to be lower than they would be otherwise. And that means, by the way, that the deficit is going to be lower than it would be otherwise.”

That sounded great, but as we’ve come to understand with ObamaCare’s selling points, that means it’s probably false. And indeed we are getting more evidence on that score. The New York Times reports on the latest data from Oregon’s Medicaid study:

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“If you’ve got insurance, then … preventive care is going to be covered, and that should make a difference,” President Obama said in 2010, describing ways his unpopular health-care reform law “should save us all a lot of money. I mean, one of the toughest things about this health care debate was—and sometimes I fault myself for not having been able to make the case more clearly to the country—we spend—each of us who have health insurance spend about a thousand dollars of our premiums on somebody else’s care.”

How were we all spending that money on other patients’ care? “What happens is, you don’t have health insurance, you go to the emergency room,” and the costs for those expensive ER visits get passed along. “And that’s why,” Obama boldly declared, “we feel pretty confident that over the long term, as a consequence of the Affordable Care Act, premiums are going to be lower than they would be otherwise; health care costs overall are going to be lower than they would be otherwise. And that means, by the way, that the deficit is going to be lower than it would be otherwise.”

That sounded great, but as we’ve come to understand with ObamaCare’s selling points, that means it’s probably false. And indeed we are getting more evidence on that score. The New York Times reports on the latest data from Oregon’s Medicaid study:

Supporters of President Obama’s health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings, the Times correctly notes, “go against one of the central arguments of the law’s supporters”—a phrase we’re getting used to hearing by now. It’s another casualty not just of the dishonesty that marked the efforts to mislead the public enough to get the law through Congress but also of the degree of intellectual isolation so typical of ObamaCare’s supporters, who closed themselves off from the evidence that would have helped them make more informed decisions, as the Times adds:

“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard University’s School of Public Health and one of the authors of the study.

Sure—when the government passes a major reform law first and asks questions about its bedrock assumptions later, don’t be surprised to be surprised as the facts reveal themselves. But is that intellectual isolation even an excuse? The Times piece not so subtly suggests that a combination of basic economics and common sense could have solved this puzzle for the administration’s pseudo-wonks:

Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of Technology, another author, said the increased use of emergency rooms is driven by a basic economic principle: When services get less expensive, people use them more. Previous studies have found that uninsured people face substantial out-of-pocket costs that can put them in debt when they go to the emergency room. Medicaid reduces those costs.

No kidding. And that preempts a line in the story that might have put the administration’s ignorance in a better light—but is a blistering, if unintentional, condemnation of government in general. Readers are told that this Medicaid study is the “gold standard” in terms of being able to accurately analyze the effects of the policies under consideration, but that such experiments “are rarely used for domestic health care policy.”

The article is full of such now they tell us revelations, including doctors telling the Times that (contra President Obama) preventive care is quite limited in preventing ER visits, and policy experts saying that the cost savings would have been modest even if Obama had been right about such care—though he wasn’t.

But it’s actually worse for ObamaCare than it sounds, because the new health law risks exacerbating the situation—turning a minor increase in costs into a potentially more consequential expense. As CNN reported in October, “Obamacare is expected to increase patient demand for medical services. Combine that with a worsening shortage of doctors, and next year you may have to wait a little longer to get a doctor’s appointment.”

That wait time increase, according to one of the authors of the study, is a major factor, as might be expected, in the increase in ER visits:

Heidi Allen, an assistant professor at Columbia University and an author of the study, said much of the non-urgent emergency department use among patients she interviewed happened because those patients could not get same-day appointments with their primary care doctors.

Again, much of this is common sense, the rest basic economics. That neither seems to have been utilized in reforming America’s health-care system is both appalling and, by now, all too apparent.

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Smarter Cuts Needed

Secretary of Defense Chuck Hagel has just announced that he is cutting major headquarters, including his own Office of the Secretary of Defense, by some 20 percent. This is a welcome development, for there is little doubt that headquarters are vastly bloated. But the cost savings that will be realized are minuscule in the context of a defense budget of more than $500 billion a year; the immediate reductions that Hagel announced to his own front office will save only $1 billion over five years–i.e., $200 million a year. The pressure is on to cut more because Congress is unlikely to turn off sequestration, at least not in full, which could result, when combined with previous cuts, in a defense budget $1 trillion smaller than projected over the next decade.

There is no way to responsibly cut that amount from the Defense Department without hampering our power-projection capability–and hence the entire underpinning of our domestic security and of the international security system. But if we are going to have to make nearly impossible choices, then the least-bad alternative is to cut back personnel costs which have soared in the past decade–and, one hopes, plow some of the savings into training, readiness, and procurement to rejuvenate our sagging military capabilities. (Ha! Dream on! The savings are likely to wind up financing civilian entitlement programs.)

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Secretary of Defense Chuck Hagel has just announced that he is cutting major headquarters, including his own Office of the Secretary of Defense, by some 20 percent. This is a welcome development, for there is little doubt that headquarters are vastly bloated. But the cost savings that will be realized are minuscule in the context of a defense budget of more than $500 billion a year; the immediate reductions that Hagel announced to his own front office will save only $1 billion over five years–i.e., $200 million a year. The pressure is on to cut more because Congress is unlikely to turn off sequestration, at least not in full, which could result, when combined with previous cuts, in a defense budget $1 trillion smaller than projected over the next decade.

There is no way to responsibly cut that amount from the Defense Department without hampering our power-projection capability–and hence the entire underpinning of our domestic security and of the international security system. But if we are going to have to make nearly impossible choices, then the least-bad alternative is to cut back personnel costs which have soared in the past decade–and, one hopes, plow some of the savings into training, readiness, and procurement to rejuvenate our sagging military capabilities. (Ha! Dream on! The savings are likely to wind up financing civilian entitlement programs.)

As the last several defense secretaries have warned, the Defense Department faces soaring costs for pay and benefits legislated by a Congress understandably eager to reward current service personnel and veterans for their contributions. The Washington Post succinctly summarizes the problem:

Putting veterans’ care aside, the military’s health care costs have grown annually by 6.3 percent for the past decade, rising to $52.2 billion in the department’s most recent budget proposal. Health care spending now accounts for about half the military spending on personnel costs, and 9.5 percent of the defense budget. The military now spends just as much on salaries as it does providing health care benefits.

And that total is expected to grow. Todd Harrison, a policy analyst at the Center for Strategic and Budgetary Assessments, recently crunched the numbers on what would happen if personnel costs kept growing at the same rate they have for the past decade, and the overall defense budget only kept pace with inflation. Under that scenario, the entire defense budget would be consumed by paying benefits, both for health care and other services, in 2039.

Put another way, if we stay on the current trajectory, the Defense Department will become a giant HMO that occasionally blows up a terrorist or two.

This is obviously an unsustainable trajectory, but to do anything about it, the Defense Department will have to enlist Congress’s help, which so far has not been forthcoming. Congress prefers to cut defense, and other discretionary programs, across the board, thereby hurting readiness. Lawmakers are too scared to support targeted cuts to benefits and pay that will bring a backlash from the powerful veterans’ lobby.

It is well past time for legislators of both parties to step up to this difficult task. If they want reductions in military spending, this is where they should pursue them–while keeping in mind that it is still irresponsible to cut the “top line” (i.e., total defense outlays) in a world where the demands on the U.S. military only continue to grow.

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A Republican Alternative to ObamaCare—Courtesy of the New York Times

In his weekly address this weekend (prerecorded so he could play golf and mingle with the common folk on Martha’s Vineyard), President Obama talks about implementing the Affordable Care Act, which everyone but the Obama administration calls ObamaCare.

As usual, the talk was full of nasty and misleading partisanship. After listing the popular aspects of the law, such as the guarantee of coverage despite pre-existing conditions, he accuses Republicans of wanting to make sure Americans don’t receive those benefits:

They’re actually having a debate between hurting Americans who will no longer be denied affordable care just because they’ve been sick – and harming the economy and millions of Americans in the process.  And many Republicans are more concerned with how badly this debate will hurt them politically than they are with how badly it’ll hurt the country. A lot of Republicans seem to believe that if they can gum up the works and make this law fail, they’ll somehow be sticking it to me.  But they’d just be sticking it to you.

Republicans, of course, are not against many of the aspects of ObamaCare, they are against its bureaucratic bloat, incredible waste, poor and backward-looking design (it’s basically the old Blue Cross Blue Shield model of half a century ago that Medicare was based on) and government control of one-sixth of the American economy. But as long as there is not even a broad-brush Republican plan to reform the medical marketplace, Obama will be able to beat up Republicans. As Harry Truman explained sixty odd years ago, you can’t beat something with nothing.

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In his weekly address this weekend (prerecorded so he could play golf and mingle with the common folk on Martha’s Vineyard), President Obama talks about implementing the Affordable Care Act, which everyone but the Obama administration calls ObamaCare.

As usual, the talk was full of nasty and misleading partisanship. After listing the popular aspects of the law, such as the guarantee of coverage despite pre-existing conditions, he accuses Republicans of wanting to make sure Americans don’t receive those benefits:

They’re actually having a debate between hurting Americans who will no longer be denied affordable care just because they’ve been sick – and harming the economy and millions of Americans in the process.  And many Republicans are more concerned with how badly this debate will hurt them politically than they are with how badly it’ll hurt the country. A lot of Republicans seem to believe that if they can gum up the works and make this law fail, they’ll somehow be sticking it to me.  But they’d just be sticking it to you.

Republicans, of course, are not against many of the aspects of ObamaCare, they are against its bureaucratic bloat, incredible waste, poor and backward-looking design (it’s basically the old Blue Cross Blue Shield model of half a century ago that Medicare was based on) and government control of one-sixth of the American economy. But as long as there is not even a broad-brush Republican plan to reform the medical marketplace, Obama will be able to beat up Republicans. As Harry Truman explained sixty odd years ago, you can’t beat something with nothing.

But if the Democratic Party is, ever increasingly, the party of government, the Republicans should be ever increasingly the party of the free market. No one argues that medical care should be allocated strictly according to market forces. But where market forces can exert economic discipline far more efficiently than bureaucratic fiat, they should be used and Republicans should advocate their use unashamedly. They should advocate allowing insurance companies to compete across state lines, so that people can evade the costly mandates that some states impose (in New York, you must be covered for acupuncture, in vitro fertilization, chiropractic treatments, etc.). This would instantly and greatly lower insurance premiums in those high-cost states. Removing medical malpractice from the tort-law system, which benefits only tort lawyers (a very powerful Democratic constituency), would save many billions as “defensive medicine” disappeared and malpractice premiums were drastically lowered.

And forcing medical service providers to make their prices public, just as the providers of most other services must, would also greatly lower medical costs. Two weeks ago, I wrote about the medical outrage called the chargemaster, the exhaustive list of prices for procedures, drugs, and medical equipment that every hospital maintains and which every hospital refuses to reveal—until they send the bill. Interestingly, even the avidly pro-ObamaCare New York Times editorial page has noticed that price transparency is a big problem in the American medical marketplace.

Tina Rosenberg writes in today’s Sunday Review section:

Here is a basic fact of health care in the United States: Doctors and hospitals know what they charge, but patients don’t know what they pay. As in any market, when one side has no information, that side loses: price secrecy is a major reason medical bills are so high. In my previous column, I wrote about the effect of this lack of transparency on the bills patients pay out of pocket.

Here is an obvious reform that wouldn’t cost the federal government one cent and would exert an immediate and powerful downward pressure on medical costs: require that medical service providers make those chargemasters public. Market forces would instantly force the prices down towards the low end.

The natural forces that dominate an economy would do the work, and the Republicans can have the credit for lowering medical costs. What’s not to like?

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Why Non-Profit Hospitals Are So Profitable

Every business has a business model. Some go for prestige, selling the label as well as the product. That’s why a Mercedes costs a lot more than a comparable Lexus. The cars are equal in design, equipment, and road handling. So, in effect, when you buy a Mercedes, you’re spending a lot of money for the hood ornament. Other businesses go for volume by means of low prices. Wal-Mart is the perfect example. Still others advertise heavily and try to give the illusion that there are bargains to be had. Joseph A. Bank, the men’s clothing chain, advertises endlessly on television with sales pitches such as, “Buy one suit and get three more FREE!” Translation: The first suit has a nominal price four times higher than it should be.

And then there is the business model of “non-profit” hospitals, which are, in fact, among the most profitable enterprises in the country.

Every hospital has what is called a “chargemaster,” a list of what it charges for everything from a day in the ICU to a single aspirin. The hospital guards access to its chargemaster like the federal government guarded the Manhattan Project (only with more success, as Stalin knew all about the atomic bomb).

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Every business has a business model. Some go for prestige, selling the label as well as the product. That’s why a Mercedes costs a lot more than a comparable Lexus. The cars are equal in design, equipment, and road handling. So, in effect, when you buy a Mercedes, you’re spending a lot of money for the hood ornament. Other businesses go for volume by means of low prices. Wal-Mart is the perfect example. Still others advertise heavily and try to give the illusion that there are bargains to be had. Joseph A. Bank, the men’s clothing chain, advertises endlessly on television with sales pitches such as, “Buy one suit and get three more FREE!” Translation: The first suit has a nominal price four times higher than it should be.

And then there is the business model of “non-profit” hospitals, which are, in fact, among the most profitable enterprises in the country.

Every hospital has what is called a “chargemaster,” a list of what it charges for everything from a day in the ICU to a single aspirin. The hospital guards access to its chargemaster like the federal government guarded the Manhattan Project (only with more success, as Stalin knew all about the atomic bomb).

There’s a reason for that: the charges, like those at Joseph A. Bank, are utterly outrageous. A generic version of Tylenol can be $1.50, when you can buy a hundred of them at the local supermarket for the same price. But, as with Joseph A. Bank, most hospital patients don’t pay them. Medicare and insurance companies pay a fraction of the nominal prices. MD Anderson, a high-powered cancer hospital in Houston, charges $283 for a simple chest X-ray and Medicare pays the hospital $20.44.

But if someone without insurance, or with limited insurance, shows up needing serious medical care, he usually gets charged the full, outrageous, prices. And since the patient has no bargaining power whatever in those circumstances, there is little he can do about it except empty his retirement account or file for bankruptcy.

Time magazine had a long article by Steven Brill on this a few months ago that is well worth reading. Be prepared to become very, very angry. ObamaCare does not address the problem of sky-high prices that hit the most vulnerable the hardest. No wonder MD Anderson’s operating profit in 2010 was $531 million on revenues of $2.05 billion. That’s a 26-percent profit margin, unheard of in any service industry other than hospitals. Being a “non-profit” organization, it pays no income taxes.

The solution, of course, is sunshine: require these non-profit hospitals to post their chargemaster lists. If gas stations and automobile dealers are required to post their prices, why can’t medical service providers? The only reasons they are treated as state secrets is because they are a disgrace. Once the prices are public knowledge, they would, simply through market forces, begin to converge towards the lower end.

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Medicine and Market Forces

One of the clearest signs that market forces are being stymied is a wide spread between the top and bottom price for a commodity. Nowhere is this more conspicuous than in medical services. The price of treating, say, a simple fracture of the arm can, and does, vary by hundreds of percent. A simple remedy for this would be to require medical service providers to post prices for routine procedures. Market forces would immediately begin to cause those prices to converge toward the bottom end.

Would it be a panacea for all that’s wrong with American medicine? Of course not. But would it be a powerful inducement to cut costs and make medicine more efficient, lowering prices further? It could hardly help but be so. And, like that sovereign remedy for all that ails us—chicken soup—it can’t hurt. A big plus would be that it wouldn’t cost government a dime.

Now’s there’s evidence from a clinic, the Surgery Center of Oklahoma, that it actually works (h/t Instapundit). It started posting prices, which turned out to be far lower than other facilities, and people started coming from far and wide to take advantage of the lower prices. One of the local TV stations in Oklahoma City did a story on the clinic last week. It’s worth watching.

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One of the clearest signs that market forces are being stymied is a wide spread between the top and bottom price for a commodity. Nowhere is this more conspicuous than in medical services. The price of treating, say, a simple fracture of the arm can, and does, vary by hundreds of percent. A simple remedy for this would be to require medical service providers to post prices for routine procedures. Market forces would immediately begin to cause those prices to converge toward the bottom end.

Would it be a panacea for all that’s wrong with American medicine? Of course not. But would it be a powerful inducement to cut costs and make medicine more efficient, lowering prices further? It could hardly help but be so. And, like that sovereign remedy for all that ails us—chicken soup—it can’t hurt. A big plus would be that it wouldn’t cost government a dime.

Now’s there’s evidence from a clinic, the Surgery Center of Oklahoma, that it actually works (h/t Instapundit). It started posting prices, which turned out to be far lower than other facilities, and people started coming from far and wide to take advantage of the lower prices. One of the local TV stations in Oklahoma City did a story on the clinic last week. It’s worth watching.

As one of the founders explains:

“When we first started we thought we were about half the price of the hospitals,” Dr. Lantier said. “Then we found out we’re less than half price. Then we find out we’re a sixth to an eighth of what their prices are. I can’t believe the average person can afford health care at these prices.”

There are two things of particular interest in this story. One, the first non-local people to come to the clinic were from Canada. Why would people come from the single-payer paradise of Canada and pay their own money for a procedure they could get locally for free? That’s easy. Unless the condition is life threatening (and even if it is, if the patient is “too old”), you have to wait on line in Canada for elective procedures. And wait and wait and wait. Rationing is how Canadian medicine—totally devoid of market forces—keeps down costs.

Two, while the clinic accepts private insurance, it doesn’t take Medicare or Medicaid. Why? Those government programs forbid posting prices. One can only wonder why. It could be simply that bureaucrats love to promulgate rules, whether they make any sense or not. But I suspect it is because the real, ultimate goal of government health programs is to take control of one-sixth of the American economy. Anything that would make that harder, such as lower costs, is to be discouraged if not forbidden.

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The Political Implications of the Increase in Life Expectancy

The new, April, issue of National Geographic has maps of life expectancy for each county in the United States for 1989 and for 2009. (Apparently the digital version allows you to click on any particular county and get the local information, once you shell out $19.95 for a digital subscription.)

The story emphasizes the fact that life expectancy for men has increased more than it has for women over these 20 years and suggests that this may be due to inadequate treatment for women with high blood pressure and cholesterol. But it seems to me (though I am no epidemiologist) that that discrepancy might be due to the fact that women live longer than men and thus have less upside potential.

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The new, April, issue of National Geographic has maps of life expectancy for each county in the United States for 1989 and for 2009. (Apparently the digital version allows you to click on any particular county and get the local information, once you shell out $19.95 for a digital subscription.)

The story emphasizes the fact that life expectancy for men has increased more than it has for women over these 20 years and suggests that this may be due to inadequate treatment for women with high blood pressure and cholesterol. But it seems to me (though I am no epidemiologist) that that discrepancy might be due to the fact that women live longer than men and thus have less upside potential.

To me, the most startling fact in this data dump is just how fast life expectancy has increased for both sexes: 4.6 years for men and 2.7 years for women. That’s a 6.4 percent increase for men and a 3.4 percent increase for women in just two decades.

There was a similar leap in life expectancy in the early 20th century, but that increase was due to much lower infant and childhood mortality thanks to vaccines against such child-killers as whooping cough and diphtheria and the mandated pasteurization of milk, which eliminated the horrendous number of infant deaths caused by impure milk.

This latter-day increase comes at the end of life. Partly it is due to medicine’s greatly increased ability to cure or manage such killers as pneumonia, heart disease, and cancer. Partly it is due to a greatly improved environment, especially in cities and factories. And partly it is due to improved life styles, with more exercise and less fat, alcohol and tobacco.

There is no reason to think that this increase in life expectancy will abate any time soon. Indeed, it may accelerate. And that has tremendous public-policy implications with regard to Social Security, Medicare, etc. And as the percentage of old people increases in the population, their political clout will increase with it.

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Health Care Vote Not Just for Show?

Some conservatives have complained that the House vote to repeal ObamaCare tomorrow is just for show and has no chance of passing the Senate or — even if it miraculously did — surviving a presidential veto. True, but so what? Many voters are just starting to tune in to the general election, and it’s worth getting the latest positions of House lawmakers on the record. For Democrats running in conservative districts, this could be the last shot to oppose the unpopular health care law before the election. For Republicans, it’s a chance to show they’re on the side of the majority of Americans who oppose ObamaCare.

And for the White House, it’s a potential political embarrassment, depending on how many Democrats switch over to the anti-ObamaCare side. The Hill reports:

Only three Democrats voted for repeal after the GOP took control of the House last year, but Republicans are confident they can add to this number on Wednesday in spite of the Supreme Court’s ruling that the law is constitutional.

Already, one politically vulnerable Democrat, Rep. Larry Kissell (N.C.), has said he will vote to repeal the health care law after opposing the same measure a year ago.

The GOP’s hope is that a strong House vote — and fresh Democratic opposition — will thwart the White House’s effort to boost political support for the law in light of the Court ruling, said one House Republican leadership aide. Conservatives complaining about symbolic votes are being unrealistic.

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Some conservatives have complained that the House vote to repeal ObamaCare tomorrow is just for show and has no chance of passing the Senate or — even if it miraculously did — surviving a presidential veto. True, but so what? Many voters are just starting to tune in to the general election, and it’s worth getting the latest positions of House lawmakers on the record. For Democrats running in conservative districts, this could be the last shot to oppose the unpopular health care law before the election. For Republicans, it’s a chance to show they’re on the side of the majority of Americans who oppose ObamaCare.

And for the White House, it’s a potential political embarrassment, depending on how many Democrats switch over to the anti-ObamaCare side. The Hill reports:

Only three Democrats voted for repeal after the GOP took control of the House last year, but Republicans are confident they can add to this number on Wednesday in spite of the Supreme Court’s ruling that the law is constitutional.

Already, one politically vulnerable Democrat, Rep. Larry Kissell (N.C.), has said he will vote to repeal the health care law after opposing the same measure a year ago.

The GOP’s hope is that a strong House vote — and fresh Democratic opposition — will thwart the White House’s effort to boost political support for the law in light of the Court ruling, said one House Republican leadership aide. Conservatives complaining about symbolic votes are being unrealistic.

ObamaCare isn’t going away unless President Obama is voted out of office, which means all the GOP can do at the moment is apply political pressure to Democrats and sympathize with voter anger about the law. Because House Democratic leaders are trying to change the subject away from health care, that means it’s probably working:

Democrats, meanwhile, are seeking to portray the GOP as myopically focused on health care at the expense of the economy and other problems. The office of Minority Leader Nancy Pelosi (D-Calif.) released a video mocking the vote by using the mantra employed by Speaker John Boehner (R-Ohio): “Where are the jobs?”

To refresh Pelosi’s memory, it wasn’t the Republicans who jammed through Obama’s health care law instead of focusing on job creation. Now that ObamaCare’s been spared by the Supreme Court, Democrats would prefer to ignore the unpopular law until after November. House votes like the one tomorrow won’t let them.

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Freedom is Mandatory Union Dues

There is something about conservatives using the word “freedom” that drives the left insane. Maybe because progressives like to see themselves as champions of the people, fighting against the system, rather than what they actually are: statists, attempting to impose their beliefs on individuals through government power.

At the Huffington Post, AFL-CIO  boss Richard Trumka reimagines the concept of “freedom” today in a column that is just as Orwellian as you would think (h/t Washington Examiner):

I do believe that freedom isn’t free — but today the corporate and political right wing is trying to cheapen this truly American value. They’ve been cynically using the word “freedom” to rally the American public against its own best interests.

When the U.S. Supreme Court upheld the Affordable Care Act, Sarah Palin tweeted, “Obama lies; freedom dies.”

She’s referring, I guess, to the freedom to go without health care when you’re sick.

In its otherwise positive decision, the Supreme Court gave states the “freedom” to deny Medicaid coverage to their poorest residents — even though the federal government would pick up the tab.

Wisconsin Gov. Scott Walker received the National Rifle Association’s “Defender of Freedom” award recently. I guess they meant Gov. Walker is defending teachers’ freedom from joining with coworkers to bargain fairly about things like class size. …

Let’s call this right-wing “freedom” catch phrase what it really is: a grossly political strategy to dupe the public, which holds the word “freedom” as something sacred.

This Independence Day, I say let’s go back to a truer use of the word “freedom.” Let’s start with President Franklin Roosevelt’s Four Freedoms: freedom of speech and expression, freedom of worship, freedom from want and freedom from fear. I would add the freedom to bargain collectively.

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There is something about conservatives using the word “freedom” that drives the left insane. Maybe because progressives like to see themselves as champions of the people, fighting against the system, rather than what they actually are: statists, attempting to impose their beliefs on individuals through government power.

At the Huffington Post, AFL-CIO  boss Richard Trumka reimagines the concept of “freedom” today in a column that is just as Orwellian as you would think (h/t Washington Examiner):

I do believe that freedom isn’t free — but today the corporate and political right wing is trying to cheapen this truly American value. They’ve been cynically using the word “freedom” to rally the American public against its own best interests.

When the U.S. Supreme Court upheld the Affordable Care Act, Sarah Palin tweeted, “Obama lies; freedom dies.”

She’s referring, I guess, to the freedom to go without health care when you’re sick.

In its otherwise positive decision, the Supreme Court gave states the “freedom” to deny Medicaid coverage to their poorest residents — even though the federal government would pick up the tab.

Wisconsin Gov. Scott Walker received the National Rifle Association’s “Defender of Freedom” award recently. I guess they meant Gov. Walker is defending teachers’ freedom from joining with coworkers to bargain fairly about things like class size. …

Let’s call this right-wing “freedom” catch phrase what it really is: a grossly political strategy to dupe the public, which holds the word “freedom” as something sacred.

This Independence Day, I say let’s go back to a truer use of the word “freedom.” Let’s start with President Franklin Roosevelt’s Four Freedoms: freedom of speech and expression, freedom of worship, freedom from want and freedom from fear. I would add the freedom to bargain collectively.

The “freedom to go without health care when we’re sick” isn’t the issue, unless Trumka is arguing that the state should force every sick person in the country to get medical attention. We all have the freedom to decide whether or not to see a doctor when we are sick, just like we should all have the freedom to decide not to pay for health care (insurance) when we are well. We have the freedom to move if we disagree with our state’s decision to not participate in Medicare expansion. And we also have the freedom to elect a new state governor who will participate in it, or lobby the current governor to do it, if that’s our preference.

We should all have the freedom to decide whether or not to pay monthly dues to a union, instead of having the money automatically pulled from our paychecks. Trumka opposes “teachers’ freedom from joining with coworkers to bargain” — in other words, he thinks teachers should be forced to join with coworkers to bargain. Shouldn’t someone who professes to care about teachers support their freedom to make their own choices regarding their paychecks and their workplaces?

Trumka seems to grasp that this statist mentality is unpopular with the public, and that labor’s messaging strategy in Wisconsin was a failure. That’s why he’s so adamant about trying to reframe his positions as “pro-freedom,” as illogical as it sounds. The conservative arguments are working, and the left has very little ammunition to fight back.

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