Commentary Magazine


Topic: physician

History Made Visible

Humans are visual animals. Just as a dog, suddenly aware of the unexpected, turns his nose toward it and starts sniffing, we humans turn our eyes toward things to try to figure them out. Of course, many things are invisible because of distance, size, lack of light, or obstruction. Much of the history of technology has been about overcoming these problems, with telescopes, microscopes, infrared sensors, radar, television, etc.  Once we can see something clearly, we can usually figure it out.

But some things are just inherently not visible. Epidemics, for instance. So we humans, clever creatures that we are, have devised ways to make even them visible. When cholera broke out in London in 1854, no one had a clue as to why or how the disease was spreading. A physician named John Snow stuck a pin in a map of London to indicate the residence of everyone who had developed cholera. It was quickly evident that the cases were clustered tightly around a particular public well from which people were drawing water for household use. Close the well, said Snow, and the epidemic will end. Snow, widely considered the father of epidemiology, was right, and the epidemic quickly abated when authorities closed the well.

Statistics, too, are a way of making the inherently invisible visible because they can be converted into graphs and charts.  Add the power of computers and you can produce charts that border on the magical. Consider this one published in Business Insider. It charts the fertility rate (the number of babies born per woman) against life expectancy over the past 50 years for a large number of countries. Each country is represented by a circle, its size a function of that country’s population.

The first thing you notice is that the fertility rate has been dropping sharply in most countries, while life expectancy has been rising equally sharply. The circles migrate toward the lower right of the chart over time to show this. But one of the large circles suddenly drops off a cliff beginning about 1970 as its fertility rate drops precipitously. How come? Click on the bubble and its name comes up: China and its one-child-per-family policy. And some countries suddenly reverse course, and their life expectancy collapses, moving their circles rapidly back toward the left of the chart. What is causing that? Click on the circles and the names of the countries come up: Rwanda, Cambodia, etc.

In other words, this chart makes history itself visible. Is that cool, or what?

Humans are visual animals. Just as a dog, suddenly aware of the unexpected, turns his nose toward it and starts sniffing, we humans turn our eyes toward things to try to figure them out. Of course, many things are invisible because of distance, size, lack of light, or obstruction. Much of the history of technology has been about overcoming these problems, with telescopes, microscopes, infrared sensors, radar, television, etc.  Once we can see something clearly, we can usually figure it out.

But some things are just inherently not visible. Epidemics, for instance. So we humans, clever creatures that we are, have devised ways to make even them visible. When cholera broke out in London in 1854, no one had a clue as to why or how the disease was spreading. A physician named John Snow stuck a pin in a map of London to indicate the residence of everyone who had developed cholera. It was quickly evident that the cases were clustered tightly around a particular public well from which people were drawing water for household use. Close the well, said Snow, and the epidemic will end. Snow, widely considered the father of epidemiology, was right, and the epidemic quickly abated when authorities closed the well.

Statistics, too, are a way of making the inherently invisible visible because they can be converted into graphs and charts.  Add the power of computers and you can produce charts that border on the magical. Consider this one published in Business Insider. It charts the fertility rate (the number of babies born per woman) against life expectancy over the past 50 years for a large number of countries. Each country is represented by a circle, its size a function of that country’s population.

The first thing you notice is that the fertility rate has been dropping sharply in most countries, while life expectancy has been rising equally sharply. The circles migrate toward the lower right of the chart over time to show this. But one of the large circles suddenly drops off a cliff beginning about 1970 as its fertility rate drops precipitously. How come? Click on the bubble and its name comes up: China and its one-child-per-family policy. And some countries suddenly reverse course, and their life expectancy collapses, moving their circles rapidly back toward the left of the chart. What is causing that? Click on the circles and the names of the countries come up: Rwanda, Cambodia, etc.

In other words, this chart makes history itself visible. Is that cool, or what?

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More Obama!

The Washington Post tries to throw Obama and the Democrats a lifeline. It’s understandable that the liberal media — which witnessed a complete repudiation of Obama and his agenda at the polls — would scramble to help him out. After all, they invested so much credibility in helping to elect him. But the advice they offer is simply daft:

Strategists at both ends of Pennsylvania Avenue say it is now clear that, although Obama’s name will not be on the ballot, it will fall to him to build the case for the activist approach that he has pressed his party to take over the past 16 months. And just as important, they say, he must take the lead in making the argument against the Republicans.

Are they joking? The president who in 17 months could not sell ObamaCare to the American people and whose agenda has shifted the country to the right is now expected to remind the entire populace, when his poll numbers are sliding downward, that Democrats believe in big government, lots of regulation, and higher taxes? The Republican reaction is likely to be: Oh, please do!

And by the way, the reporters identify not a single “strategist” other than David Axelrod and congressional Democrats. So the sentence is misleading. It should begin “Democratic pols at both ends of Pennsylvania Avenue have convinced themselves, despite evidence of the president’s declining popularity …”

The reporters then bizarrely offer up Mark Critz as an example of how candidates can craft their own message. But wait: that message was anti-Obama. As George Will reminds Post readers over on the op-ed page, Critz is “right-to-life and pro-gun. He accused his opponent of wanting heavier taxes. He said he would have voted against Barack Obama’s health-care plan and promised to vote against cap-and-trade legislation, which is a tax increase supposedly somehow related to turning down the planet’s thermostat.”

And David Broder, who is not exactly a strategist but is also no GOP booster, is even more blunt in the Post‘s opinion section:

We saw the anti-Washington sentiment Tuesday in Kentucky, where Rand Paul, the physician son of libertarian Rep. Ron Paul, easily defeated Senate Minority Leader Mitch McConnell’s handpicked candidate for the Republican nomination for a vacant Senate seat — and credited his win to the Tea Partyers. The same sentiment carried to Arkansas, where incumbent Democratic Sen. Blanche Lincoln was forced into a runoff by her labor-backed challenger, Lt. Gov. Bill Halter. And it claimed its largest victim of the year so far in Pennsylvania’s Sen. Arlen Specter. Run out of the Republican Party last year by a GOP challenger, he fell embarrassingly to a less-known younger congressman in a bid for the Democratic nomination. His failure showed the Obama White House once again to be a toothless tiger — with its endorsements now having failed in Virginia, New Jersey, Massachusetts and Pennsylvania. No good news for the president there.

Republicans would dearly love Obama to test the Post reporters’ theory that the Democrats’ problem is not enough big-government cheerleading. And they would be ecstatic if he came to do it in every close district in the country. Then there will be no denying that the results will be a true reflection of the country’s evaluation of him.

The Washington Post tries to throw Obama and the Democrats a lifeline. It’s understandable that the liberal media — which witnessed a complete repudiation of Obama and his agenda at the polls — would scramble to help him out. After all, they invested so much credibility in helping to elect him. But the advice they offer is simply daft:

Strategists at both ends of Pennsylvania Avenue say it is now clear that, although Obama’s name will not be on the ballot, it will fall to him to build the case for the activist approach that he has pressed his party to take over the past 16 months. And just as important, they say, he must take the lead in making the argument against the Republicans.

Are they joking? The president who in 17 months could not sell ObamaCare to the American people and whose agenda has shifted the country to the right is now expected to remind the entire populace, when his poll numbers are sliding downward, that Democrats believe in big government, lots of regulation, and higher taxes? The Republican reaction is likely to be: Oh, please do!

And by the way, the reporters identify not a single “strategist” other than David Axelrod and congressional Democrats. So the sentence is misleading. It should begin “Democratic pols at both ends of Pennsylvania Avenue have convinced themselves, despite evidence of the president’s declining popularity …”

The reporters then bizarrely offer up Mark Critz as an example of how candidates can craft their own message. But wait: that message was anti-Obama. As George Will reminds Post readers over on the op-ed page, Critz is “right-to-life and pro-gun. He accused his opponent of wanting heavier taxes. He said he would have voted against Barack Obama’s health-care plan and promised to vote against cap-and-trade legislation, which is a tax increase supposedly somehow related to turning down the planet’s thermostat.”

And David Broder, who is not exactly a strategist but is also no GOP booster, is even more blunt in the Post‘s opinion section:

We saw the anti-Washington sentiment Tuesday in Kentucky, where Rand Paul, the physician son of libertarian Rep. Ron Paul, easily defeated Senate Minority Leader Mitch McConnell’s handpicked candidate for the Republican nomination for a vacant Senate seat — and credited his win to the Tea Partyers. The same sentiment carried to Arkansas, where incumbent Democratic Sen. Blanche Lincoln was forced into a runoff by her labor-backed challenger, Lt. Gov. Bill Halter. And it claimed its largest victim of the year so far in Pennsylvania’s Sen. Arlen Specter. Run out of the Republican Party last year by a GOP challenger, he fell embarrassingly to a less-known younger congressman in a bid for the Democratic nomination. His failure showed the Obama White House once again to be a toothless tiger — with its endorsements now having failed in Virginia, New Jersey, Massachusetts and Pennsylvania. No good news for the president there.

Republicans would dearly love Obama to test the Post reporters’ theory that the Democrats’ problem is not enough big-government cheerleading. And they would be ecstatic if he came to do it in every close district in the country. Then there will be no denying that the results will be a true reflection of the country’s evaluation of him.

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J Street Loses a Congressional Recruit

Are liberal Democrats starting to be wary of the siren calls of J Street? This story from Philadelphia’s Jewish Exponent shows that at least one congressional candidate has figured out that associating with the far-Left lobby can be dangerous for his political health.

The Exponent’s Bryan Schwartzman reports that Doug Pike, one of the contenders for the Democratic nomination for Pennsylvania’s 6th congressional district, has “asked J Street officials this week to remove him from its list of 41 endorsed candidates, and said he’s planning to return some $6,000 donated via the group.” It appears that Pike, who is fighting for the right to challenge incumbent Republican Jim Gerlach, has gotten the message from voters and contributors that aligning himself with J Street is not the path to the hearts or the wallets of pro-Israel Democrats.

Pike, the son of Otis Pike, a onetime New York congressman, is a former Philadelphia Inquirer editorial writer and is locked in a tough fight against Manan Trivedi, a physician and Iraq-war veteran who has got the endorsement of two key Democratic committees in the district, which stretches across three suburban counties in the western suburbs of Philadelphia. Schwartzman says that one pro-Israel fundraiser claims “a number of potential contributors walked away from Pike after the J Street endorsement became known, and after Gerlach — considered a strong Israel backer — decided not to run for governor.”

Pike told the Exponent that “when he first sought J Street’s endorsement back in September, he had underestimated his policy differences with the group.” Of special interest, in the context of this past week’s dispute between the Obama administration and Israel, is that Pike was “troubled” by J Street’s recent stance that Israel halt construction in eastern Jerusalem because J Street has backed Obama against Netanyahu on the issue of plans to build Jewish homes in an eastern Jerusalem neighborhood. “People simply assumed when they heard that I was endorsed by J Street that I agreed with them on everything,” said Pike. “The endorsement was an impediment to my being able to explain my convictions about Israel’s security.”

Pike’s attempt to extricate himself from J Street’s death grip may or may not save his candidacy, but it ought to serve as a warning to other Democrats who assume that the group’s claim that it is within the mainstream is true. J Street representatives and other left-wingers have asserted that Obama’s 2008 victory — and his huge share of the Jewish vote — proved that mainstream pro-Israel groups like AIPAC no longer represented the community’s view. But, as Pike has found out, most rank-and-file Jewish Democrats, even those who call themselves liberals, do not support putting pressure on Israel to make more concessions to the Palestinians and are appalled by the administration’s attack on Jewish rights in Jerusalem.

So is the White House, which has become even more brazen in its open contempt for the Israeli government, capable of understanding what Doug Pike has now discovered — that sooner or later, its attitude toward Israel, which is inspired in part by its misconception that J Street is representative of mainstream Jewish opinion, may be a huge political mistake?

Are liberal Democrats starting to be wary of the siren calls of J Street? This story from Philadelphia’s Jewish Exponent shows that at least one congressional candidate has figured out that associating with the far-Left lobby can be dangerous for his political health.

The Exponent’s Bryan Schwartzman reports that Doug Pike, one of the contenders for the Democratic nomination for Pennsylvania’s 6th congressional district, has “asked J Street officials this week to remove him from its list of 41 endorsed candidates, and said he’s planning to return some $6,000 donated via the group.” It appears that Pike, who is fighting for the right to challenge incumbent Republican Jim Gerlach, has gotten the message from voters and contributors that aligning himself with J Street is not the path to the hearts or the wallets of pro-Israel Democrats.

Pike, the son of Otis Pike, a onetime New York congressman, is a former Philadelphia Inquirer editorial writer and is locked in a tough fight against Manan Trivedi, a physician and Iraq-war veteran who has got the endorsement of two key Democratic committees in the district, which stretches across three suburban counties in the western suburbs of Philadelphia. Schwartzman says that one pro-Israel fundraiser claims “a number of potential contributors walked away from Pike after the J Street endorsement became known, and after Gerlach — considered a strong Israel backer — decided not to run for governor.”

Pike told the Exponent that “when he first sought J Street’s endorsement back in September, he had underestimated his policy differences with the group.” Of special interest, in the context of this past week’s dispute between the Obama administration and Israel, is that Pike was “troubled” by J Street’s recent stance that Israel halt construction in eastern Jerusalem because J Street has backed Obama against Netanyahu on the issue of plans to build Jewish homes in an eastern Jerusalem neighborhood. “People simply assumed when they heard that I was endorsed by J Street that I agreed with them on everything,” said Pike. “The endorsement was an impediment to my being able to explain my convictions about Israel’s security.”

Pike’s attempt to extricate himself from J Street’s death grip may or may not save his candidacy, but it ought to serve as a warning to other Democrats who assume that the group’s claim that it is within the mainstream is true. J Street representatives and other left-wingers have asserted that Obama’s 2008 victory — and his huge share of the Jewish vote — proved that mainstream pro-Israel groups like AIPAC no longer represented the community’s view. But, as Pike has found out, most rank-and-file Jewish Democrats, even those who call themselves liberals, do not support putting pressure on Israel to make more concessions to the Palestinians and are appalled by the administration’s attack on Jewish rights in Jerusalem.

So is the White House, which has become even more brazen in its open contempt for the Israeli government, capable of understanding what Doug Pike has now discovered — that sooner or later, its attitude toward Israel, which is inspired in part by its misconception that J Street is representative of mainstream Jewish opinion, may be a huge political mistake?

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Just a Notch on a Belt

Buried deep inside an angst-filled column complaining that Obama is underappreciated and overly criticized, Richard Cohen concedes what many on both the Right and Left suspect: “He wanted a health-care bill. Why? To cover the uncovered. Maybe. To rein in the insurance companies. Maybe. To lower costs. Maybe. What mattered most was getting a bill, any bill. This is not a cause. It’s a notch on a belt.” We suspect that is true in part because Obama never really told us what he wanted in the bill. He never sent a proposal to Congress. He didn’t spell out specific requirements for his plan in that game-changing (not) speech in September. Each time Congress moved ahead with one version or another, Obama praised the effort without much comment on the content. Some thought it was tactical. But maybe he never really cared what was in it.

That conclusion is reinforced by the bill’s content and timing. As for the content, it doesn’t do what the president in broadest strokes said he wanted to accomplish. James Capretta points out that this isn’t “universal” care:

The House and Senate bills would add 15 million or more people to [Medicaid's] rolls without any guarantee whatsoever that there will be doctors and hospitals that can see them. Ironically, the very Democrats who most frequently tout “universality” as the goal are also the ones who ensure it will never actually come about by insisting that America’s lower-income families enroll in government-run insurance — with no other options. Beyond the Medicaid expansion, Obamacare is really an obligation, not a right. Every citizen would be required to sign up with a government-approved health-insurance plan or pay a tax penalty for going without coverage.

And even its proponents concede there will still be 23 million or so uninsured. Nor does the bill meet the president’s goals of deficit neutrality or cost cutting:

[T]he claim that bill lowers the deficit means that, in addition to cutting Medicare by half a trillion dollars, the Senate would also raise half a trillion in new taxes — during a recession. Only a series of accounting gimmicks — such as implementing benefits beginning in 2014 but raising taxes starting in 2010, and double-counting Medicare savings — allowed Senate majority leader Harry Reid to get a CBO cost estimate that pretends to add “not one dime” to the deficit. Medicare actuary Foster found that the Senate bill would bend the cost curve up, not down, and that the new taxes on drugs, devices, and health-insurance plans would increase prices and health-insurance costs for consumers.

But the telltale sign that Obama doesn’t really much care about the merits of the bill or any of the bill’s promised benefits is the timeline. The Heritage Foundation lays this out in detail:

2010: Physician Medicare payments decrease 21% effective March 1, 2010

2011: “Annual Fee” tax on health insurance, allocated according to share of total premiums. Begins at $2 billion in 2011, then increases to $4 billion in 2012, $7 billion in 2013, $9 billion in the years 2014, 2015, and 2016, and eventually $10 billion for 2017 and every year thereafter. Two insurers in Nebraska and one in Michigan are exempt from this tax.

2012: Medicare payment penalties for hospitals with the highest readmission rates for selected conditions.

2013: Medicare tax increased from 2.9% to 3.8% for incomes over $250,000 (joint filers) or $200,000 (all others). (This is stated as an increase of 0.9 percentage points, to only the employee’s share of the FICA tax.)

2014: Individual mandate begins: Tax penalties for not having insurance begin at $95 or 0.5% of income, whichever is higher, rising to $495 or 1% of income in 2015 and $750 or 2% of income thereafter (indexed for inflation after 2016). These penalties are per adult, half that amount per child, to a maximum of three times the per-adult amount per family. The penalty is capped at the national average premium for the “bronze” plan.

2015: Establishment of Independent Medicare Advisory Board (IMAB) to recommend cuts in Medicare benefits; these cuts will go into effect automatically unless Congress passes, and the President signs, an override bill.

2016: Individual mandate penalty rises to $750 per adult ($375 per child), maximum $2,250 per family, or 2% of family income, whichever is higher (capped at the national average premium for the “bronze” plan). After 2016, the penalty will be increased each year to adjust for inflation.

2017: Itemized deduction for out-of-pocket medical expenses is limited to expenses over 10% of AGI for those over age 65.

Bottom line: nothing but taxes and Medicare cuts begin before 2014. This is not a serious plan to address a health-care “crisis,” is it? No. It is an effort to throw something up against the wall and clean up the mess later. It won’t be proven “not to work” before Obama’s last election because it isn’t designed to really do anything, other than raise taxes, for the next four years. It is the ultimate placeholder that Obama can check off on his to-do list without the responsibility for actually solving the crisis he told us we had to fix urgently – before Christmas 2009.

It is hard, then, to quibble with Cohen. This isn’t a serious effort to reform health care. It’s lazy governance from a president who couldn’t face failure or craft a coherent bill. He and Democrats in the House and Senate imagine that the voters are too dumb to figure this out. We’ll test that proposition in November.

Buried deep inside an angst-filled column complaining that Obama is underappreciated and overly criticized, Richard Cohen concedes what many on both the Right and Left suspect: “He wanted a health-care bill. Why? To cover the uncovered. Maybe. To rein in the insurance companies. Maybe. To lower costs. Maybe. What mattered most was getting a bill, any bill. This is not a cause. It’s a notch on a belt.” We suspect that is true in part because Obama never really told us what he wanted in the bill. He never sent a proposal to Congress. He didn’t spell out specific requirements for his plan in that game-changing (not) speech in September. Each time Congress moved ahead with one version or another, Obama praised the effort without much comment on the content. Some thought it was tactical. But maybe he never really cared what was in it.

That conclusion is reinforced by the bill’s content and timing. As for the content, it doesn’t do what the president in broadest strokes said he wanted to accomplish. James Capretta points out that this isn’t “universal” care:

The House and Senate bills would add 15 million or more people to [Medicaid's] rolls without any guarantee whatsoever that there will be doctors and hospitals that can see them. Ironically, the very Democrats who most frequently tout “universality” as the goal are also the ones who ensure it will never actually come about by insisting that America’s lower-income families enroll in government-run insurance — with no other options. Beyond the Medicaid expansion, Obamacare is really an obligation, not a right. Every citizen would be required to sign up with a government-approved health-insurance plan or pay a tax penalty for going without coverage.

And even its proponents concede there will still be 23 million or so uninsured. Nor does the bill meet the president’s goals of deficit neutrality or cost cutting:

[T]he claim that bill lowers the deficit means that, in addition to cutting Medicare by half a trillion dollars, the Senate would also raise half a trillion in new taxes — during a recession. Only a series of accounting gimmicks — such as implementing benefits beginning in 2014 but raising taxes starting in 2010, and double-counting Medicare savings — allowed Senate majority leader Harry Reid to get a CBO cost estimate that pretends to add “not one dime” to the deficit. Medicare actuary Foster found that the Senate bill would bend the cost curve up, not down, and that the new taxes on drugs, devices, and health-insurance plans would increase prices and health-insurance costs for consumers.

But the telltale sign that Obama doesn’t really much care about the merits of the bill or any of the bill’s promised benefits is the timeline. The Heritage Foundation lays this out in detail:

2010: Physician Medicare payments decrease 21% effective March 1, 2010

2011: “Annual Fee” tax on health insurance, allocated according to share of total premiums. Begins at $2 billion in 2011, then increases to $4 billion in 2012, $7 billion in 2013, $9 billion in the years 2014, 2015, and 2016, and eventually $10 billion for 2017 and every year thereafter. Two insurers in Nebraska and one in Michigan are exempt from this tax.

2012: Medicare payment penalties for hospitals with the highest readmission rates for selected conditions.

2013: Medicare tax increased from 2.9% to 3.8% for incomes over $250,000 (joint filers) or $200,000 (all others). (This is stated as an increase of 0.9 percentage points, to only the employee’s share of the FICA tax.)

2014: Individual mandate begins: Tax penalties for not having insurance begin at $95 or 0.5% of income, whichever is higher, rising to $495 or 1% of income in 2015 and $750 or 2% of income thereafter (indexed for inflation after 2016). These penalties are per adult, half that amount per child, to a maximum of three times the per-adult amount per family. The penalty is capped at the national average premium for the “bronze” plan.

2015: Establishment of Independent Medicare Advisory Board (IMAB) to recommend cuts in Medicare benefits; these cuts will go into effect automatically unless Congress passes, and the President signs, an override bill.

2016: Individual mandate penalty rises to $750 per adult ($375 per child), maximum $2,250 per family, or 2% of family income, whichever is higher (capped at the national average premium for the “bronze” plan). After 2016, the penalty will be increased each year to adjust for inflation.

2017: Itemized deduction for out-of-pocket medical expenses is limited to expenses over 10% of AGI for those over age 65.

Bottom line: nothing but taxes and Medicare cuts begin before 2014. This is not a serious plan to address a health-care “crisis,” is it? No. It is an effort to throw something up against the wall and clean up the mess later. It won’t be proven “not to work” before Obama’s last election because it isn’t designed to really do anything, other than raise taxes, for the next four years. It is the ultimate placeholder that Obama can check off on his to-do list without the responsibility for actually solving the crisis he told us we had to fix urgently – before Christmas 2009.

It is hard, then, to quibble with Cohen. This isn’t a serious effort to reform health care. It’s lazy governance from a president who couldn’t face failure or craft a coherent bill. He and Democrats in the House and Senate imagine that the voters are too dumb to figure this out. We’ll test that proposition in November.

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The Corrective Election of 2010

On Fox News Sunday, Dana Perino provided a useful summary of what health-care “reform” now looks like. In short, it’s not reform at all:

Well, I think that at the end of the day this is a massive entitlement expansion that’s going to subsidize a lot of people without the reform that was needed. So you look at the CBO report — if you actually tease it out, they’re basically saying, “We don’t know really what’s going to happen.” It says that 23 million people are going to remain uninsured, so I don’t know how to break out those numbers. In addition to that, it does say that in 2010 they assume that doctors will be reduced in their reimbursements by 21 percent. This called “doc fix” up on Capitol Hill. It never happens.

The non-reform health-care bill does, to the disgust of liberals, make insurance companies very happy. The government is coercing customers to buy the companies’ products under penalty of prosecution and fine. The non-reform health-care bill does, to the horror of seniors, slash $500B out of Medicare with no conceivable alternative other than rationing to meet its new budget. The non-reform health-care bill does, to the delight of trial lawyers, do nothing to reform the tort system or the problem of defensive medicine. And the non-reform health-care bill does, to the chagrin of deficit hawks, do nothing to bend the cost-curve or cut the deficit. (James Capretta explains: “For starters, as CBO notes, the bill presumes that Medicare fees for physician services will get cut by more than 20 percent in 2011, and then stay at the reduced level indefinitely. There is strong bipartisan opposition to such cuts. Fixing that problem alone will cost more than $200 billion over a decade, pushing the Reid plan from the black and into a deep red.”) Finally, the non-reform health-care bill will, to the embarrassment of good-government types, in all likelihood get passed through a combination of bribery and secrecy, with virtually no time for thoughtful consideration.

On every level it’s a policy train wreck. As Robert J. Samuelson summed up:

It will not control costs. It will worsen the budget outlook. It will lead to higher taxes. It will disrupt how, or whether, companies provide insurance for their workers. As the real-life (as opposed to rhetorical) consequences unfold, they will rebut Obama’s claim that he has “solved” the health-care problem. His reputation will suffer.

Its noxious impact and the manner by which it was passed will annoy voters and motivate already enraged conservatives and skeptical independents in 2010. The Democrats have no cover on this one, just as they lacked one on the stimulus plan, which was passed on a near party-line vote. (The final vote on the non-reform health-care bill will be even more partisan.) If, as with the stimulus, voters cannot be lulled into believing that atrocious legislation is really a marvelous thing, the consequences will be significant and the 2010 election will make 1994 look like a mere ripple on the political landscape.

Elections have consequences, certainly. That’s how we wound up with huge congressional majorities in both houses and an ultra-liberal president. But there’s always another election coming up to correct the missteps and excesses of those who won last time. If ObamaCare manages to be passed into law, as is almost certain, and the voters slowly learn what the non-reform bill does, then be prepared for one of the great corrective elections in American history.

On Fox News Sunday, Dana Perino provided a useful summary of what health-care “reform” now looks like. In short, it’s not reform at all:

Well, I think that at the end of the day this is a massive entitlement expansion that’s going to subsidize a lot of people without the reform that was needed. So you look at the CBO report — if you actually tease it out, they’re basically saying, “We don’t know really what’s going to happen.” It says that 23 million people are going to remain uninsured, so I don’t know how to break out those numbers. In addition to that, it does say that in 2010 they assume that doctors will be reduced in their reimbursements by 21 percent. This called “doc fix” up on Capitol Hill. It never happens.

The non-reform health-care bill does, to the disgust of liberals, make insurance companies very happy. The government is coercing customers to buy the companies’ products under penalty of prosecution and fine. The non-reform health-care bill does, to the horror of seniors, slash $500B out of Medicare with no conceivable alternative other than rationing to meet its new budget. The non-reform health-care bill does, to the delight of trial lawyers, do nothing to reform the tort system or the problem of defensive medicine. And the non-reform health-care bill does, to the chagrin of deficit hawks, do nothing to bend the cost-curve or cut the deficit. (James Capretta explains: “For starters, as CBO notes, the bill presumes that Medicare fees for physician services will get cut by more than 20 percent in 2011, and then stay at the reduced level indefinitely. There is strong bipartisan opposition to such cuts. Fixing that problem alone will cost more than $200 billion over a decade, pushing the Reid plan from the black and into a deep red.”) Finally, the non-reform health-care bill will, to the embarrassment of good-government types, in all likelihood get passed through a combination of bribery and secrecy, with virtually no time for thoughtful consideration.

On every level it’s a policy train wreck. As Robert J. Samuelson summed up:

It will not control costs. It will worsen the budget outlook. It will lead to higher taxes. It will disrupt how, or whether, companies provide insurance for their workers. As the real-life (as opposed to rhetorical) consequences unfold, they will rebut Obama’s claim that he has “solved” the health-care problem. His reputation will suffer.

Its noxious impact and the manner by which it was passed will annoy voters and motivate already enraged conservatives and skeptical independents in 2010. The Democrats have no cover on this one, just as they lacked one on the stimulus plan, which was passed on a near party-line vote. (The final vote on the non-reform health-care bill will be even more partisan.) If, as with the stimulus, voters cannot be lulled into believing that atrocious legislation is really a marvelous thing, the consequences will be significant and the 2010 election will make 1994 look like a mere ripple on the political landscape.

Elections have consequences, certainly. That’s how we wound up with huge congressional majorities in both houses and an ultra-liberal president. But there’s always another election coming up to correct the missteps and excesses of those who won last time. If ObamaCare manages to be passed into law, as is almost certain, and the voters slowly learn what the non-reform bill does, then be prepared for one of the great corrective elections in American history.

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Flotsam and Jetsam

More doctors say “no” to Obamacare: “A coalition representing 240,000 physician specialists, like the American College of Surgeons and the American Society of Cataract and Refractive Surgery, said it ‘must oppose the bill as currently written.’” I wonder how many doctors are going to leave the AMA over its “expressed support for the legislation’s central elements.”

There is at least one major impediment to a health-care bill: “After months of trying to craft a 60-vote coalition based on the finer points of health care policy, Senate Democrats are growing increasingly worried that abortion will upend what had become a clear path to approving the overhaul bill.”

Uh oh: “Senate Finance Chairman Max Baucus’ office confirmed late Friday night that the Montana Democrat was carrying on an affair with his state office director, Melodee Hanes, when he nominated her to be U.S. attorney in Montana. According to a source familiar with their relationship, Hanes and Baucus began their relationship in the summer of 2008 – nearly a year before Baucus and his wife, Wanda, divorced in April 2009.”

Mona Charen: “Barack Obama is demonstrating bottomless reservoirs of gracelessness. A full 13 months after his election, in the course of justifying the deployment of 30,000 more troops to Afghanistan, President Obama could not spare a word of praise for George W. Bush — not even when recounting the nation’s ‘unified’ response to 9/11. To the contrary, throughout his pained recitation of the choices we face in Afghanistan, he adverted at least half a dozen times to the supposed blunders of his predecessor.”

It seems as though the envoy-itis hasn’t worked out so well for the Obami foreign policy. But this bit of super spin about George Mitchell is quite amusing: “throughout a year of exhausting shuttle diplomacy to the Middle East and European capitals, he has not been able to achieve the major task Obama assigned him: getting Israelis and Palestinians back to the peace table.” Er, that’s one way of describing the most counterproductive year in Middle East diplomacy in decades, or maybe in history.

Meanwhile, Michael Goldfarb goes after the mealy-mouthed envoy to Sudan, Scott Gration. But the president is what matters here: “He pledged to put an end to the genocide there, and in early 2007 Biden even went so far as to call for deploying American troops to the country. As Obama’s first year comes to a close, his administration is indulging an envoy whose approach is defined by his desire to engage the war criminals who rule Sudan. Gration is Obama’s guy, and ultimately, he is implementing Obama’s policy.”

Obama drops seven points in a month in the CNN/Opinion Research poll; down to a 48-to-50% approval/disapproval rating. And that is among “American adults,” not all of whom are registered voters.

Charles Krauthammer on the “executive privilege” objection to the Obami’s social secretary’s testifying before Congress: “What is comical about this is it’s being invoked for a social secretary in a circumstance where, in the original Supreme Court rulings, it was intended for high officials with important state secrets. What was the state secret here — the nature of the flower arrangements at the head table? You know, it is as if somebody is invoking the Fifth Amendment in a dispute over a parking ticket.”

Roger Pilon of CATO explains the environmentalists’ dilemma: “At bottom, the greens face three basic problems. First, by no means is the science of global warming ‘settled’ — if anything, the fraud Climategate surfaced has settled that question. Second, even if global warming were a settled science, the contribution of human activity is anything but certain. And finally, most important, even if the answers to those two questions were clear, the costs — or benefits — of global warming are unknown, but the costs of the proposals promoted by the greens are astronomical.”

More doctors say “no” to Obamacare: “A coalition representing 240,000 physician specialists, like the American College of Surgeons and the American Society of Cataract and Refractive Surgery, said it ‘must oppose the bill as currently written.’” I wonder how many doctors are going to leave the AMA over its “expressed support for the legislation’s central elements.”

There is at least one major impediment to a health-care bill: “After months of trying to craft a 60-vote coalition based on the finer points of health care policy, Senate Democrats are growing increasingly worried that abortion will upend what had become a clear path to approving the overhaul bill.”

Uh oh: “Senate Finance Chairman Max Baucus’ office confirmed late Friday night that the Montana Democrat was carrying on an affair with his state office director, Melodee Hanes, when he nominated her to be U.S. attorney in Montana. According to a source familiar with their relationship, Hanes and Baucus began their relationship in the summer of 2008 – nearly a year before Baucus and his wife, Wanda, divorced in April 2009.”

Mona Charen: “Barack Obama is demonstrating bottomless reservoirs of gracelessness. A full 13 months after his election, in the course of justifying the deployment of 30,000 more troops to Afghanistan, President Obama could not spare a word of praise for George W. Bush — not even when recounting the nation’s ‘unified’ response to 9/11. To the contrary, throughout his pained recitation of the choices we face in Afghanistan, he adverted at least half a dozen times to the supposed blunders of his predecessor.”

It seems as though the envoy-itis hasn’t worked out so well for the Obami foreign policy. But this bit of super spin about George Mitchell is quite amusing: “throughout a year of exhausting shuttle diplomacy to the Middle East and European capitals, he has not been able to achieve the major task Obama assigned him: getting Israelis and Palestinians back to the peace table.” Er, that’s one way of describing the most counterproductive year in Middle East diplomacy in decades, or maybe in history.

Meanwhile, Michael Goldfarb goes after the mealy-mouthed envoy to Sudan, Scott Gration. But the president is what matters here: “He pledged to put an end to the genocide there, and in early 2007 Biden even went so far as to call for deploying American troops to the country. As Obama’s first year comes to a close, his administration is indulging an envoy whose approach is defined by his desire to engage the war criminals who rule Sudan. Gration is Obama’s guy, and ultimately, he is implementing Obama’s policy.”

Obama drops seven points in a month in the CNN/Opinion Research poll; down to a 48-to-50% approval/disapproval rating. And that is among “American adults,” not all of whom are registered voters.

Charles Krauthammer on the “executive privilege” objection to the Obami’s social secretary’s testifying before Congress: “What is comical about this is it’s being invoked for a social secretary in a circumstance where, in the original Supreme Court rulings, it was intended for high officials with important state secrets. What was the state secret here — the nature of the flower arrangements at the head table? You know, it is as if somebody is invoking the Fifth Amendment in a dispute over a parking ticket.”

Roger Pilon of CATO explains the environmentalists’ dilemma: “At bottom, the greens face three basic problems. First, by no means is the science of global warming ‘settled’ — if anything, the fraud Climategate surfaced has settled that question. Second, even if global warming were a settled science, the contribution of human activity is anything but certain. And finally, most important, even if the answers to those two questions were clear, the costs — or benefits — of global warming are unknown, but the costs of the proposals promoted by the greens are astronomical.”

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Flotsam and Jetsam

The debate has begun: “Republican senators went on the offensive against the Democratic healthcare initiative the morning after the bill moved forward on a procedural vote, blasting the bill as a job-killer and mechanism of ‘excessive government control.’ … ‘We don’t often ignore the wishes of the American people,’ [Mitch] McConnell (R-Ky.) said, noting ‘it’s hard to handicap’ the outcome.”

Sen. Ben Nelson has started things rolling: “Sen. Ben Nelson (D-Neb.), who is uncommitted moving forward, said he has delivered two pages of proposed changes to Majority Leader Harry Reid. … ‘There will be a lot of discussion back and forth about what might get enough votes,’ Nelson said after the vote. ‘There will have to be fairly significant changes for others as well, not just me. Nuance will not be enough.”

Sen. Chuck Schumer says there aren’t any new taxes. Sen. Jon Kyl disagrees: “If you have insurance you get taxed. If you don’t have insurance you get taxed. If you need a lifesaving medical device like a stint or a diabetic pump you get taxed. … The Congressional Budget Office says and the Joint Tax Committee says that these taxes imposed on others will be passed through.”

Republicans are focusing on the controversy over mammography guidelines to make their point about ObamaCare: “GOP lawmakers said the Democratic health care plan, which the Senate allowed to inch forward Saturday night and remains President Barack Obama’s top domestic priority, would set the nation toward massive government control. ‘Do these recommendations make sense from a cost standpoint? Absolutely, from a cost standpoint, they’re right,’ said Rep. Tom Coburn, an Oklahoma Republican who is a medical doctor. ‘From a patient standpoint, they’re atrocious. And that’s the problem with a bureaucracy stepping between a physician and their patient.’”

In case you had any doubt about the three-ring circus: “The five men facing trial in the Sept. 11 attacks will plead not guilty so that they can air their criticisms of U.S. foreign policy, the lawyer for one of the defendants said Sunday. Scott Fenstermaker, the lawyer for accused terrorist Ali Abd al-Aziz Ali, said the men would not deny their role in the 2001 attacks but ‘would explain what happened and why they did it.’”

Another new low for Obama in the Gallup poll.

John McCain on cap-and-trade: “‘Their start has been horrendous,’ McCain said Thursday. ‘Obviously, they’re going nowhere.’ McCain has emerged as a vocal opponent of the climate bill — a major reversal for the self-proclaimed maverick who once made defying his party on global warming a signature issue of his career.”

Bradley Smith: “Harry Reid actually said this debate is about whether Americans will live ‘free from the fear of illness and death,’ and says these things can be prevented by the Pelosi/Reid/Obama approach to healthcare. This must be a really good plan! Of course, you won’t be able to live free from the fear of being thrown in jail for buying the wrong health insurance coverage, but hey, there are trade-offs in life.”

Another bad news item on hiring: “Employers already are squeezed by tight credit, rising health care costs, wary consumers and a higher minimum wage. Now, the surging jobless rate is imposing another cost. It’s forcing higher state taxes on companies to pay for unemployment insurance claims. Some employers say the extra costs make them less likely to hire. That could be a worrisome sign for the economic recovery, because small businesses create about 60 percent of new jobs. Other employers say they’ll cut or freeze pay.” Which suggests that we should be lowering, not raising, taxes and reducing mandates, not increasing them, on business.

The debate has begun: “Republican senators went on the offensive against the Democratic healthcare initiative the morning after the bill moved forward on a procedural vote, blasting the bill as a job-killer and mechanism of ‘excessive government control.’ … ‘We don’t often ignore the wishes of the American people,’ [Mitch] McConnell (R-Ky.) said, noting ‘it’s hard to handicap’ the outcome.”

Sen. Ben Nelson has started things rolling: “Sen. Ben Nelson (D-Neb.), who is uncommitted moving forward, said he has delivered two pages of proposed changes to Majority Leader Harry Reid. … ‘There will be a lot of discussion back and forth about what might get enough votes,’ Nelson said after the vote. ‘There will have to be fairly significant changes for others as well, not just me. Nuance will not be enough.”

Sen. Chuck Schumer says there aren’t any new taxes. Sen. Jon Kyl disagrees: “If you have insurance you get taxed. If you don’t have insurance you get taxed. If you need a lifesaving medical device like a stint or a diabetic pump you get taxed. … The Congressional Budget Office says and the Joint Tax Committee says that these taxes imposed on others will be passed through.”

Republicans are focusing on the controversy over mammography guidelines to make their point about ObamaCare: “GOP lawmakers said the Democratic health care plan, which the Senate allowed to inch forward Saturday night and remains President Barack Obama’s top domestic priority, would set the nation toward massive government control. ‘Do these recommendations make sense from a cost standpoint? Absolutely, from a cost standpoint, they’re right,’ said Rep. Tom Coburn, an Oklahoma Republican who is a medical doctor. ‘From a patient standpoint, they’re atrocious. And that’s the problem with a bureaucracy stepping between a physician and their patient.’”

In case you had any doubt about the three-ring circus: “The five men facing trial in the Sept. 11 attacks will plead not guilty so that they can air their criticisms of U.S. foreign policy, the lawyer for one of the defendants said Sunday. Scott Fenstermaker, the lawyer for accused terrorist Ali Abd al-Aziz Ali, said the men would not deny their role in the 2001 attacks but ‘would explain what happened and why they did it.’”

Another new low for Obama in the Gallup poll.

John McCain on cap-and-trade: “‘Their start has been horrendous,’ McCain said Thursday. ‘Obviously, they’re going nowhere.’ McCain has emerged as a vocal opponent of the climate bill — a major reversal for the self-proclaimed maverick who once made defying his party on global warming a signature issue of his career.”

Bradley Smith: “Harry Reid actually said this debate is about whether Americans will live ‘free from the fear of illness and death,’ and says these things can be prevented by the Pelosi/Reid/Obama approach to healthcare. This must be a really good plan! Of course, you won’t be able to live free from the fear of being thrown in jail for buying the wrong health insurance coverage, but hey, there are trade-offs in life.”

Another bad news item on hiring: “Employers already are squeezed by tight credit, rising health care costs, wary consumers and a higher minimum wage. Now, the surging jobless rate is imposing another cost. It’s forcing higher state taxes on companies to pay for unemployment insurance claims. Some employers say the extra costs make them less likely to hire. That could be a worrisome sign for the economic recovery, because small businesses create about 60 percent of new jobs. Other employers say they’ll cut or freeze pay.” Which suggests that we should be lowering, not raising, taxes and reducing mandates, not increasing them, on business.

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The Gap Widens . . .

Today’s Los Angeles Times has an interesting article about the widening gap developing between al Qaeda and its former allies:

Al Qaeda increasingly faces sharp criticism from once-loyal sympathizers who openly question its ideology and tactics, including attacks that kill innocent Muslims, according to U.S. intelligence officials, counter-terrorism experts and the group’s own communications. . . . The criticism apparently has grown serious enough that Al Qaeda’s chief strategist, Ayman Zawahiri, felt compelled to solicit online questions. He responded in an audio message released this month. For more than 90 minutes, Bin Laden’s second-in-command tried to defuse the anger . . . Sayyed Imam Sharif, an Egyptian physician who once was a senior theologian for Al Qaeda, was one of Zawahiri’s oldest associates. The author of violent manifestoes over the last two decades, Sharif did an about-face while incarcerated in Egypt. Several other prominent Muslim clerics and former militants have similarly condemned Al Qaeda.

I have written about this phenomenon elsewhere. Sayyed Imam Sharif–a former Zawahiri mentor who has been called a “living legend within the global jihadist movement”–has done more than an about-face. He has recommended the formation of a special Islamic court to try both Osama bin Laden and Zawahiri and called the 9/11 attacks a “catastrophe for all Muslims.”

This is part of a hugely important, and massively underreported, development: the Muslim world turning again jihadism. We are seeing both a bottom-up and a top-down reaction against al Qaeda, its brutal tactics, and its ideological and religious underpinnings. The situation is still fluid. And there is a huge amount that remains to be done: the struggle over the nature and future of Islam will take (at a minimum) generations. But since the Iraq war began, we have seen much of the Arab and Muslim world turn sharply against bin Ladenism. The “Anbar Awakening” seems to be spreading not only to the rest of Iraq but to the wider Muslim world. This is in part the result of the savagery of jihadists and in part the result of the U.S. military having dealt punishing blows to AQI and other terrorist cells.

It’s fashionable to argue that everything is going poorly in the war against jihadism. In fact, the deeper currents seem to be running in our favor. If, five years ago, you had said that close to the end of this decade a large and growing number of Muslims in the Middle East and elsewhere would be rejecting Islamic extremism, most people would have considered that enormous and heartening progress. And most people would have been right.

Today’s Los Angeles Times has an interesting article about the widening gap developing between al Qaeda and its former allies:

Al Qaeda increasingly faces sharp criticism from once-loyal sympathizers who openly question its ideology and tactics, including attacks that kill innocent Muslims, according to U.S. intelligence officials, counter-terrorism experts and the group’s own communications. . . . The criticism apparently has grown serious enough that Al Qaeda’s chief strategist, Ayman Zawahiri, felt compelled to solicit online questions. He responded in an audio message released this month. For more than 90 minutes, Bin Laden’s second-in-command tried to defuse the anger . . . Sayyed Imam Sharif, an Egyptian physician who once was a senior theologian for Al Qaeda, was one of Zawahiri’s oldest associates. The author of violent manifestoes over the last two decades, Sharif did an about-face while incarcerated in Egypt. Several other prominent Muslim clerics and former militants have similarly condemned Al Qaeda.

I have written about this phenomenon elsewhere. Sayyed Imam Sharif–a former Zawahiri mentor who has been called a “living legend within the global jihadist movement”–has done more than an about-face. He has recommended the formation of a special Islamic court to try both Osama bin Laden and Zawahiri and called the 9/11 attacks a “catastrophe for all Muslims.”

This is part of a hugely important, and massively underreported, development: the Muslim world turning again jihadism. We are seeing both a bottom-up and a top-down reaction against al Qaeda, its brutal tactics, and its ideological and religious underpinnings. The situation is still fluid. And there is a huge amount that remains to be done: the struggle over the nature and future of Islam will take (at a minimum) generations. But since the Iraq war began, we have seen much of the Arab and Muslim world turn sharply against bin Ladenism. The “Anbar Awakening” seems to be spreading not only to the rest of Iraq but to the wider Muslim world. This is in part the result of the savagery of jihadists and in part the result of the U.S. military having dealt punishing blows to AQI and other terrorist cells.

It’s fashionable to argue that everything is going poorly in the war against jihadism. In fact, the deeper currents seem to be running in our favor. If, five years ago, you had said that close to the end of this decade a large and growing number of Muslims in the Middle East and elsewhere would be rejecting Islamic extremism, most people would have considered that enormous and heartening progress. And most people would have been right.

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McCain Takes On Bill Ayers

John McCain, in an interview on Sunday, went on the offensive against Barack Obama on the subject of Bill Ayers:

Because if you’re going to associate and have as a friend and serve on a board and have a guy kick off your campaign that says he’s unrepentant, that he wished bombed more — and then, the worst thing of all, that, I think, really indicates Senator Obama’s attitude, is he had the incredible statement that he compared Mr. Ayers, an unrepentant terrorist, with Senator Tom Coburn, Senator Coburn, a physician who goes to Oklahoma on the weekends and brings babies into life — comparing those two — I mean, that’s not –that’s an attitude, frankly, that certainly isn’t in keeping with the overall attitude… And it’s very insulting to a great man, a great doctor, a great humanitarian, to compare to him with a guy who says, after 2001, I wish we had bombed more. . . But how can you countenance someone who was engaged in bombings which could have or did kill innocent people…”

And he wasn’t buying Obama’s excuse that he was only eight at the time of the bombings:

But he became friends with him and spent time with him while the guy was unrepentant over his activities as a member of a terrorist organization, the Weathermen. I don’t — and then to compare him with Dr. Tom Coburn, who spends so much of his life bringing babies into this world — that, in my view is really — borders out outrage.

And so it went. Obviously, this is an issue it makes sense for McCain to focus on: it raises questions about Obama which McCain wants voters to ponder. You can expect to hear from his team about Obama’s support from groups like Hamas and his association with individuals like Wright and Ayers. The challenge for Obama will be to explain why voters shouldn’t hold his associations with Wright, Ayers, and many others against him.

John McCain, in an interview on Sunday, went on the offensive against Barack Obama on the subject of Bill Ayers:

Because if you’re going to associate and have as a friend and serve on a board and have a guy kick off your campaign that says he’s unrepentant, that he wished bombed more — and then, the worst thing of all, that, I think, really indicates Senator Obama’s attitude, is he had the incredible statement that he compared Mr. Ayers, an unrepentant terrorist, with Senator Tom Coburn, Senator Coburn, a physician who goes to Oklahoma on the weekends and brings babies into life — comparing those two — I mean, that’s not –that’s an attitude, frankly, that certainly isn’t in keeping with the overall attitude… And it’s very insulting to a great man, a great doctor, a great humanitarian, to compare to him with a guy who says, after 2001, I wish we had bombed more. . . But how can you countenance someone who was engaged in bombings which could have or did kill innocent people…”

And he wasn’t buying Obama’s excuse that he was only eight at the time of the bombings:

But he became friends with him and spent time with him while the guy was unrepentant over his activities as a member of a terrorist organization, the Weathermen. I don’t — and then to compare him with Dr. Tom Coburn, who spends so much of his life bringing babies into this world — that, in my view is really — borders out outrage.

And so it went. Obviously, this is an issue it makes sense for McCain to focus on: it raises questions about Obama which McCain wants voters to ponder. You can expect to hear from his team about Obama’s support from groups like Hamas and his association with individuals like Wright and Ayers. The challenge for Obama will be to explain why voters shouldn’t hold his associations with Wright, Ayers, and many others against him.

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The “No”s Have It

I recently wrote about the Oxford Union‘s upcoming debate on the Middle East, which was scheduled to take place tonight. The motion to be debated stated: “This House Believes that One State is the Only Solution to the Israel-Palestine Conflict.” The motion was to be seconded by the Israeli revisionist historians Avi Shlaim and Ilan Pappe and by Ghada Karmi, a Palestinian physician with an academic appointment at Exeter University. On the “no” side: the British human rights activist Peter Tatchell, along with former Irish MP Lord David Trimble, who is staunchly pro-Israel. And, bizarrely, the passionately anti-Zionist academic Norman Finkelstein.

How, you may ask, does this qualify as a debate? Five out of the six invited participants are all harsh critics, to one degree or another, of the state of Israel. But Finkelstein really belongs in a class by himself, for the hysterical fervor and vitriol of his anti-Zionism and his obsession with minimizing the moral meaning of the Holocaust. Trimble demanded that Finkelstein be dropped from the panel as a precondition for his participation; when the Union accepted Trimble’s argument, Shlaim, Pappe, and Karmi decided to withdraw in protest. Clearly, they felt that without Finkelstein on the other side of the floor, there was now a chance the debate might be fair. The debate is taking place tonight nonetheless, with three Oxford students replacing Shlaim, Pappe, and Karmi, and Paul Usiskin of Peace Now UK replacing Finkelstein.

Why Shlaim, Pappe, and Karmi thought that running away from worthy opponents like Trimble would help their cause is a mystery, but largely besides the point. It is in the nature of such ideologues to engage only in battles they are absolutely sure of winning. Apparently, Finkelstein’s absence undercut their advantage too greatly: instead of being five-sixths anti-Zionist, the panel would be only two-thirds. I predict that the trio will try to snatch victory from the jaws of defeat by claiming that Finkelstein was “silenced,” and that their withdrawal was a gesture of solidarity with their “dissident” friend. To which one should reply with the words of Hillel Halkin, appearing yesterday in the New York Sun:

Deservedly, Mr. Finkelstein was recently denied tenure at De Paul because of a Jewish campaign to demonstrate that he lacked all academic integrity. It was a fight worth winning, not because qualified scholars with anti-Israel politics should not be allowed to teach at universities, but because men whose only qualification is their politics do not belong in institutions of higher learning.

Halkin could have written these words about Shlaim, Pappe, and Karmi as well.

I recently wrote about the Oxford Union‘s upcoming debate on the Middle East, which was scheduled to take place tonight. The motion to be debated stated: “This House Believes that One State is the Only Solution to the Israel-Palestine Conflict.” The motion was to be seconded by the Israeli revisionist historians Avi Shlaim and Ilan Pappe and by Ghada Karmi, a Palestinian physician with an academic appointment at Exeter University. On the “no” side: the British human rights activist Peter Tatchell, along with former Irish MP Lord David Trimble, who is staunchly pro-Israel. And, bizarrely, the passionately anti-Zionist academic Norman Finkelstein.

How, you may ask, does this qualify as a debate? Five out of the six invited participants are all harsh critics, to one degree or another, of the state of Israel. But Finkelstein really belongs in a class by himself, for the hysterical fervor and vitriol of his anti-Zionism and his obsession with minimizing the moral meaning of the Holocaust. Trimble demanded that Finkelstein be dropped from the panel as a precondition for his participation; when the Union accepted Trimble’s argument, Shlaim, Pappe, and Karmi decided to withdraw in protest. Clearly, they felt that without Finkelstein on the other side of the floor, there was now a chance the debate might be fair. The debate is taking place tonight nonetheless, with three Oxford students replacing Shlaim, Pappe, and Karmi, and Paul Usiskin of Peace Now UK replacing Finkelstein.

Why Shlaim, Pappe, and Karmi thought that running away from worthy opponents like Trimble would help their cause is a mystery, but largely besides the point. It is in the nature of such ideologues to engage only in battles they are absolutely sure of winning. Apparently, Finkelstein’s absence undercut their advantage too greatly: instead of being five-sixths anti-Zionist, the panel would be only two-thirds. I predict that the trio will try to snatch victory from the jaws of defeat by claiming that Finkelstein was “silenced,” and that their withdrawal was a gesture of solidarity with their “dissident” friend. To which one should reply with the words of Hillel Halkin, appearing yesterday in the New York Sun:

Deservedly, Mr. Finkelstein was recently denied tenure at De Paul because of a Jewish campaign to demonstrate that he lacked all academic integrity. It was a fight worth winning, not because qualified scholars with anti-Israel politics should not be allowed to teach at universities, but because men whose only qualification is their politics do not belong in institutions of higher learning.

Halkin could have written these words about Shlaim, Pappe, and Karmi as well.

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French Health Care for All?

Over the past week, David Gratzer of the Manhattan Institute and Jonathan Cohn of the New Republic have been engaged in a fascinating debate over health care reform, hosted at TNR’s website. The two agree that American health care has serious problems, including a large uninsured population and very high costs. But they disagree about whether government-funded systems in other countries offer a model America should follow.

Their debate basically comes down to a disagreement about health-quality statistics. But both Cohn and Gratzer ignore almost entirely the attitude of the American public toward bureaucracy in health care. Recent experience suggests that Americans would be very unlikely to put up with even the modest constraints on doctors and patients in the French system that Cohn proposes as a model (let alone the overwhelmingly burdensome constraints employed in some other state-funded systems, like those in Canada and Britain).

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Over the past week, David Gratzer of the Manhattan Institute and Jonathan Cohn of the New Republic have been engaged in a fascinating debate over health care reform, hosted at TNR’s website. The two agree that American health care has serious problems, including a large uninsured population and very high costs. But they disagree about whether government-funded systems in other countries offer a model America should follow.

Their debate basically comes down to a disagreement about health-quality statistics. But both Cohn and Gratzer ignore almost entirely the attitude of the American public toward bureaucracy in health care. Recent experience suggests that Americans would be very unlikely to put up with even the modest constraints on doctors and patients in the French system that Cohn proposes as a model (let alone the overwhelmingly burdensome constraints employed in some other state-funded systems, like those in Canada and Britain).

The American public’s rejection of the HMO model of health insurance offers some evidence on this point. Health maintenance organizations try to contain costs by using case managers to review physician referrals and care decisions, and so to avoid unnecessary procedures and expenses. They work: during the HMO craze in the mid-1990’s, private health-care spending per capita grew by just 2 percent annually, while today it grows by nearly 10 percent.

But as HMO’s became more popular, resentment grew too, among both doctors and patients, about the way health decisions were being made by bureaucrats rather than doctors. HMO’s quickly became some of the most hated institutions in America, participation declined sharply, and today many plans that still call themselves HMO’s don’t actually follow the case-manager model.

Everything Americans didn’t like about HMO’s would be worse under the kind of government-funded system many other Western democracies have. Americans have far less patience for intrusion into health-care choices than Europeans seem to (a point that elicited some broader reflection on government and culture by Jonah Goldberg last week).

In response to this concern, advocates of state-funded care might make the perfectly serious point that covering the uninsured is more important than playing to the selfish whims of the American middle class. That’s how wonks should think. But it’s not how any politician could allow himself to think, and so it’s not how any practical and plausible reform of the system could work.

The fact is, the American middle class would hate—and rebel against—the kind of reform Cohn has in mind, and that in turn would take the political wind out of the effort to help the uninsured. That means health-care reform needs to work by addressing some of the concerns of the (insured) middle class—concerns about stability and portability—while building ways of insuring the uninsured.

That latter effort, though, can’t proceed by creating new, more powerful middle-class anxieties about who makes medical decisions and the freedom of doctors. This also means it can’t proceed by replacing our private insurance system with a public one. It needs, rather, to use public resources to help those who can’t afford private insurance obtain private insurance.

French health care works for the French. But for cultural reasons as much as economic ones, it’s very hard to see how it could work here.

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From COMMENTARY: Health Care in Three Acts

As President Bush prepares to address the issue of health care in his State of the Union address, COMMENTARY is fortunate to have a trenchant analysis of the wider problem, “Health Care in Three Acts,” by Eric Cohen and Yuval Levin, coming out in the February issue. Here is an advance look.

Americans say they are very worried about health care: on generic lists of voter concerns, health issues regularly rank just behind terrorism and the Iraq war. And politicians are eager to do something about it. To empower consumers, the White House has advanced the idea of Health Savings Accounts; to help the uninsured, it has explored using Medicaid more creatively. Senator Edward Kennedy of Massachusetts, the Democrats’ leader on this issue, has backed “Medicare for all.” The American Medical Association has called for tax credits to put private coverage within reach of more Americans. A number of recent books have proposed solutions to our health-care problems ranging from socialized medicine on the Left to laissez-faire schemes of cost containment on the Right. In Washington and in the state capitals, pressure is building for serious reforms.

But what exactly are Americans worried about? Untangling that question is harder than it looks. In a 2006 poll, the Kaiser Family Foundation found that while a majority proclaimed themselves dissatisfied with both the quality and the cost of health care in general, fully 89 percent said they were satisfied with the quality of care they themselves receive. Eighty-eight percent of those with health insurance rated their coverage good or excellent—the highest approval rating since the survey began 15 years ago. A modest majority, 57 percent, were satisfied even with its cost.

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As President Bush prepares to address the issue of health care in his State of the Union address, COMMENTARY is fortunate to have a trenchant analysis of the wider problem, “Health Care in Three Acts,” by Eric Cohen and Yuval Levin, coming out in the February issue. Here is an advance look.

Americans say they are very worried about health care: on generic lists of voter concerns, health issues regularly rank just behind terrorism and the Iraq war. And politicians are eager to do something about it. To empower consumers, the White House has advanced the idea of Health Savings Accounts; to help the uninsured, it has explored using Medicaid more creatively. Senator Edward Kennedy of Massachusetts, the Democrats’ leader on this issue, has backed “Medicare for all.” The American Medical Association has called for tax credits to put private coverage within reach of more Americans. A number of recent books have proposed solutions to our health-care problems ranging from socialized medicine on the Left to laissez-faire schemes of cost containment on the Right. In Washington and in the state capitals, pressure is building for serious reforms.

But what exactly are Americans worried about? Untangling that question is harder than it looks. In a 2006 poll, the Kaiser Family Foundation found that while a majority proclaimed themselves dissatisfied with both the quality and the cost of health care in general, fully 89 percent said they were satisfied with the quality of care they themselves receive. Eighty-eight percent of those with health insurance rated their coverage good or excellent—the highest approval rating since the survey began 15 years ago. A modest majority, 57 percent, were satisfied even with its cost.

Evidently, though, this widespread contentment with one’s own lot coexists with concern on two other fronts. Thus, in the very same Kaiser poll, nearly 90 percent considered the number of Americans without health insurance to be a serious or critical national problem. Similarly, a majority of those with insurance of their own fear that they will lose their coverage if they change jobs, or that, “in the next few years,” they will no longer be able to afford the coverage they have. At least as troubling is what the public does not seem terribly bothered about—namely, the dilemmas of end-of-life care in a rapidly aging society and the exploding costs of Medicare as the baby-boom generation hits age sixty-five.

All of this makes it difficult to speak of health care as a single coherent challenge, let alone to propose a single workable solution. In fact, America faces three fairly distinct predicaments, affecting three fairly distinct portions of the population—the poor, the middle class, and the elderly—and each of them calls for a distinct approach.

For the poor, the problem is affording coverage. Forty-six million Americans were uninsured in 2005, according to the Census Bureau. This is about 15.9 percent of the population, which has been the general range now for more than a decade, peaking at 16.3 percent in 1998.

But that stark figure fails to convey the shifting face and varied make-up of the uninsured. On average, a family that loses its coverage will become insured again in about five months, and only one-sixth of the uninsured lack coverage for two years or more. In addition, about a fifth of the uninsured are not American citizens, and therefore could not readily benefit from most proposed reforms. Roughly a third of the uninsured are eligible for public-assistance programs (especially Medicaid) but have not signed up, while another fifth (many of them young adults, under thirty-five) earn more than $50,000 a year but choose not to buy coverage.

It is also crucial to distinguish between a lack of insurance coverage and a lack of health care. American hospitals cannot refuse patients in need who are without insurance; roughly $100 billion is spent annually on care for such patients, above and beyond state and federal spending on Medicaid. The trouble is that most of this is emergency care, which includes both acute situations that might have been prevented and minor problems that could have been treated in a doctor’s office for considerably less money. The real problem of the uninsured poor, then, is not that they are going without care, but that their lack of regular and reliable coverage works greatly to the detriment of their family stability and physical well-being, and is also costly to government.

For the middle class, the problem is different: the uncertainty caused in part by the rigid link between insurance and employment and in part by the vicissitudes of health itself. America’s employment-based insurance system is unique in the world, a product of historical circumstances and incremental reforms that have made health care an element of compensation for work rather than either a simple marketplace commodity or a government entitlement. This system now covers roughly 180 million Americans. It works well for the vast majority of them, but the link it creates between one’s job and one’s health coverage, and the peculiar economic inefficiencies it yields, result in ever-mounting costs for employers and, in an age of high job mobility, leave many families anxious about future coverage even in good times.

The old, finally, face yet another set of problems: the steep cost of increasingly advanced care (which threatens to paralyze the government) and the painful decisions that come at the limits of medicine and the end of life. Every American over sixty-five is eligible for at least some coverage by the federal Medicare program, which pays much of the cost of most hospital stays, physician visits, laboratory services, diagnostic tests, outpatient services, and, as of 2006, prescription drugs. Established in 1965, Medicare is funded in part by a flat payroll tax of 2.9 percent on nearly every American worker and, beyond that, by general federal revenue. Most recipients pay only a monthly premium that now stands at $88.50, plus co-payments on many procedures and hospital stays.

But precisely because Medicare is largely funded by a payroll tax, it suffers acutely from the problems of an aging society. In 1950, just over 8 percent of Americans were over sixty-five. Today that figure stands at nearly 15 percent, and by 2030 it is expected to reach over 20 percent, or 71 million Americans. Moreover, the oldest of the old, those above the age of eighty-five, who require the most intense and costly care, are now the fastest growing segment of the population; their number is expected to quadruple in the next half-century.

For Medicare, therefore, just as for Social Security, the number of recipients is increasing while the number of younger workers to pay the bills is declining. But Medicare faces a greater danger still. Its costs are a function not only of the number of eligible recipients but of the price of the services they use. Over the past few years, health-care spending in America has increased by about 8 percent each year, most steeply for older Americans who have the most serious health problems. As these costs continue to rise much faster than the wages on which Medicare’s funding is based, the program’s fiscal decline will be drastic, with commensurately drastic consequences for the federal budget.

Three different “crises,” then, each of a different weight and character. The crisis of the uninsured, while surely a serious challenge, has often been overstated, especially on the Left, in an effort to promote more radical reforms than are necessary. The crisis of insured middle-class families has been misdiagnosed both by the Right, which sees it purely as a function of economic inefficiency, and by the Left, which sees it as an indictment of free-market medicine. And the crisis of Medicare has been vastly understated by everyone, in an effort to avoid taking the painful measures necessary to prevent catastrophe. In each case, a clearer understanding may help point the way to more reasonable reforms.

In the case of the uninsured, the best place to begin is with the solution most frequently proposed to their plight: a government-run system of health care for all Americans.

Under such a system—which exists in some form in most other industrialized democracies—the government pays everyone’s medical bills, and in many cases even owns and runs the health-care system itself. The appeal of this idea lies in its basic fairness and simplicity: everyone gets the same care, from the same source, in the same way, based purely on need. In one form or another—actual proposals have varied widely, with Hillary Clinton’s labyrinthine scheme of 1993 merely the best known of many—this “single-payer” model remains the preferred health-care solution of the American Left. But it is ill-suited to the actual problems of America’s uninsured, and adopting it would greatly exacerbate other problems as well.

Everywhere it has been tried, the single-payer model has yielded inefficient service and lower-quality care. In Britain today, more than 700,000 patients are waiting for hospital treatment. In Canada, it takes, on average, seventeen weeks to see a specialist after a referral. In Germany and France, roughly half of the men diagnosed with prostate cancer will die from the disease, while in the United States only one in five will. According to one study, 40 percent of British cancer patients in the mid-1990’s never got to see an oncologist at all.

Such dire statistics have in fact caused many Western democracies with single-payer systems to turn toward market mechanisms for relief. The Swedes have begun to privatize home care and laboratory services. Australia now offers generous tax incentives to citizens who eschew the public system for private care. To send a message to the government, the Canadian Medical Association recently elected as its president a physician who runs a private hospital in Vancouver, actually illegal in Canada. “This is a country in which dogs can get a hip replacement in under a week,” the new president told a newspaper interviewer, “while humans can wait two or three years.”

Defenders of the single-payer concept often point out that, despite patient complaints about the quality of care, overall measures of health in countries with such systems are roughly equivalent to those in America. That may be so, but the chief reason lies in social and cultural factors—crime rates, diet, and so forth—that make life in many other Western nations safer and healthier than life in America, and that would not be altered by a single-payer health system. Besides, citizens in those other nations benefit enormously from medical innovations produced and made possible by America’s dynamic private market; if that market were hobbled by a European-style bureaucracy, their quality of care would suffer along with ours.

And quality of care, it is important to remember, is one thing that most Americans are happy with. Any reform that promises to replace immediate access to specialists with long waiting lines, or the freedom to choose one’s own doctor with restrictive government mandates, is certain to evoke deep hostility, and thereby to cut into public support for efforts to help the uninsured.

On this score, proponents of socialized medicine would do well to consult the cautionary example of the health-maintenance organization (HMO). HMO’s are insurers who contract directly with providers, often for a flat fee, reviewing physician referrals and medical decisions in order to prevent unnecessary procedures or expenses. By the mid-1990’s, this capacity for cost-containment had made HMO’s very attractive to policy-makers and families alike. And they delivered on their cost-cutting promise. In those years, as David Gratzer notes in his recent book The Cure (Encounter, 325 pp., $25.95), private health-care spending per capita grew by just 2 percent annually (today the figure is nearly 10 percent, though the reasons for this, as we shall see below, go beyond just the decline of HMO’s).*

But the public soon chafed under the authoritarian character of a system in which case managers were entrusted with decisions that often seemed arbitrary, while doctors resented having their medical judgment questioned by bureaucrats. Participation soon declined, and HMO’s themselves began to take on the characteristics of traditional insurance plans. By the middle of this decade, they had joined the bipartisan list of stock American villains: in the 2004 presidential campaign, President Bush accused Senator John Kerry of getting “millions from executives at HMO’s,” while Kerry pledged to “free our government from the dominance of the lobbyists, the drug industry, big oil, and HMO’s—so that we can give America back its future and its soul.”

In a single-payer government system, everything Americans dislike about HMO’s would be worse: rationing, top-down control, perverse incentives, and, for patients, very little say. As has happened in Europe, a single-payer approach would also turn health-care costs entirely into government costs, grossly distorting public spending and threatening to crowd out other important government functions. The result would be a political, fiscal, and social disaster.

There is a better way to assist the uninsured: not universal government health care but universal private insurance coverage. Such an effort could begin by identifying the populations in need. Those who are uninsured by their own choice could be offered incentives to purchase at least some minimal coverage, or be penalized for failing to do so. Those who cannot afford insurance could be given subsidies to purchase private coverage based on their level of income, and then pooled into a common group to give them some purchasing power and options. Their coverage would still not equal that available to people in the most generous employer-based plans, but it would offer reliable access to care without destroying the quality and flexibility of the American system.

Although such a plan might not be cheap, it would not be nearly so expensive or complex as a single-payer system. The money for it could be taken, in part, from Medicaid funds now used to pay doctors and hospitals for care already provided to the uninsured, with such “uncompensated-care” programs gradually transformed into a voucher system for purchasing private coverage. But though it might rely on some federal dollars, the reform itself would best be undertaken and managed at the state level. After all, health insurance is regulated by the states, Medicaid is largely managed by the states, and different states face different challenges and possess different resources.

In Massachusetts and Florida, ideas like these are already being tested, although it is too early to judge the results. The federal government can help other states try this more practical approach by clearing away regulatory obstacles and by providing incentives for experiments in creative reforms.

This brings us to the health-care anxieties of middle-class Americans. Although these concerns are in most respects much less pressing than those of the poor, they are real enough. Middle-class families are, besides, the heart and soul of America’s culture and economy, as well as the essential political force for any sober assessment and improvement of America’s health-care system.

Generally speaking, the worries expressed by these Americans stem from the peculiarities of our employer-based insurance market. It is, indeed, a very odd thing that more than 180 million Americans should be covered by insurance purchased for them by their employers. The companies we work for do not buy our food and clothing, or our car and home insurance. They pay us for our labor, and we use that money to buy what we want.

No less odd is the character of what we call health insurance. Insurance usually means coverage for extreme emergencies or losses. We expect auto insurance to kick in when our car is badly damaged in an accident, not when we need a routine oil change; homeowner’s insurance covers us after a fire, flood, or break-in, not when we need to repair the deck or unclog the gutters. But when it comes to health, we expect some element of virtually every expense to be covered, including routine doctor checkups and regular care.

America’s insurance system is largely a historical accident. During World War II, the federal government imposed wage controls on American employers. No longer able to raise salaries to compete for employees, companies turned instead to offering the lure of fringe benefits, and the era of employer-based health care was born. Thanks to a 1943 IRS ruling allowing an exemption for money spent by employers on health insurance, an enormous tax incentive was created as well. Rather than giving a portion of every dollar to the government, employees could get a full dollar’s worth of insurance through their company.

Of course, wage controls are long gone, but the system they inadvertently created, including the tax exemption, remains in place. Although this system has served most Americans very well, it has two significant drawbacks. First, by forging a tight link between one’s job and one’s health insurance, it makes losing a job, or changing jobs, a scary proposition, especially for parents. Second, it lacks any serious check on costs. Because insurance often pays the bulk of every single bill (instead of kicking in only for emergencies or extreme expenses), most American families do not know, or attend to, the actual cost of their health care.

Any car owner can tell you the price of a gallon of gas or an oil change. But what is the price of knee surgery? Or even a regular doctor’s visit? Does one hospital or doctor charge more than another? Most patients pay only a deductible that, while often not cheap, bears almost no relation to the price of the service they receive. As a result, they do not behave like consumers, shopping for the best price and thereby forcing providers to compete for their dollar.

Inured to such issues, families worry most about the lack of portability of their insurance, leaving it to economists to worry about the distorting effects of price inefficiencies. To gain the support of middle-class parents, any reform to the system would therefore need to address the former issue first.

Policy-makers on the Left have tended to understand this, but have over-read the anxiety of families, seeing it as a broad indictment of America’s free-market health care. They have thus offered the same bad solution to the problems of the insured as they do to the problems of the uninsured: a government-run system that will replace our present one. As for conservative policy-makers, they sometimes tend to overlook the concerns of middle-class families altogether, focusing on inefficiency before portability.

The conservative health-care solution of the moment is the health savings account, or HSA. It has two components: a savings account to which individuals and employers can make tax-free contributions to be drawn on exclusively for routine health-care costs, and a high-deductible insurance plan to help pay for catastrophic expenses.

Since individuals can take their HSA’s with them when they change jobs (provided the new employer allows it), this option can indeed help promote insurance portability. But, generally speaking, that is neither its foremost aim nor its effect. Instead, it is seen by its proponents as helping to level the playing field by giving to individuals the same tax breaks that employers get in purchasing coverage, and as helping to train people to think like consumers, since in spending their own money they will have an incentive to spend as little of it as possible. In short, proponents of the HSA want to use market mechanisms to achieve lower costs and improved quality.

This is certainly a worthy goal—but does it meet the concerns of most Americans? David Gratzer, an advocate of the HSA, tells the story of a woman who used such an account in exactly the desired way. Needing foot surgery, and impelled to spend her own money wisely, she

took charge of the situation and thought about what she really needed. When a simple day-surgery was suggested, she looked around and decided on a local surgery center. She asked about clinic fees and offered to pay upfront—thereby getting a 50-percent discount. When she found out that an anesthetist would come in specifically to do the foot block, she asked her surgeon just to do it. She also negotiated the surgeon’s compensation down from $1,260 to $630. Finally, she got a prescription from her doctor for both antibiotics and painkillers, but only filled the former. “In the past, my attitude would have been, ‘just have all the prescriptions filled because insurance was paying for it, whether or not I need them.’”

Although Gratzer offers this as an ideal example, it will surely strike many people as a nightmare. Haggling with doctors, ignoring prescriptions, bypassing a specialist to save money—is this the solution to middle-class health-care worries? Who among us feels confident taking so much responsibility for judgments over his own health, let alone over the care of his children or his elderly parents?

If the HSA is to have wide appeal, it must be sold first and foremost as a means not of efficiency but of portability—and as part of a broader effort to expand the portability of health insurance generally. Nor should such an effort be aimed, at least at first, at undoing our employer-based system. Perhaps, given a blank slate, no sensible person would ever have designed the current system. But we do not have a blank slate. We have a system providing care that the vast majority of insured Americans are quite happy with—and that has also helped America resist the pressure for government-run health care of the kind for which every other developed nation is now paying a heavy price.

We have, in other words, a system that works but is in need of repairs, most notably in the realm of improved portability. Making this happen will require better cooperation between state and federal policy-makers. An exclusively national solution would require federalizing the regulation of health insurance, which is both undesirable and politically unachievable. Instead, states should be encouraged to develop insurance marketplaces like the one now taking shape in Massachusetts. Mediating between providers and purchasers, these would allow employers, voluntary groups, and individuals to select from a common set of private options. Whether working full-time, part-time, or not at all, individuals and families could choose from the same menu of plans and thus maintain constant coverage even as their job situations or life circumstances change. For those who cannot afford insurance and do not receive it from an employer, Medicaid dollars could be used to subsidize the purchase of a private plan.

The federal government, meanwhile, could ensure that Medicaid dollars allotted to states can be used to support such a structure of subsidies. It could also pursue other, smaller measures, like extending or eliminating the time limit on the COBRA program, which allows individuals leaving a job to keep their employment-based plan by paying the full premium. As states begin implementing marketplace reforms, the federal government could also find ways to encourage regional and eventually national marketplaces, which would enable the purchase of insurance across state lines.

In any such scheme, Health Savings Accounts would surely have a place. So would other measures of cost containment like greater price transparency. But the key to any large reform must be its promise to address the real worries of insured American families by preserving what is good about the current system while facing up to its limits and confronting its looming difficulties.

Unfortunately, when it comes to paying for the health care of older Americans, there are few attractive options. Costs have risen steeply in recent years, while the economic footing of the Medicare program has been steadily eroding. Nor are demographic realities likely to change for at least a generation; to the contrary, they may only worsen. So the solution must involve some form of cost containment.

This will not be easy. As Arnold Kling points out in Crisis of Abundance (Cato Institute, 120 pp., $16.95), costs are rising not because of increasing prices for existing medical services but because of a profound transformation in the way medicine is practiced in America. Between 1975 and 2002, the U.S. population increased by 35 percent, but the number of physicians in the country grew by over 100 percent. The bulk of these were specialists, whose services cost a great deal more than those of general practitioners. New technologies of diagnosis (like MRI exams) have also become routine, and not just for the old, and the number and variety of treatments, including surgeries, have likewise increased. We spend more because more can be done for us.

All of this spells heavier demands on the Medicare budget, to the point where the program’s fiscal prospects have become very bleak. Already accounting for roughly 15 percent of federal spending, Medicare will be at 25 percent by 2030 and growing. In David Gratzer’s words, “Medicare threatens to be the program that ate the budget.”

Worse yet, one of the most expensive and complicated burdens of an aging society is not even covered by Medicare. This is long-term care, involving daily medical and personal assistance to people incapable of looking after themselves. The Congressional Budget Office estimates that Americans spent roughly $137 billion on long-term care in 2000, and that by 2020 the figure will reach $207 billion. Longer lives, and the high incidence of dementia among the oldest of the old, are bound to impose an extraordinary new financial strain on middle-income families, whose consequent demand for government help will only worsen our already looming fiscal crisis.

Medicaid, which covers health care for the poor, does pay for some long-term care in most states. To qualify for this, and to avoid burdening their children, a growing number of the elderly have opted to spend down their assets when the need arises. But this ends up burdening their children anyway, if less directly. States already spend more on Medicaid than on primary and secondary education combined; if Medicaid comes to shoulder the bulk of long-term costs in the coming decades, it will bankrupt state coffers and place enormous strains on the federal budget.

Of course, the challenges of an aging society reach well beyond economics. As more and more Americans face an extended decline in their final years, elderly patients and their families will confront painful choices about how much care is worthwhile, who should assume the burdens of care-giving, and when to forgo additional life-sustaining treatment. Compared to this profound human challenge, fiscal dilemmas can seem relatively paltry. But they too necessitate hard and unavoidable choices.

One way or another, the Medicare program will have to be adjusted to a society with radically different demographics from the one it was designed to serve. If “seventy is the new fifty,” as a popular bumper sticker tells us, then the age of Medicare eligibility must begin to move up as well. That will inevitably impose a hardship on those who are already not vigorous in their sixties, as well as on those whose jobs are too physically demanding for even a healthy sixty-five-year-old. So hand in hand with raising the age of eligibility will need to go programs encouraging (or requiring) health-care savings earlier in life. At the same time, Medicare benefits will gradually have to become means-tested, so that help goes where it is most needed and benefits are most generous to those with the lowest incomes and fewest assets.

More fundamentally, the structure of the Medicare program will have to change. Its benefits now increase in an open-ended way that both reflects and drives the upward movement of health costs; if Medicare is to remain sustainable, constraints will gradually have to be put in place, so that benefits grow by a set percentage each year. The program will also need its own distinct and reasonably reliable funding source, which will require an adjustment in the design of the payroll tax.

Any such reforms will be politically explosive, to put it mildly. No politician in his right mind would run on a platform of limiting Medicare eligibility and capping its benefits. And yet, a decade from now, caring for aging parents will have become a burning issue for a great swath of America’s families as parents find themselves squeezed between the needs of their own parents and the needs of their children. Every politician will be expected to offer a solution, and will be subject to dangerous temptations: promising limitless care at the very moment when fiscal responsibility requires setting limits, or promising to “solve” our fiscal problems by abandoning the elderly. The least that responsible policy-makers can do now is to familiarize Americans with the realities of our aging society, so that when the time comes for difficult choices, we will not be blind-sided.

Understanding America’s three distinct health-care challenges, and the deficiencies of conventional responses to them, is the first step toward reform. Any approach we take will assuredly cost the taxpayers money. Already, nearly a third of the federal budget is spent on health-care, and that portion is certain to grow. The choice, however, is between paying the necessary price to ameliorate our genuine problems or paying far more to satisfy ideological whims or avoid politically painful decisions.

Neither socialized medicine nor a pure market approach is suited to America’s three health-care challenges, while the bipartisan conspiracy to ignore the looming crisis of Medicare in particular will return to haunt our children. Coming to grips with the true nature of our challenges suggests, instead, a set of pragmatic answers designed to address the real problems of the uninsured, of middle-class families, and of the elderly while protecting America’s private health-insurance system and looking out for the long-term fiscal health of the nation.

Even as we pursue practical options for reform, however, it behooves us to remember that health itself will always remain out of our ultimate control. Medicine works at the boundaries of life, and its limits remind us of our own. While our health-care system can be improved, our unease about health can never truly be quieted. And while reform will require hard decisions, solutions that would balance the books by treating the disabled and debilitated as unworthy of care are no solutions at all. In no small measure, America’s future vitality and character will depend upon our ability to rise to this challenge with the right mix of creativity and sobriety.

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