Commentary Magazine


Topic: Yuval Levin

Why Politics Matters

My Ethics and Public Policy Center colleague Yuval Levin, who edits the quarterly National Affairs, recently was interviewed by William Kristol as part of his “Conversations With” series.

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My Ethics and Public Policy Center colleague Yuval Levin, who edits the quarterly National Affairs, recently was interviewed by William Kristol as part of his “Conversations With” series.

In the course of their conversation Mr. Levin, in speaking about policy, says it’s about problem-solving–not ultimate problems but practical ones. This is vital in allowing a society to function well and to become its best self. And he added this:

Politics in the end is moved by arguments. The intellectual work does matter. I think it does absolutely shape outcomes. But it happens in a way that relies on a kind of food chain. Things have to move through our intellectual world and it doesn’t move directly from that kind of work to policymaking; there has to be some time to digest, to think it through. I think that happens on a lot of important issues in our politics. So I am impressed with how ideas move politics but you know it’s not a direct process. Not a simple one.

This is vital to remember. In thinking about politics, after all, people are frustrated with the gridlock and the conflict, the deal-making, the maneuvering, and the mundane. They are disenchanted with the pace and direction of change and those who are in public life for personal aggrandizement. Americans are frustrated and angry with politicians, with politics, and with one another. And so it’s important to remind ourselves, as Levin does, that politics is moved by arguments–haltingly, imperfectly, but inevitably.

(It’s probably worth adding here, if only as a side note, that in America we tend to romanticize our past. Even the Constitutional Convention of 1787–which featured the most extraordinary collection of political minds since ancient Athens–had its own low moments, frustrations and fierce, polarizing battles. It was one of our greatest founders, James Madison, who in Federalist #55 wrote, “Had every Athenian citizen been a Socrates, every Athenian assembly would still have been a mob.” And our greatest president, Lincoln, presided over a nation that was a good deal more polarized–lethally polarized–than ours is today. So some perspective is in order.)

There are several layers to public and political arguments. One of them is focused on hard facts and empirical data, on social science and different governing approaches related to a range of issues like crime, education, health care, welfare, economic growth, and social mobility.

But the other, deeper layer has to do with arguments grounded in political theory, dealing with matters like liberty and equality, individual responsibility and civic duty, justice and human dignity. The greatest practitioners of statecraft are able to make both sets of arguments–to show a mastery of public policy and the ability to articulate a public philosophy. To explain the means and the ends of government and the good society.

At the core of every social, political, and economic system is a picture of human nature, to paraphrase the 20th century columnist Walter Lippmann. The way that picture developments determines the lives we lead, the institutions we build, and the civilization we create. The political philosophy of Madison produces one set of results; the political philosophy of Marx produces another. So yes: ideas move politics in one direction or the other, toward justice or away from it. Like all things human, it’s imperfect, frustrating, and fraught with failure. It’s a long, hard grind. And it’s not always aesthetically pleasing. But cynicism that leads to political disengagement–the world-weary, pox-on-both-your-houses, what difference does it make, I don’t give a damn attitude that seems rather fashionable and trendy these days–can lead to disaster. Because someone’s ideas will prevail. If ones that advance justice and human flourishing win out, it won’t be by accident or by default. It’ll be the product of determined effort; of those who do not grow weary in doing good.

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The New Republic’s Sinking Standards

Marc Tracy’s profile of my Ethics and Public Policy Center colleague Yuval Levin is unusually shallow, even by the standards of the “new” New Republic. I suppose that is something of an achievement.

Mr. Tracy’s piece doesn’t deny – it could not possibly deny – the intellectual influence of Levin on modern conservatism. So the next line of attack is that Levin, more operative than anything else, is simply toeing the (Republican) party line: 

Levin, however, doesn’t propose challenging GOP orthodoxy; he simply tries to make it sound less radical. That’s not the most high-minded project. But that’s the job of the state-of-the-art conservative intellectual, more operative than philosopher. … Indeed, it’s hard not to notice that Levin follows the Republican Party line on just about every issue of note—from taxes to education to abortion.

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Marc Tracy’s profile of my Ethics and Public Policy Center colleague Yuval Levin is unusually shallow, even by the standards of the “new” New Republic. I suppose that is something of an achievement.

Mr. Tracy’s piece doesn’t deny – it could not possibly deny – the intellectual influence of Levin on modern conservatism. So the next line of attack is that Levin, more operative than anything else, is simply toeing the (Republican) party line: 

Levin, however, doesn’t propose challenging GOP orthodoxy; he simply tries to make it sound less radical. That’s not the most high-minded project. But that’s the job of the state-of-the-art conservative intellectual, more operative than philosopher. … Indeed, it’s hard not to notice that Levin follows the Republican Party line on just about every issue of note—from taxes to education to abortion.

As David Frum points out in his artful takedown of Tracy’s piece, “What about the possibility that the Republican line is following Yuval? On Medicare, at least, that happens to be the case – for better or worse.”

I can testify on this matter firsthand. When Representative Paul Ryan was developing his first budget in the aftermath of the 2010 election, there was real concern among some members of the House leadership as to whether to include premium support as part of the reform of Medicare. I was in private meetings in early 2011 in which some prominent House members and some very intelligent conservatives argued that this would be a bridge too far, that whatever the substantive arguments in favor of premium support it would be politically catastrophic. That argument was in fact made by real political operatives – pollsters, to be precise – in the meeting.

Some of us, on the other hand, argued that Republicans had an obligation, given the fiscal crisis that is being driven primarily by Medicare, to fundamentally reform the program and that Republicans could not be taken seriously as a party that stood for limited government unless it tackled Medicare. The most articulate and persuasive advocate for that point of view was Yuval Levin.

The point is that the notion that premium support was “GOP orthodoxy” as recently as two years ago is silly and sloppy; and one big reason the idea has now carried the day is because of the intelligent, informed and, yes, high-minded advocacy of Levin. On a supremely important issue he has changed the Republican Party, not the other way around. 

Even using the frivolous Tracy standard that an idea is only meritorious if it runs counter to what the Republican orthodoxy is at any given moment in time, Levin has not followed the conventional GOP line. For example, he argued, to little avail, that Republicans should have been vocal advocates against raising the payroll tax. He has said that in our current situation cutting marginal tax rates is not key to economic growth, hardly a Grover Norquist-like position. And he has been arguing the cause of upward mobility and civil society for quite some time. Only now, post-2012 election, are some Republican lawmakers catching up to him.

It may very well be that Mr. Tracy was unaware of all this, which would make him a bad reporter; or perhaps he was aware of this but chose to ignore it, which would make him a dishonest one. Whatever the explanation, the piece by Tracy is both light and misleading. Which is why it was a perfect fit for The New Republic

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Whence Sacrifice?

“We live in a sacrifice-free bubble of volitional delusion.” If Mitt Romney put his private fundraising speeches through a syllable-multiplying machine he might come up with something like that—generalizing, demonizing, and dismissive of entitlement-happy American moochers. And liberal columnists would mug him for it.

But in fact a liberal columnist wrote it. The line appeared in Frank Bruni’s Sunday New York Times column about the lost American virtue of sacrifice. “It’s odd,” writes Bruni. “We revere the Americans who lived through World War II and call them the ‘greatest generation’ precisely because of the sacrifices they made. But we seem more than content to let that brand of greatness pass us by.”

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“We live in a sacrifice-free bubble of volitional delusion.” If Mitt Romney put his private fundraising speeches through a syllable-multiplying machine he might come up with something like that—generalizing, demonizing, and dismissive of entitlement-happy American moochers. And liberal columnists would mug him for it.

But in fact a liberal columnist wrote it. The line appeared in Frank Bruni’s Sunday New York Times column about the lost American virtue of sacrifice. “It’s odd,” writes Bruni. “We revere the Americans who lived through World War II and call them the ‘greatest generation’ precisely because of the sacrifices they made. But we seem more than content to let that brand of greatness pass us by.”

Indeed we do. And he certainly tells conservatives nothing new when he writes: “The size of the federal debt and the pace of its growth can’t be ignored.” And those of us who’ve long been dismayed by the Obama administration’s use of class warfare can only agree with Bruni’s contention that “[t]hese days sacrifice is what you recommend for others, not what you volunteer for yourself.”

But there is an extraordinary absence in Bruni’s discussion: the word “culture” appears nowhere. The column redefines sacrifice as a government ask, and not a personal or cultural virtue at all. For Bruni, sacrifice is to be reclaimed with an eleventh hour pronouncement from the president to render unto Caesar. Government will tell us to part with what is ours so that it can get America’s house in order. Simple as that. He wants Barack Obama and Mitt Romney to talk seriously about American sacrifice in the upcoming debates so that Americans will in turn think seriously about it themselves.

There is a great and growing divide between what our political reality demands and what our culture now produces, and Bruni gets nowhere near it. Sacrifice is vanishing because the cultural institutions that promote or sanctify it—family, faith, and patriotism—are on the wane. “In 1960, two-thirds (68%) of all [American] twenty-somethings were married,” a 2010 Pew study found. “In 2008, just 26% were.” And in 2011, American births fell to a 12-year low. To previous generations the demands of family meant a life defined by self-denial, delayed gratification, and the giving of one’s time, energy, and money. Is a 42 percent drop in those who claim such an existence supposed to have no effect on the quality of our national character?  Can this be fixed with a White House call to duty?

To the snickering celebration of progressives, religious belief is tumbling in America as well.  Particularly among the so-called “millennial” generation. Among Americans 30 and younger, belief in God has fallen 15 percentage points in the last five years. With that belief  goes the divine endorsement of selflessness, charity, and sacrifice. Indeed, the simultaneous rise in youth devotion to the Occupy movement offers a beautiful illustration of a generation’s transition out of an institution of sacrifice and into a sub-culture of entitlement. Frank Bruni should try interrupting an anti-banking drum-circle chant to tell Occupiers they need to sacrifice more because Obama says so.

And of course there’s the fading belief in American exceptionalism, today considered by progressives to be a kind of imperialist thought crime. Last November, Pew found that 49 percent of Americans agree with the statement, “Our people are not perfect, but our culture is superior to others,” while 46 percent of Americans disagreed. (In 2007, 55 percent said American culture was superior; in 2002, it was 60 percent).  Why make sacrifices for a country that’s no better than any other on the planet?

It makes sense that Bruni avoids discussing the cultural underpinnings of our increasingly selfish citizenry. As Yuval Levin discusses in a brilliant essay in the current issue of the Weekly Standard, “the progressive view of government has long involved the effort to shrink and clear the space between the individual and the state.” Culture, in the progressive view, should collapse itself to make room for increased government as needed. It is not surprising then that Bruni not only looks to the president to simply decree a renewed sense of sacrifice but that he also considers the end of military conscription as a possible culprit for sacrifice’s waning.

The challenge of course goes beyond the nature of our government. One can rail against the entitlement policies of Barack Obama and others but in a sense those policies are a form of accommodation with a culture that’s turning away from the non-governmental institutions that promote personal responsibility, charity, and sacrifice. Frank Bruni finds it “odd” that we’re giving up on a virtue we praise only because he pays no attention to how that virtue was instilled and passed on. He quotes a string of presidents who spoke of American sacrifice in this or that light, as if “sacrifice” is an incantation or logic command to be programmed into our political life when desperately needed.  It is not. Sacrifice, rather, is the personal and cultural reality of people who’ve toiled in hopes of seeing its delayed rewards—for themselves or for others. A sense of sacrifice is what generations of Americans found in the institutions that they built and maintained specifically because they expected neither moral nor material elevation from their government.

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Thinking Deeply About Government’s Purpose, Not Just Its Size

My Ethics and Public Policy Center colleague Yuval Levin, who is also editor of National Affairs, was interviewed by ConservativeHome’s Ryan Streeter. Yuval’s insights are typically wise and learned. I was particularly interested in his response to the question “If you could wave a wand and change one thing about the GOP, what would it be?” According to Yuval:

I would make it so that every time we are tempted to talk about the size of government we talk also (and more so) about the purpose of government. This would make us more focused on policy particulars than on vague abstractions, better able to offer an alternative to the left’s agenda rather than just slowing the pace of its implementation, and better able to speak to the aspirations of the larger public.

The out-of-control size and cost of government today are symptoms of the fact that we have lost sight of the question of what government is for. The answer to that question is not “nothing,” after all. But it is also not “everything.” A basic answer to that question, rather, is laid out pretty well in Article I, section 8 of the United States Constitution. Maybe modern life has piled some complexities and difficulties on us that require some additions to the list presented there, and of course the Constitution contains a mechanism for making such additions. But as long as we are obsessed with how much it all costs we are not able to focus on the more important question of how to make government more effective and energetic in those areas where we want it to act, and how to keep it from acting in those areas where we don’t (and where we therefore think that families, communities, and other mediating institutions should act instead).

This counsel is extremely wise. It is not as if the size of government is irrelevant; far from it. There are important fiscal and moral ramifications created by a “nanny state.” But to focus solely on the size of government rather than on its core purposes is a mistake, both philosophically and politically. God willed the state, as Edmund Burke put it; but what does He want the state to achieve? This is hardly a new question, but it is one that every serious student of politics needs to engage.

As a practical matter, take the issue of order. “Among the many objects to which a wise and free people find it necessary to direct their attention,” John Jay wrote in Federalist Paper No. 3, “that of providing for their safety seems to be the first.” The “tranquility of order” (the phrase comes from Augustine) is the first responsibility of government; without it, we can hardly expect things like justice, prosperity, or virtue to flourish. Order, in turn, cannot be achieved without government — and among the threats to domestic order, crime surely ranks high. Read More

My Ethics and Public Policy Center colleague Yuval Levin, who is also editor of National Affairs, was interviewed by ConservativeHome’s Ryan Streeter. Yuval’s insights are typically wise and learned. I was particularly interested in his response to the question “If you could wave a wand and change one thing about the GOP, what would it be?” According to Yuval:

I would make it so that every time we are tempted to talk about the size of government we talk also (and more so) about the purpose of government. This would make us more focused on policy particulars than on vague abstractions, better able to offer an alternative to the left’s agenda rather than just slowing the pace of its implementation, and better able to speak to the aspirations of the larger public.

The out-of-control size and cost of government today are symptoms of the fact that we have lost sight of the question of what government is for. The answer to that question is not “nothing,” after all. But it is also not “everything.” A basic answer to that question, rather, is laid out pretty well in Article I, section 8 of the United States Constitution. Maybe modern life has piled some complexities and difficulties on us that require some additions to the list presented there, and of course the Constitution contains a mechanism for making such additions. But as long as we are obsessed with how much it all costs we are not able to focus on the more important question of how to make government more effective and energetic in those areas where we want it to act, and how to keep it from acting in those areas where we don’t (and where we therefore think that families, communities, and other mediating institutions should act instead).

This counsel is extremely wise. It is not as if the size of government is irrelevant; far from it. There are important fiscal and moral ramifications created by a “nanny state.” But to focus solely on the size of government rather than on its core purposes is a mistake, both philosophically and politically. God willed the state, as Edmund Burke put it; but what does He want the state to achieve? This is hardly a new question, but it is one that every serious student of politics needs to engage.

As a practical matter, take the issue of order. “Among the many objects to which a wise and free people find it necessary to direct their attention,” John Jay wrote in Federalist Paper No. 3, “that of providing for their safety seems to be the first.” The “tranquility of order” (the phrase comes from Augustine) is the first responsibility of government; without it, we can hardly expect things like justice, prosperity, or virtue to flourish. Order, in turn, cannot be achieved without government — and among the threats to domestic order, crime surely ranks high.

This line of reasoning inevitably leads us to law-enforcement policies ranging from incarceration to policing strategies to the “broken windows” theory. (In the 1980s, Professors James Q. Wilson and George L. Kelling argued that public disorder — as evidenced by unrepaired broken windows — is evidence of a permissive moral environment, a signal that no one cares, and therefore acts as a magnet to criminals.) And in looking at some of the great success stories in lowering crime, such as New York City in the 1990s, one finds that the key to success wasn’t the size or cost of government, but its efficacy. The question Mayor Rudy Giuliani and his police chief, William Bratton, asked wasn’t “How big should the police department be?” but rather “What should the police department be doing?”

The answer to that question led to a policy revolution in law enforcement.

The point is that fundamental questions about the role and purpose of the state aren’t academic ones; a public philosophy needs to be at the center of our debates about public policy, and we need public figures who themselves are able to think clearly and deeply about these matters.

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Flotsam and Jetsam

Another conservative woman drives the media elite around the bend: “Like father, like daughter, it seems. Much as Dick Cheney staked out the far right wing of the Bush administration, winning the respect and gratitude of GOP hawks despite his low popularity nationwide, Liz seems eager to make her reputation by unnerving her party’s moderates.”

Another reminder from James Capretta and Yuval Levin on the dangers of ObamaCare: “The heart of the Democratic plan is a promise to provide subsidized insurance coverage to some 35 to 40 million people. This will cost about $200 billion per year by 2019. And despite all of the talk of bending the cost curve, the Congressional Budget Office says the price will grow by 8 percent per year every year thereafter—which parallels the rapid cost growth of Medicare and Medicaid over the last four decades. In other words, the White House and congressional Democrats want to create another runaway entitlement program, piled on top of the unaffordable ones that are already slated to bankrupt the government.”

Another smart point by COMMENTARY contributor Tevi Troy: “Contrary to the conventional wisdom, health care has been a poor issue for the Democrats. A step by step approach works far better politically than attempting to redo the whole system. Given this history, Democrats interested in their political survival, not to mention the state of our health care system, should be very wary of voting yes.” And yet so many seem intent on committing political suicide.

Another way of looking at the Democratic civil war on health care, from CATO’s Michael Cannon: “The Democrats’ dogged, bloodthirsty crusade for universal coverage has been possible only because the wonks have seduced or silenced the hacks within the Democratic party. It appears the hacks may be ready to launch a rebellion.” By “hacks” he means the poor shlubs who run for office or help others to.

Another questionable Obama nominee: “Senate Republicans are preparing to challenge President Obama’s nominee for ambassador to El Salvador over her previous ties to an alleged asset of Cuban intelligence. Lawyer Mari Carmen Aponte was previously nominated to be an ambassador under President Bill Clinton, but withdrew her name from consideration after reports of her relationship with Cuban national Roberto Tamayo surfaced. … Tamayo, with whom she co-habitated for eight years starting in 1986, was an asset to the Cuban intelligence agency DGI. Former Cuban intelligence agent and defector Florentino Aspillaga also alleged Tamayo tried to recruit Aponte.” There was no other qualified nominee?

Another report suggesting that ObamaCare is a tough sell with wary Democrats: “House Democratic leaders don’t have the votes to pass healthcare reform. At least not yet. Speaker Nancy Pelosi (D-Calif.) has expressed confidence that when push comes to shove, healthcare reform will pass Congress. But there will be plenty of pushing in the days ahead. Pelosi is clearly down in the vote count. Thirty-four House Democrats are either firm no votes or leaning no, according to The Hill’s whip list. Dozens more are undecided. Pelosi is clearly down in the vote count. Thirty-four House Democrats are either firm no votes or leaning no, according to The Hill’s whip list. Dozens more are undecided.”

Another foolish thing the Obami could do on Iran: send another New Year’s greeting to the mullahs!

Another example of what passes for “transparency” in this administration: “At Friday’s White House briefing, press secretary Robert Gibbs was asked, for the fifth time in less than three weeks, about Democratic Rep. Joe Sestak’s charge that the White House offered Sestak a high-ranking job if Sestak would drop his challenge to Democratic Sen. Arlen Specter in Pennsylvania. And for the fifth time, Gibbs refused to answer the question of whether the White House offered a bribe to protect the fortunes of a key political ally.”

Another conservative woman drives the media elite around the bend: “Like father, like daughter, it seems. Much as Dick Cheney staked out the far right wing of the Bush administration, winning the respect and gratitude of GOP hawks despite his low popularity nationwide, Liz seems eager to make her reputation by unnerving her party’s moderates.”

Another reminder from James Capretta and Yuval Levin on the dangers of ObamaCare: “The heart of the Democratic plan is a promise to provide subsidized insurance coverage to some 35 to 40 million people. This will cost about $200 billion per year by 2019. And despite all of the talk of bending the cost curve, the Congressional Budget Office says the price will grow by 8 percent per year every year thereafter—which parallels the rapid cost growth of Medicare and Medicaid over the last four decades. In other words, the White House and congressional Democrats want to create another runaway entitlement program, piled on top of the unaffordable ones that are already slated to bankrupt the government.”

Another smart point by COMMENTARY contributor Tevi Troy: “Contrary to the conventional wisdom, health care has been a poor issue for the Democrats. A step by step approach works far better politically than attempting to redo the whole system. Given this history, Democrats interested in their political survival, not to mention the state of our health care system, should be very wary of voting yes.” And yet so many seem intent on committing political suicide.

Another way of looking at the Democratic civil war on health care, from CATO’s Michael Cannon: “The Democrats’ dogged, bloodthirsty crusade for universal coverage has been possible only because the wonks have seduced or silenced the hacks within the Democratic party. It appears the hacks may be ready to launch a rebellion.” By “hacks” he means the poor shlubs who run for office or help others to.

Another questionable Obama nominee: “Senate Republicans are preparing to challenge President Obama’s nominee for ambassador to El Salvador over her previous ties to an alleged asset of Cuban intelligence. Lawyer Mari Carmen Aponte was previously nominated to be an ambassador under President Bill Clinton, but withdrew her name from consideration after reports of her relationship with Cuban national Roberto Tamayo surfaced. … Tamayo, with whom she co-habitated for eight years starting in 1986, was an asset to the Cuban intelligence agency DGI. Former Cuban intelligence agent and defector Florentino Aspillaga also alleged Tamayo tried to recruit Aponte.” There was no other qualified nominee?

Another report suggesting that ObamaCare is a tough sell with wary Democrats: “House Democratic leaders don’t have the votes to pass healthcare reform. At least not yet. Speaker Nancy Pelosi (D-Calif.) has expressed confidence that when push comes to shove, healthcare reform will pass Congress. But there will be plenty of pushing in the days ahead. Pelosi is clearly down in the vote count. Thirty-four House Democrats are either firm no votes or leaning no, according to The Hill’s whip list. Dozens more are undecided. Pelosi is clearly down in the vote count. Thirty-four House Democrats are either firm no votes or leaning no, according to The Hill’s whip list. Dozens more are undecided.”

Another foolish thing the Obami could do on Iran: send another New Year’s greeting to the mullahs!

Another example of what passes for “transparency” in this administration: “At Friday’s White House briefing, press secretary Robert Gibbs was asked, for the fifth time in less than three weeks, about Democratic Rep. Joe Sestak’s charge that the White House offered Sestak a high-ranking job if Sestak would drop his challenge to Democratic Sen. Arlen Specter in Pennsylvania. And for the fifth time, Gibbs refused to answer the question of whether the White House offered a bribe to protect the fortunes of a key political ally.”

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Puzzling Out the Health-Care Vote

With my friend Yuval Levin, than whom no one seems more able to maintain a grasp on the slippery thread of this business, I’ve been trying to work through just what exactly the procedure for a successful health-care vote is. It would seem to be this (and don’t blame Yuval if I get any of this wrong).

Stage 1. The House of Representatives must now pass the Senate bill, which passed in December. In so doing, it will effectively be voiding its own bill, which was passed with a 5-vote margin in early November — because none of the  goodies and bargains House members negotiated among themselves are present in the Senate bill. Specifically, there’s no “public option” in the Senate bill, as there is in the House bill; and there’s no “Stupak amendment” forbidding the use of public funds for abortion in the Senate bill. That amendment was necessary for House Democratic leaders to secure its five-vote victory in November.

Ordinarily, the House and Senate bills would go to a conference committee, which would negotiate over the differences in them, combine them into a single bill, and send that new bill back to both chambers for a final vote. This single bill would be considered a new piece of legislation, and therefore would have to be voted on again by everybody. Once that is done, the single bill would go to the president’s desk for signature.

But because of Scott Brown’s election, there are no longer 60 votes in the Senate for a health-care bill—and 60 votes are needed in the Senate to end discussion of a bill and bring it to a vote. Without 60 votes bringing the discussion to “cloture,” a bill can remain open for debate forever in the process called “filibustering.” So there can’t be a health-care bill if the Senate has to take up a new version of it, because any new version will be fillibustered by Republicans.

So the House has to vote on the Senate bill to avoid another vote in the Senate. For then there is a single piece of legislation all tied up in a bow that doesn’t have to go to committee.

So why doesn’t that just happen?

Well, if there is to be a health-care bill, it will happen. The House will have to vote through the Senate bill without changing it. That’s just the reality. But that’s only going to happen if House members are promised that some of their concerns are taken into consideration. And so there will have to be a second bill. Immediately afterward. A second bill that fixes what’s wrong with the first bill. And this is where all this talk about “reconciliation” comes in.

Stage 2. Reconciliation. The second bill will function as a series of amendments to and fixes of the first bill. Now, ordinarily, that  should kill the whole process outright, because the same problems the first bill faced should apply to a second bill in the Senate—the need for 60 votes to close debate, etc. But that wouldn’t be the case if the second bill is treated as a “reconciliation” measure. A reconciliation measure is a the only one in the Senate that bypasses the 60-vote cloture rule and allows a simple majority vote. Keith Hennessey describes it thus:

A reconciliation bill is a special type of bill.  The full name is a “budget reconciliation” bill.  It’s purpose is to combine into one bill the work of multiple committees that are changing federal spending and tax laws.  It is an incredibly powerful tool that bypasses [unlimited debate and cloture] but only for very limited purposes.  Senators, and the Senate as a whole … allow these rules to be bypassed only for a specific purpose.

The use of “reconciliation” to pass health-care measures would be unprecedented. And there are real questions about whether the parliamentarian of the Senate will be able, even bending so far over he turns himself into a pretzel, to say that a vote on (for example) stripping abortion coverage from the bill fits the legal definition of what “reconciliation” is.

But forget that for a second. Let’s assume the Senate parliamentarian is entirely pliable. A reconciliation bill will be written. What then?

Stage 3. The House takes all the heat. Ah. Here’s the rub. It appears that, in an effort to make this as easy as possible on the Senate, the House is now under pressure from the Senate and the White House to vote for the reconciliation bill before the Senate. At which point the Senate will take it up and ramrod through the second bill with 51 votes, Obama signs it, and there’s health-care.

This strategy requires the House not only to vote for a wildly unpopular bill once, but then to vote on its sequel almost immediately afterward. In other words, House members are going to be forced to cast two wildly unpopular, highly visible votes in succession, without anybody else taking the heat. And there is going to be deal-making and back-scratching and all manner of sleazy behavior to achieve it, all of which will just increase the public sense of a corrupt process that has ensnared Democrats just as corruption seemed to ensnare Republicans in 2006. All so the Senate can sneak it through. And the House has good reason not to trust that the Senate will hold to its part of the bargain. What if there is a colossal meltdown in public support just before the reconciliation vote? What if the Senate decides to change it a little and throws it all back into chaos again? What if House members were to cast two votes and there was no health care at the end of the process?

The only thing that can make this insane business tolerable or bearable for House Democrats is geniune conviction —  conviction that this is the once-in-a-lifetime chance to put the country on the glidepath to a national health-care system. That is what can make the process seem to transcend the sleazy deals and buyoffs for those who are going to have to face voters and explain themselves and their votes.

So if, in the end, this process works as the White House wants it to work, it will do so because of core Democratic and liberal beliefs. Republicans and conservatives need to understand that; the political horror faced by every Democrat who does not have an entirely safe seat can be mitigated in part by the belief that there may be enough Democrats who can live their lives proud to have brought this measure to fruition.

Thus, the best hope of derailing health care will not derive from high motives – stopping this dreadful measure before it becomes law — but rather very low motives —sheer, panicked self-preservation on the part of Democratic pols hoping against hope to hold on in spite of the looming Republican wave.

With my friend Yuval Levin, than whom no one seems more able to maintain a grasp on the slippery thread of this business, I’ve been trying to work through just what exactly the procedure for a successful health-care vote is. It would seem to be this (and don’t blame Yuval if I get any of this wrong).

Stage 1. The House of Representatives must now pass the Senate bill, which passed in December. In so doing, it will effectively be voiding its own bill, which was passed with a 5-vote margin in early November — because none of the  goodies and bargains House members negotiated among themselves are present in the Senate bill. Specifically, there’s no “public option” in the Senate bill, as there is in the House bill; and there’s no “Stupak amendment” forbidding the use of public funds for abortion in the Senate bill. That amendment was necessary for House Democratic leaders to secure its five-vote victory in November.

Ordinarily, the House and Senate bills would go to a conference committee, which would negotiate over the differences in them, combine them into a single bill, and send that new bill back to both chambers for a final vote. This single bill would be considered a new piece of legislation, and therefore would have to be voted on again by everybody. Once that is done, the single bill would go to the president’s desk for signature.

But because of Scott Brown’s election, there are no longer 60 votes in the Senate for a health-care bill—and 60 votes are needed in the Senate to end discussion of a bill and bring it to a vote. Without 60 votes bringing the discussion to “cloture,” a bill can remain open for debate forever in the process called “filibustering.” So there can’t be a health-care bill if the Senate has to take up a new version of it, because any new version will be fillibustered by Republicans.

So the House has to vote on the Senate bill to avoid another vote in the Senate. For then there is a single piece of legislation all tied up in a bow that doesn’t have to go to committee.

So why doesn’t that just happen?

Well, if there is to be a health-care bill, it will happen. The House will have to vote through the Senate bill without changing it. That’s just the reality. But that’s only going to happen if House members are promised that some of their concerns are taken into consideration. And so there will have to be a second bill. Immediately afterward. A second bill that fixes what’s wrong with the first bill. And this is where all this talk about “reconciliation” comes in.

Stage 2. Reconciliation. The second bill will function as a series of amendments to and fixes of the first bill. Now, ordinarily, that  should kill the whole process outright, because the same problems the first bill faced should apply to a second bill in the Senate—the need for 60 votes to close debate, etc. But that wouldn’t be the case if the second bill is treated as a “reconciliation” measure. A reconciliation measure is a the only one in the Senate that bypasses the 60-vote cloture rule and allows a simple majority vote. Keith Hennessey describes it thus:

A reconciliation bill is a special type of bill.  The full name is a “budget reconciliation” bill.  It’s purpose is to combine into one bill the work of multiple committees that are changing federal spending and tax laws.  It is an incredibly powerful tool that bypasses [unlimited debate and cloture] but only for very limited purposes.  Senators, and the Senate as a whole … allow these rules to be bypassed only for a specific purpose.

The use of “reconciliation” to pass health-care measures would be unprecedented. And there are real questions about whether the parliamentarian of the Senate will be able, even bending so far over he turns himself into a pretzel, to say that a vote on (for example) stripping abortion coverage from the bill fits the legal definition of what “reconciliation” is.

But forget that for a second. Let’s assume the Senate parliamentarian is entirely pliable. A reconciliation bill will be written. What then?

Stage 3. The House takes all the heat. Ah. Here’s the rub. It appears that, in an effort to make this as easy as possible on the Senate, the House is now under pressure from the Senate and the White House to vote for the reconciliation bill before the Senate. At which point the Senate will take it up and ramrod through the second bill with 51 votes, Obama signs it, and there’s health-care.

This strategy requires the House not only to vote for a wildly unpopular bill once, but then to vote on its sequel almost immediately afterward. In other words, House members are going to be forced to cast two wildly unpopular, highly visible votes in succession, without anybody else taking the heat. And there is going to be deal-making and back-scratching and all manner of sleazy behavior to achieve it, all of which will just increase the public sense of a corrupt process that has ensnared Democrats just as corruption seemed to ensnare Republicans in 2006. All so the Senate can sneak it through. And the House has good reason not to trust that the Senate will hold to its part of the bargain. What if there is a colossal meltdown in public support just before the reconciliation vote? What if the Senate decides to change it a little and throws it all back into chaos again? What if House members were to cast two votes and there was no health care at the end of the process?

The only thing that can make this insane business tolerable or bearable for House Democrats is geniune conviction —  conviction that this is the once-in-a-lifetime chance to put the country on the glidepath to a national health-care system. That is what can make the process seem to transcend the sleazy deals and buyoffs for those who are going to have to face voters and explain themselves and their votes.

So if, in the end, this process works as the White House wants it to work, it will do so because of core Democratic and liberal beliefs. Republicans and conservatives need to understand that; the political horror faced by every Democrat who does not have an entirely safe seat can be mitigated in part by the belief that there may be enough Democrats who can live their lives proud to have brought this measure to fruition.

Thus, the best hope of derailing health care will not derive from high motives – stopping this dreadful measure before it becomes law — but rather very low motives —sheer, panicked self-preservation on the part of Democratic pols hoping against hope to hold on in spite of the looming Republican wave.

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Flotsam and Jetsam

Sen. Harry Reid is doubling down on ObamaCare and will jam it through with 50 votes if he can evade all the parliamentary challenges. Republicans question whether he has the votes for reconciliation. I’m not sure Nancy Pelosi has 218 on her side. But it sure does put to rest the notion that Democrats are listening to voters after the Scott Brown debacle.

You wonder how he says it with a straight face: “President Obama warned lawmakers on both sides of the aisle Saturday not to turn the upcoming White House health-care summit into ‘political theater,’ but rather ‘to seek common ground in an effort to solve a problem that’s been with us for generations.'”

Yuval Levin and James C. Capretta observe: “Well, so much for the pivot to jobs. Late last week, the Obama administration and congressional Democrats made clear that, rather than turn to voters’ economic concerns in this winter of discontent, they want to persist in pushing the health care proposals they have championed for a year—proposals voters have rejected by every means at their disposal. … It is now clear that the ‘summit’ the president has called for February 25 is not intended to consider different approaches to health care financing, but rather to create an illusion of momentum that might just lull disoriented congressional Democrats into ramming the health care bill through the budget reconciliation process.”

John Bolton tries to explain to the Obami that “negotiation is not a policy. It is a technique.” And on Iran, it has failed.

Rick Santorum apologizes for helping to elect Arlen Specter in 2004.

Ron Paul wins the straw poll at CPAC, leading credence to the view that the gathering isn’t all that relevant. (But then again, CPAC straw polls haven’t really foreshadowed the nominee in past years.) Paul was then booed, and “CPAC organizers were plainly embarrassed by the results, which could reduce the perceived impact of a contest that was once thought to offer a window into which White House hopefuls were favored by movement conservatives.”

Well, it did accomplish one thing: Tim Pawlenty earned bipartisan bad reviews. Gail Collins: “He doesn’t seem naturally irate. People call him T-Paw, which sounds like a character in a children’s cartoon — maybe a lovable saber-toothed tiger with big feet. Or a pre-Little League game in which children who can’t hit anything with a bat are allowed to just thwack at the ball with their fists. Politicians often get into trouble when they’re trying to sound more furious than they feel.”

Dana Milbank: “Obama’s greatest mistake was failing to listen to Emanuel on health care. Early on, Emanuel argued for a smaller bill with popular items, such as expanding health coverage for children and young adults, that could win some Republican support. He opposed the public option as a needless distraction. The president disregarded that strategy and sided with Capitol Hill liberals who hoped to ram a larger, less popular bill through Congress with Democratic votes only. The result was, as the world now knows, disastrous.” And we know Emanuel’s position on this — and the KSM trial (opposed), and closing Guantanamo (opposed) — because he’s leaked it, trying to let everyone know it’s not his fault that the president is going down the tubes.

Sen. Harry Reid is doubling down on ObamaCare and will jam it through with 50 votes if he can evade all the parliamentary challenges. Republicans question whether he has the votes for reconciliation. I’m not sure Nancy Pelosi has 218 on her side. But it sure does put to rest the notion that Democrats are listening to voters after the Scott Brown debacle.

You wonder how he says it with a straight face: “President Obama warned lawmakers on both sides of the aisle Saturday not to turn the upcoming White House health-care summit into ‘political theater,’ but rather ‘to seek common ground in an effort to solve a problem that’s been with us for generations.'”

Yuval Levin and James C. Capretta observe: “Well, so much for the pivot to jobs. Late last week, the Obama administration and congressional Democrats made clear that, rather than turn to voters’ economic concerns in this winter of discontent, they want to persist in pushing the health care proposals they have championed for a year—proposals voters have rejected by every means at their disposal. … It is now clear that the ‘summit’ the president has called for February 25 is not intended to consider different approaches to health care financing, but rather to create an illusion of momentum that might just lull disoriented congressional Democrats into ramming the health care bill through the budget reconciliation process.”

John Bolton tries to explain to the Obami that “negotiation is not a policy. It is a technique.” And on Iran, it has failed.

Rick Santorum apologizes for helping to elect Arlen Specter in 2004.

Ron Paul wins the straw poll at CPAC, leading credence to the view that the gathering isn’t all that relevant. (But then again, CPAC straw polls haven’t really foreshadowed the nominee in past years.) Paul was then booed, and “CPAC organizers were plainly embarrassed by the results, which could reduce the perceived impact of a contest that was once thought to offer a window into which White House hopefuls were favored by movement conservatives.”

Well, it did accomplish one thing: Tim Pawlenty earned bipartisan bad reviews. Gail Collins: “He doesn’t seem naturally irate. People call him T-Paw, which sounds like a character in a children’s cartoon — maybe a lovable saber-toothed tiger with big feet. Or a pre-Little League game in which children who can’t hit anything with a bat are allowed to just thwack at the ball with their fists. Politicians often get into trouble when they’re trying to sound more furious than they feel.”

Dana Milbank: “Obama’s greatest mistake was failing to listen to Emanuel on health care. Early on, Emanuel argued for a smaller bill with popular items, such as expanding health coverage for children and young adults, that could win some Republican support. He opposed the public option as a needless distraction. The president disregarded that strategy and sided with Capitol Hill liberals who hoped to ram a larger, less popular bill through Congress with Democratic votes only. The result was, as the world now knows, disastrous.” And we know Emanuel’s position on this — and the KSM trial (opposed), and closing Guantanamo (opposed) — because he’s leaked it, trying to let everyone know it’s not his fault that the president is going down the tubes.

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Flotsam and Jetsam

It’s about time someone took it to Meghan McCain: “She’s an über-cool politics chick with lots to say of the conventional-thinking NYTimesish variety, and she’s got credulous lefties lapping up her disses of conservatives like kittens at cream bowls.” And what better way to get that attention than to diss the woman who drives liberals mad? Funny how liberal pundits whine that the former governor, who has articulated positions on a range of issues, doesn’t “know anything,” but they’re willing to spend endless hours talking to a 25-year-old who’s, well, never done anything.

Lori Lowenthal Marcus has the goods on the latest J Street scam: “In short, J Street manipulated the Hillel of Greater Philadelphia (of which I am a board member) into leasing to them space in the Hillel building for their J Street Local launch by entering into a firm agreement, and then ignoring that agreement to Hillel’s detriment. J Street’s deception made Hillel’s carefully planned and extensive pre-event efforts to soothe concerned donors, students, and others that there was no—and that it would be made very clear that there was no—connection between Hillel and J Street.”

House Democrats aid the Justice Department in stonewalling on the New Black Panther Party case: “In their bid to protect President Obama’s liberal political appointees at the Justice Department, congressional Democrats are surrendering their responsibility to keep a presidential administration honest.”

Not so much sycophantic laughter in the White House briefing room: “‘There definitely aren’t a lot of laughs around the briefing room these days,’ says Washington Examiner White House correspondent Julie Mason. ‘Robert’s little digs and evasions have lost their power to amuse — particularly since we haven’t had a presser since July. … Reporters know how close the press secretary is to the president, and yet the quality of the information we get doesn’t often reflect that.” Well, rudeness and lack of candor are pretty much par for the course for the Obami.

Big Labor is steamed it’s gotten nothing for all those millions: “Labor groups are furious with the Democrats they helped put in office — and are threatening to stay home this fall when Democratic incumbents will need their help fending off Republican challengers. … The so-called ‘card check’ bill that would make it easier to unionize employees has gone nowhere. A pro-union Transportation Security Administration nominee quit before he even got a confirmation vote. And even though unions got a sweetheart deal to keep their health plans tax-free under the Senate health care bill, that bill has collapsed, leaving unions exposed again.” And not even Harold Craig Becker could get confirmed.

Obama is bringing people together — Paul Krugman and Bill Kristol agree that his crony-capitalism comments on Wall Street bonuses were horridly tone-deaf. Next thing you know, Jane Hamsher and Yuval Levin will agree on ObamaCare. Oh, wait. It takes real skill to build such a broad-based coalition.

It’s something, but hardly enough: “A day after Iran said it was beginning to feed low enriched uranium through centrifuges at its Natanz pilot facility to create nuclear medical isotopes, the U.S. has announced sanctions on four engineering firms said to be controlled by Iran’s Islamic Revolutionary Guards Corps (IRGC).”

Because Nancy Pelosi never met a tax cut she could support, this will be a problem: “House Majority Leader Steny Hoyer (D-Md.) is praising the Senate for including a payroll tax credit in its jobs package, but it could set up a battle in his House Democratic caucus. Economic conditions are ripe for a provision that serves as an incentive for employers to expand their workforces, in Hoyer’s vies. The economy is growing again, and surveys indicate growing confidence by business.” Republicans are probably lucky that Pelosi and not Hoyer is Speaker. Hoyer actually sounds in touch with reality.

Cognitive-dissonance alert! David Brooks warms to Rep. Paul Ryan’s vision: “Government would have very few decision-making powers. Instead it would essentially redistribute money so that individuals could better secure their own welfare provision. Medicare and Social Security would essentially be turned into cash programs. The elderly would receive $11,000 a year to purchase insurance. The tax code would be radically simplified.” But Obama doesn’t believe in any of that, so … ?

First, Michael Steele. Now Gov. David Paterson is playing the race card.

It’s about time someone took it to Meghan McCain: “She’s an über-cool politics chick with lots to say of the conventional-thinking NYTimesish variety, and she’s got credulous lefties lapping up her disses of conservatives like kittens at cream bowls.” And what better way to get that attention than to diss the woman who drives liberals mad? Funny how liberal pundits whine that the former governor, who has articulated positions on a range of issues, doesn’t “know anything,” but they’re willing to spend endless hours talking to a 25-year-old who’s, well, never done anything.

Lori Lowenthal Marcus has the goods on the latest J Street scam: “In short, J Street manipulated the Hillel of Greater Philadelphia (of which I am a board member) into leasing to them space in the Hillel building for their J Street Local launch by entering into a firm agreement, and then ignoring that agreement to Hillel’s detriment. J Street’s deception made Hillel’s carefully planned and extensive pre-event efforts to soothe concerned donors, students, and others that there was no—and that it would be made very clear that there was no—connection between Hillel and J Street.”

House Democrats aid the Justice Department in stonewalling on the New Black Panther Party case: “In their bid to protect President Obama’s liberal political appointees at the Justice Department, congressional Democrats are surrendering their responsibility to keep a presidential administration honest.”

Not so much sycophantic laughter in the White House briefing room: “‘There definitely aren’t a lot of laughs around the briefing room these days,’ says Washington Examiner White House correspondent Julie Mason. ‘Robert’s little digs and evasions have lost their power to amuse — particularly since we haven’t had a presser since July. … Reporters know how close the press secretary is to the president, and yet the quality of the information we get doesn’t often reflect that.” Well, rudeness and lack of candor are pretty much par for the course for the Obami.

Big Labor is steamed it’s gotten nothing for all those millions: “Labor groups are furious with the Democrats they helped put in office — and are threatening to stay home this fall when Democratic incumbents will need their help fending off Republican challengers. … The so-called ‘card check’ bill that would make it easier to unionize employees has gone nowhere. A pro-union Transportation Security Administration nominee quit before he even got a confirmation vote. And even though unions got a sweetheart deal to keep their health plans tax-free under the Senate health care bill, that bill has collapsed, leaving unions exposed again.” And not even Harold Craig Becker could get confirmed.

Obama is bringing people together — Paul Krugman and Bill Kristol agree that his crony-capitalism comments on Wall Street bonuses were horridly tone-deaf. Next thing you know, Jane Hamsher and Yuval Levin will agree on ObamaCare. Oh, wait. It takes real skill to build such a broad-based coalition.

It’s something, but hardly enough: “A day after Iran said it was beginning to feed low enriched uranium through centrifuges at its Natanz pilot facility to create nuclear medical isotopes, the U.S. has announced sanctions on four engineering firms said to be controlled by Iran’s Islamic Revolutionary Guards Corps (IRGC).”

Because Nancy Pelosi never met a tax cut she could support, this will be a problem: “House Majority Leader Steny Hoyer (D-Md.) is praising the Senate for including a payroll tax credit in its jobs package, but it could set up a battle in his House Democratic caucus. Economic conditions are ripe for a provision that serves as an incentive for employers to expand their workforces, in Hoyer’s vies. The economy is growing again, and surveys indicate growing confidence by business.” Republicans are probably lucky that Pelosi and not Hoyer is Speaker. Hoyer actually sounds in touch with reality.

Cognitive-dissonance alert! David Brooks warms to Rep. Paul Ryan’s vision: “Government would have very few decision-making powers. Instead it would essentially redistribute money so that individuals could better secure their own welfare provision. Medicare and Social Security would essentially be turned into cash programs. The elderly would receive $11,000 a year to purchase insurance. The tax code would be radically simplified.” But Obama doesn’t believe in any of that, so … ?

First, Michael Steele. Now Gov. David Paterson is playing the race card.

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The Next Chapter of Health-Care Reform

It is not clear whether anyone has the stomach for more health-care negotiations.  For the Democrats, it would be like revisiting the site of a traumatic auto accident. It is where the pain started, and it will only remind voters where the Democrats got off course. Republicans might just as soon move on to other issues rather than throw Democrats a lifeline. But there are good reasons, both substantive and political, to move forward.

As the Washington Post editors counsel, now that ObamaCare is “in mortal danger, President Obama should try treating the Senate Republicans the way he treats the ruling mullahs of Iran.” In other words, try to engage and give the other side every benefit of the doubt. More seriously, the Post notes that Republicans have some good ideas. (“Tort reform, freedom for state experimentation and other issues could advance Mr. Obama’s goals of increased access and decreased costs.”) In short, we might actually get a coherent, effective piece of legislation now that the monstrosity cooked up by Obama-Reid-Pelosi is kaput.

In a similar vein, James C. Capretta and Yuval Levin urge Republicans to move forward on three fronts:

First, they should seek to address the problem of insuring Americans with preexisting conditions through state-based high-risk pools, not cumbersome insurance regulations that try to outlaw basic economics.  … Second, they should propose to help doctors and patients limit some of the burden of rising costs with medical malpractice reform. … Third, they should argue that the states be given the lead role in developing more detailed reforms of how and where people get their insurance—to cover more people and slow the rise of costs. The overall goal should be to build well-functioning marketplaces in which insurers and providers compete to deliver the best value to cost-conscious consumers. The federal government should remove bureaucratic obstacles to state experimentation on this front, and offer support where possible, but not design one mammoth new program.

Well, it sounds like they and the Washington Post editors could hammer something out in an afternoon. But alas, the same crew who came up with ObamaCare would be negotiating with the Republicans, so we shouldn’t get our hopes up. Nevertheless, as a political matter, it makes sense, if not now then in a couple of months, for both Democrats and Republicans to give it a try. Democrats don’t want the last chapter of health-care reform to be the Cornhusker Kickback and the mandate to make everyone buy policies they don’t want from Big Insurance. And Republicans, who are auditioning for control of Congress, want to show what real reform looks like and how the “party of no” was another liberal fable cooked up while Democrats were trying to convince voters the choice was between ObamaCare and nothing at all. (The voters liked the “nothing at all” option better.)

It is understandable if lawmakers would rather move on. But given that there isn’t too much agreement on anything else (immigration, cap-and-trade), they might give health-care reform one more shot. They really can’t do worse than they did the first time.

It is not clear whether anyone has the stomach for more health-care negotiations.  For the Democrats, it would be like revisiting the site of a traumatic auto accident. It is where the pain started, and it will only remind voters where the Democrats got off course. Republicans might just as soon move on to other issues rather than throw Democrats a lifeline. But there are good reasons, both substantive and political, to move forward.

As the Washington Post editors counsel, now that ObamaCare is “in mortal danger, President Obama should try treating the Senate Republicans the way he treats the ruling mullahs of Iran.” In other words, try to engage and give the other side every benefit of the doubt. More seriously, the Post notes that Republicans have some good ideas. (“Tort reform, freedom for state experimentation and other issues could advance Mr. Obama’s goals of increased access and decreased costs.”) In short, we might actually get a coherent, effective piece of legislation now that the monstrosity cooked up by Obama-Reid-Pelosi is kaput.

In a similar vein, James C. Capretta and Yuval Levin urge Republicans to move forward on three fronts:

First, they should seek to address the problem of insuring Americans with preexisting conditions through state-based high-risk pools, not cumbersome insurance regulations that try to outlaw basic economics.  … Second, they should propose to help doctors and patients limit some of the burden of rising costs with medical malpractice reform. … Third, they should argue that the states be given the lead role in developing more detailed reforms of how and where people get their insurance—to cover more people and slow the rise of costs. The overall goal should be to build well-functioning marketplaces in which insurers and providers compete to deliver the best value to cost-conscious consumers. The federal government should remove bureaucratic obstacles to state experimentation on this front, and offer support where possible, but not design one mammoth new program.

Well, it sounds like they and the Washington Post editors could hammer something out in an afternoon. But alas, the same crew who came up with ObamaCare would be negotiating with the Republicans, so we shouldn’t get our hopes up. Nevertheless, as a political matter, it makes sense, if not now then in a couple of months, for both Democrats and Republicans to give it a try. Democrats don’t want the last chapter of health-care reform to be the Cornhusker Kickback and the mandate to make everyone buy policies they don’t want from Big Insurance. And Republicans, who are auditioning for control of Congress, want to show what real reform looks like and how the “party of no” was another liberal fable cooked up while Democrats were trying to convince voters the choice was between ObamaCare and nothing at all. (The voters liked the “nothing at all” option better.)

It is understandable if lawmakers would rather move on. But given that there isn’t too much agreement on anything else (immigration, cap-and-trade), they might give health-care reform one more shot. They really can’t do worse than they did the first time.

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Flotsam and Jetsam

Tom Jensen of Public Policy Polling observes that Sen. Michael Bennet is trailing all Republicans in a potential 2010 race, one by as much as nine points. He notes that this “is a reminder that Democratic Governors sure didn’t do their party in the Senate any favors with their appointments last year. The appointments of Michael Bennet in Colorado, Ted Kaufman in Delaware, Roland Burris in Illinois, and Kirsten Gillibrand in New York put all of those seats in play for next year and it really didn’t have to be that way.”

James Capretta and Yuval Levin explain ReidCare: “In other words, rather than build on the failed cost-control model of Medicare, they now want to actually further burden Medicare itself. Why take a roundabout path to failure when a direct one is available? The irrationality of this solution is staggering. But, of course, it’s a solution to Reid’s political problem, not to the nation’s health care financing crisis.”

The New York Times thinks ReidCare is in trouble too: “Democratic leaders hit a rough patch Friday in their push for sweeping health care legislation, as they tried to fend off criticism of their proposals from a top Medicare official, Republicans and even members of their own party. . .Republicans said [the Medicare actuary’s] report confirmed what they had been saying for months. ‘It is a remarkable report,’ said Senator Mike Johanns, Republican of Nebraska. ‘It is a roundhouse blow to the Reid plan.'” We’ll see.

Dana Milbank thinks Senate Democrats could find a better leader. He explains that “as his public-option gambit demonstrated, merely dangling proposals, regardless of how meritorious they may be, doesn’t cause them to become law — and it may cause Democrats from more conservative states, such as Lincoln’s Arkansas, to lose their jobs.” And lose his own as well. Millbank thinks his caucus might be happier with Dick Durbin or Chuck Schumer. Well, they might get their wish, given Reid’s polling.

Looking at the dismal polling on ObamaCare and the CBS polling showing Obama leading George W. Bush by only a 50-to-44-percent margin, James Taranto argues that “these results almost surely represent a backlash against Obama and Congress’s Democrats. Their insistence on pushing ahead and forcing on the country a health-care scheme that by now is almost as unpopular as it is monstrous is without a doubt a major factor here.” And it might be that a cold, ultra-liberal president who blames his problems on his predecessor really isn’t what they all had in mind.

An excellent development, and perhaps a sign that the Obami are waking up to the reality of the thugocracy of Iran: “More than $2 billion allegedly held on behalf of Iran in Citigroup Inc. accounts were secretly ordered frozen last year by a federal court in Manhattan, in what appears to be the biggest seizure of Iranian assets abroad since the 1979 Islamic revolution. . .President Barack Obama has pledged to enact new economic sanctions on Iran at year-end if Tehran doesn’t respond to international calls for negotiations over its nuclear-fuel program.”

Obama is still sliding: “The Rasmussen Reports daily Presidential Tracking Poll for Saturday shows that 25% of the nation’s voters Strongly Approve of the way that Barack Obama is performing his role as President. Forty-one percent (41%) Strongly Disapprove giving Obama a Presidential Approval Index rating of -16. That’s the lowest Approval Index rating yet recorded for this President.”

It’s the “international community” after all: “Iranian Prime Minister Mahmoud Ahmadinejad, Venezuelan President Hugo Chavez and Zimbabwean President Robert Mugabe plan to address negotiators at international climate talks in Copenhagen next week.”

Tom Jensen of Public Policy Polling observes that Sen. Michael Bennet is trailing all Republicans in a potential 2010 race, one by as much as nine points. He notes that this “is a reminder that Democratic Governors sure didn’t do their party in the Senate any favors with their appointments last year. The appointments of Michael Bennet in Colorado, Ted Kaufman in Delaware, Roland Burris in Illinois, and Kirsten Gillibrand in New York put all of those seats in play for next year and it really didn’t have to be that way.”

James Capretta and Yuval Levin explain ReidCare: “In other words, rather than build on the failed cost-control model of Medicare, they now want to actually further burden Medicare itself. Why take a roundabout path to failure when a direct one is available? The irrationality of this solution is staggering. But, of course, it’s a solution to Reid’s political problem, not to the nation’s health care financing crisis.”

The New York Times thinks ReidCare is in trouble too: “Democratic leaders hit a rough patch Friday in their push for sweeping health care legislation, as they tried to fend off criticism of their proposals from a top Medicare official, Republicans and even members of their own party. . .Republicans said [the Medicare actuary’s] report confirmed what they had been saying for months. ‘It is a remarkable report,’ said Senator Mike Johanns, Republican of Nebraska. ‘It is a roundhouse blow to the Reid plan.'” We’ll see.

Dana Milbank thinks Senate Democrats could find a better leader. He explains that “as his public-option gambit demonstrated, merely dangling proposals, regardless of how meritorious they may be, doesn’t cause them to become law — and it may cause Democrats from more conservative states, such as Lincoln’s Arkansas, to lose their jobs.” And lose his own as well. Millbank thinks his caucus might be happier with Dick Durbin or Chuck Schumer. Well, they might get their wish, given Reid’s polling.

Looking at the dismal polling on ObamaCare and the CBS polling showing Obama leading George W. Bush by only a 50-to-44-percent margin, James Taranto argues that “these results almost surely represent a backlash against Obama and Congress’s Democrats. Their insistence on pushing ahead and forcing on the country a health-care scheme that by now is almost as unpopular as it is monstrous is without a doubt a major factor here.” And it might be that a cold, ultra-liberal president who blames his problems on his predecessor really isn’t what they all had in mind.

An excellent development, and perhaps a sign that the Obami are waking up to the reality of the thugocracy of Iran: “More than $2 billion allegedly held on behalf of Iran in Citigroup Inc. accounts were secretly ordered frozen last year by a federal court in Manhattan, in what appears to be the biggest seizure of Iranian assets abroad since the 1979 Islamic revolution. . .President Barack Obama has pledged to enact new economic sanctions on Iran at year-end if Tehran doesn’t respond to international calls for negotiations over its nuclear-fuel program.”

Obama is still sliding: “The Rasmussen Reports daily Presidential Tracking Poll for Saturday shows that 25% of the nation’s voters Strongly Approve of the way that Barack Obama is performing his role as President. Forty-one percent (41%) Strongly Disapprove giving Obama a Presidential Approval Index rating of -16. That’s the lowest Approval Index rating yet recorded for this President.”

It’s the “international community” after all: “Iranian Prime Minister Mahmoud Ahmadinejad, Venezuelan President Hugo Chavez and Zimbabwean President Robert Mugabe plan to address negotiators at international climate talks in Copenhagen next week.”

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Paying Attention

According to the Associated Press

Remote-controlled explosives strapped to two mentally retarded women detonated in a coordinated attack on pet bazaars Friday, police and Iraqi officials said, killing at least 73 people in the deadliest day since the U.S. sent 30,000 extra troops to the capital this spring . . . Iraqi officials said the women apparently were mentally disabled and the explosives were detonated by remote control, indicating they may not having been willing attackers in what could be a new method by suspected Sunni insurgents to subvert stepped up security measures.

This episode reminds us of just how malevolent our enemy is. Their savagery is almost unfathomable. One wonders if this type of thing will continue to turn the Muslim world against al Qaeda in Iraq (AQI), which is exactly what is happening in the “Anbar Awakening” (the backlash against AQI has now spread beyond Anbar Province).

This attack also underscores what General Petraeus has repeatedly said: the challenges in Iraq remain formidable and we will need to maintain our presence there for some time to come. The gains we saw in 2007 were stunning – but we are still a long way from Iraq becoming a secure, unified nation. Fortunately the President has indicated that he will abide by the counsel of General Petraeus and not pull out our troops prematurely. As the Washington Post reported today:

President Bush asserted Thursday that he would not be pressured into making further troop cuts in Iraq beyond the five combat brigades already scheduled to come home by the middle of the summer. “We have come too far in this important theater, in this war on terror, not to make sure that we succeed,” Bush told a friendly audience at an event sponsored by a conservative think tank. “I will be making decisions based upon success in Iraq…. The comments were the latest indication from the administration that it may keep the number of troops in Iraq at roughly the same level they were before last year’s buildup of U.S. forces, possibly through the end of Bush’s presidency. Under existing plans, the levels are gradually falling about 5,000 troops a month, from roughly 160,000 to 130,000 by July — or approximately where they stood before Bush sent reinforcements to Iraq seeking to curtail spiraling sectarian violence. Last fall, Defense Secretary Robert M. Gates suggested that troop levels could continue falling, reaching 100,000 by 2009. But U.S. commanders in Iraq have suggested they would like to see a pause to determine whether recent security gains have taken root, and in recent statements — such as his comments here — Bush has indicated that he looks favorably upon such an approach.

Because of the successes we’ve experienced in Iraq, the attention of the nation and the political class is wandering away from that traumatized land. But the stakes in that war could not be higher – and the consequences of a defeat to AQI would be staggering. Whatever the flaws of the GOP candidates, there is a huge chasm between their views on Iraq and the views of Hillary Clinton and Barack Obama. As my colleague Yuval Levin wrote earlier today about last night’s debate, “They are intent on snatching disaster from the jaws of a real chance at progress in Iraq, and they simply don’t care if we lose. Neither of them came anywhere near words like success, or victory. It’s not in the script.”

What a thoroughly irresponsible and, if they were to become president, what a terribly dangerous position for them to hold.

According to the Associated Press

Remote-controlled explosives strapped to two mentally retarded women detonated in a coordinated attack on pet bazaars Friday, police and Iraqi officials said, killing at least 73 people in the deadliest day since the U.S. sent 30,000 extra troops to the capital this spring . . . Iraqi officials said the women apparently were mentally disabled and the explosives were detonated by remote control, indicating they may not having been willing attackers in what could be a new method by suspected Sunni insurgents to subvert stepped up security measures.

This episode reminds us of just how malevolent our enemy is. Their savagery is almost unfathomable. One wonders if this type of thing will continue to turn the Muslim world against al Qaeda in Iraq (AQI), which is exactly what is happening in the “Anbar Awakening” (the backlash against AQI has now spread beyond Anbar Province).

This attack also underscores what General Petraeus has repeatedly said: the challenges in Iraq remain formidable and we will need to maintain our presence there for some time to come. The gains we saw in 2007 were stunning – but we are still a long way from Iraq becoming a secure, unified nation. Fortunately the President has indicated that he will abide by the counsel of General Petraeus and not pull out our troops prematurely. As the Washington Post reported today:

President Bush asserted Thursday that he would not be pressured into making further troop cuts in Iraq beyond the five combat brigades already scheduled to come home by the middle of the summer. “We have come too far in this important theater, in this war on terror, not to make sure that we succeed,” Bush told a friendly audience at an event sponsored by a conservative think tank. “I will be making decisions based upon success in Iraq…. The comments were the latest indication from the administration that it may keep the number of troops in Iraq at roughly the same level they were before last year’s buildup of U.S. forces, possibly through the end of Bush’s presidency. Under existing plans, the levels are gradually falling about 5,000 troops a month, from roughly 160,000 to 130,000 by July — or approximately where they stood before Bush sent reinforcements to Iraq seeking to curtail spiraling sectarian violence. Last fall, Defense Secretary Robert M. Gates suggested that troop levels could continue falling, reaching 100,000 by 2009. But U.S. commanders in Iraq have suggested they would like to see a pause to determine whether recent security gains have taken root, and in recent statements — such as his comments here — Bush has indicated that he looks favorably upon such an approach.

Because of the successes we’ve experienced in Iraq, the attention of the nation and the political class is wandering away from that traumatized land. But the stakes in that war could not be higher – and the consequences of a defeat to AQI would be staggering. Whatever the flaws of the GOP candidates, there is a huge chasm between their views on Iraq and the views of Hillary Clinton and Barack Obama. As my colleague Yuval Levin wrote earlier today about last night’s debate, “They are intent on snatching disaster from the jaws of a real chance at progress in Iraq, and they simply don’t care if we lose. Neither of them came anywhere near words like success, or victory. It’s not in the script.”

What a thoroughly irresponsible and, if they were to become president, what a terribly dangerous position for them to hold.

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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.

Read More

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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