Commentary Magazine


Topic: health insurance

Re: Why There Are Primaries

A Florida columnist (h/t) Ben Smith offers an explanation for Charlie Crist’s belly flop in the senate primary:

This is a serial politician campaigning for his fifth office in less than 10 years (education commissioner, attorney general, governor, vice president, Senate).  Every one of his major initiatives in Florida – insurance reform, renewable energy, tax policy, health insurance and the Everglades – has fallen flat. Confronted with mounting challenges in Tallahassee, his response is to abandon ship for the Senate rather than deal with them. Even taking Rubio out of the equation, why in the world would anyone argue Crist has earned a spot in the Senate?

Well a lot of snooty pundits and Washington insiders thought they knew best. And they are still at it, grousing about a divisive primary and wailing that “blood will be spilled.” Puleez. If Crist actually is a crudy candidate with a record of underachievement, Republicans are fortunate to find that out in the primary. And if Crist goes bonkers with a hyper-negative campaign, the Florida voters can register their disapproval. It’s politics. It’s elections. And when Republicans pre-select a candidate with a problematic record and don’t hold primaries, as we saw in NY-23, disaster happens in the general election.

A Florida columnist (h/t) Ben Smith offers an explanation for Charlie Crist’s belly flop in the senate primary:

This is a serial politician campaigning for his fifth office in less than 10 years (education commissioner, attorney general, governor, vice president, Senate).  Every one of his major initiatives in Florida – insurance reform, renewable energy, tax policy, health insurance and the Everglades – has fallen flat. Confronted with mounting challenges in Tallahassee, his response is to abandon ship for the Senate rather than deal with them. Even taking Rubio out of the equation, why in the world would anyone argue Crist has earned a spot in the Senate?

Well a lot of snooty pundits and Washington insiders thought they knew best. And they are still at it, grousing about a divisive primary and wailing that “blood will be spilled.” Puleez. If Crist actually is a crudy candidate with a record of underachievement, Republicans are fortunate to find that out in the primary. And if Crist goes bonkers with a hyper-negative campaign, the Florida voters can register their disapproval. It’s politics. It’s elections. And when Republicans pre-select a candidate with a problematic record and don’t hold primaries, as we saw in NY-23, disaster happens in the general election.

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Job Killers

Offering a blast of common sense, Charles Lane suggests that we do three things to promote job growth: (1) end sugar protectionism and price supports (“In 2006, the Commerce Department estimated that the sugar program cost three confectionery manufacturing jobs for each job it saved in sugar growing and harvesting”); (2) repeal the Davis-Bacon Act, which requires federal contracts to pay the “prevailing” (i.e., union) wage, which now covers roughly a third of public construction spending, at an added cost to tax payers of $8.6B; and (3) reduce the minimum wage. He chides both the president and Republicans for failing to mention any of these in their list of job-creating ideas: “None of these measures alone, or even all three together, would eliminate unemployment. But they might significantly decrease it at a time when every job counts.”

Of course there are powerful special interests defending each of these, especially organized labor, which “argues for Davis-Bacon and the minimum wage with rhetoric about fairness and workers’ rights, despite economic evidence to the contrary.” The White House and Congress are not merely resistant to good ideas for improving the job outlook. They also want to make it worse. Cap-and-trade, card check, and ObamaCare all impose new costs, taxes, and mandates on business. Just as surely as Davis Bacon increases the cost of labor, new mandates to pay for super-duper health insurance for all but a fraction of workers will do so as well. If the minimum wage “prices low-skilled workers out of entry-level jobs,” ObamaCare will price workers at all levels out of jobs. And Midwestern senators have already figured out the job-killing implications of cap-and-trade.

It remains a wonder that politicians don’t seem to connect the dots between their policies and the impact on employment. Or maybe they do and simply don’t care. But let’s be clear: the jobs picture is bleak, and both Congress and the White House should jettison existing barriers to employment and junk agenda items that will make things worse if, as Lane says, “they’re really serious about putting America back to work.”

Offering a blast of common sense, Charles Lane suggests that we do three things to promote job growth: (1) end sugar protectionism and price supports (“In 2006, the Commerce Department estimated that the sugar program cost three confectionery manufacturing jobs for each job it saved in sugar growing and harvesting”); (2) repeal the Davis-Bacon Act, which requires federal contracts to pay the “prevailing” (i.e., union) wage, which now covers roughly a third of public construction spending, at an added cost to tax payers of $8.6B; and (3) reduce the minimum wage. He chides both the president and Republicans for failing to mention any of these in their list of job-creating ideas: “None of these measures alone, or even all three together, would eliminate unemployment. But they might significantly decrease it at a time when every job counts.”

Of course there are powerful special interests defending each of these, especially organized labor, which “argues for Davis-Bacon and the minimum wage with rhetoric about fairness and workers’ rights, despite economic evidence to the contrary.” The White House and Congress are not merely resistant to good ideas for improving the job outlook. They also want to make it worse. Cap-and-trade, card check, and ObamaCare all impose new costs, taxes, and mandates on business. Just as surely as Davis Bacon increases the cost of labor, new mandates to pay for super-duper health insurance for all but a fraction of workers will do so as well. If the minimum wage “prices low-skilled workers out of entry-level jobs,” ObamaCare will price workers at all levels out of jobs. And Midwestern senators have already figured out the job-killing implications of cap-and-trade.

It remains a wonder that politicians don’t seem to connect the dots between their policies and the impact on employment. Or maybe they do and simply don’t care. But let’s be clear: the jobs picture is bleak, and both Congress and the White House should jettison existing barriers to employment and junk agenda items that will make things worse if, as Lane says, “they’re really serious about putting America back to work.”

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Why the Universal Health-Care Insurance Fetish?

Republicans have been tossing out alternatives to government-centric ObamaCare for some time. They have suggested, among other ideas, that we change the tax treatment of individually purchased insurance plans, reform the tort system, and allow interstate insurance sales. But now Jim Prevor raises an interesting and compelling question: if people want to go without insurance and instead self-insure, why is it the government’s job to stop them? Or put differently:

The fact that the national debate has focused on insurance for health care–as opposed to the accessibility of care–is a byproduct of the particular worldview that all “basic needs” should be provided by communal institutions, preferably the government but, alternatively, highly regulated companies that do the government’s bidding.

Prevor suggests that we “give families money or vouchers that they could use to buy health insurance or any other thing they deemed helpful to their family’s future” and urges lawmakers to work on the supply side of care, not insurance, by among other things “wreak[ing] havoc on the American Medical Association’s efforts to restrain the supply of doctors.” Along the lines of Prevor’s argument, one of the more successful ventures in the Bush administration was emphasis on community health centers that expand care for needy Americans, quite apart from the insurance part of the equation. And expansion of medical accounts, which allows individuals to either buy insurance or pay for medical cost directly, would, following Prevor’s argument, maintain personal responsibility, individual choice, and make health-care purchases more accessible by allowing individuals to use pre-tax dollars to pay for their own care.

But what of the “cost shifting” problem caused by uninsured people? Well, now that the Democrats propose to dump millions of people into Medicare, which doesn’t fully compensate doctors and hospitals, it appears as though that argument is going by the wayside. Furthermore, as Mike Tanner of CATO has explained, cost shifting in the current system has been exaggerated and may account for a small portion of health-care costs. He notes that “it is a manageable problem. According to Jack Hadley and John Holahan of the left-leaning Urban Institute, uncompensated care for the uninsured amounts to less than 3% of total healthcare spending — a real cost, no doubt, but hardly a crisis.”

Tanner has also addressed the implied assumption of health-care reformers that universal health-care insurance will improve the nation’s collective health. He says that “in reviewing all the academic literature on the subject, Helen Levy of the University of Michigan’s Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago, were unable to establish a ‘causal relationship’ between health insurance and better health. Believe it or not, there is ‘no evidence,’ Levy and Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health.” A New England Journal of Medicine article in 2006 likewise found that “health insurance status was largely unrelated to the quality of care.” It seems as though even if we force people to self-insure, they may not wind up much healthier.

In sum, Prevor raises a key point: the fixation on universal health-care insurance has distorted the health-care debate. It might, as he suggests, be a good time to take a step back and see whether the quest for universal insurance is really where we should be focusing our attention. Maybe it is time, as he puts it, to remember that “the moral imperative is not making everyone buy insurance. The moral imperative is freedom.”

Republicans have been tossing out alternatives to government-centric ObamaCare for some time. They have suggested, among other ideas, that we change the tax treatment of individually purchased insurance plans, reform the tort system, and allow interstate insurance sales. But now Jim Prevor raises an interesting and compelling question: if people want to go without insurance and instead self-insure, why is it the government’s job to stop them? Or put differently:

The fact that the national debate has focused on insurance for health care–as opposed to the accessibility of care–is a byproduct of the particular worldview that all “basic needs” should be provided by communal institutions, preferably the government but, alternatively, highly regulated companies that do the government’s bidding.

Prevor suggests that we “give families money or vouchers that they could use to buy health insurance or any other thing they deemed helpful to their family’s future” and urges lawmakers to work on the supply side of care, not insurance, by among other things “wreak[ing] havoc on the American Medical Association’s efforts to restrain the supply of doctors.” Along the lines of Prevor’s argument, one of the more successful ventures in the Bush administration was emphasis on community health centers that expand care for needy Americans, quite apart from the insurance part of the equation. And expansion of medical accounts, which allows individuals to either buy insurance or pay for medical cost directly, would, following Prevor’s argument, maintain personal responsibility, individual choice, and make health-care purchases more accessible by allowing individuals to use pre-tax dollars to pay for their own care.

But what of the “cost shifting” problem caused by uninsured people? Well, now that the Democrats propose to dump millions of people into Medicare, which doesn’t fully compensate doctors and hospitals, it appears as though that argument is going by the wayside. Furthermore, as Mike Tanner of CATO has explained, cost shifting in the current system has been exaggerated and may account for a small portion of health-care costs. He notes that “it is a manageable problem. According to Jack Hadley and John Holahan of the left-leaning Urban Institute, uncompensated care for the uninsured amounts to less than 3% of total healthcare spending — a real cost, no doubt, but hardly a crisis.”

Tanner has also addressed the implied assumption of health-care reformers that universal health-care insurance will improve the nation’s collective health. He says that “in reviewing all the academic literature on the subject, Helen Levy of the University of Michigan’s Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago, were unable to establish a ‘causal relationship’ between health insurance and better health. Believe it or not, there is ‘no evidence,’ Levy and Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health.” A New England Journal of Medicine article in 2006 likewise found that “health insurance status was largely unrelated to the quality of care.” It seems as though even if we force people to self-insure, they may not wind up much healthier.

In sum, Prevor raises a key point: the fixation on universal health-care insurance has distorted the health-care debate. It might, as he suggests, be a good time to take a step back and see whether the quest for universal insurance is really where we should be focusing our attention. Maybe it is time, as he puts it, to remember that “the moral imperative is not making everyone buy insurance. The moral imperative is freedom.”

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The Unraveling

As this report explains, the Obama coalition — made up of diverse groups with conflicting understandings of what he was all about — may be unraveling. There is the “specifically eroding support among young voters and independents — in part because of the president’s economic agenda.” Well, these groups and others have reason to be put off by Obamaism and the Democrats in Congress who have been enabling the lurch to the Left.

With unemployment sky-high among young workers and the prospect of a new mandate to buy health insurance they don’t want and can’t afford, younger voters (who aren’t inclined to turn out in off-year elections anyway) may stand on the sidelines in 2010. In August Michael Barone detailed the anti-youth aspects of Obama’s agenda, noting that even Obama’s cynical foreign policy and indifference to human-rights and democracy promotion don’t offer much for those who bought into the hope-n-change routine:

That leads me to wonder whether you were dismayed when Obama responded with stony indifference to the people in the streets of Iran protesting a fraudulent election and demanding freedom and democracy. Some called for the end of a regime that subordinates women and executes homosexuals, things I’m sure you don’t like at all. Although Obama eventually indicated some sympathy, he seemed to regard those demands as a nuisance getting in the way of negotiating with President Mahmoud Ahmadinejad and the mullahs.

Independents seem to be souring on Obamaism — huge spending, nasty partisanship, and massive debt. Then there are wealthy voters who are discovering just how expensive Obama’s economic agenda might be. In June the Wall Street Journal reported:

Recently elected Democrats from higher-income areas also have been cautious about legislation that would make it easier for labor unions to organize, and about legislation imposing tough new rules on banks. Republicans have savaged the new Democrats for supporting legislation to stem global warming by capping greenhouse-gas emissions, then forcing polluters to purchase and trade emissions.

The real kicker will be the Democrats’ insistence on a massive tax hike — allowing the Bush 2001 and 2003 tax cuts to expire. Combined with health-care taxes, marginal rates on the wealthy may return to pre-Reagan-tax-cut levels. That will be quite a wake-up call for the professional class that supported Obama in great numbers. Congressmen are not unaware of this:

“They’re just hanging themselves,” says Republican Rep. Sam Graves, who last year beat back a spirited challenge in his northwestern Missouri district, which includes suburban Kansas City, and said he is looking forward to a race on taxes in 2010.

The tax issue is presenting many new Democrats with a quandary as they struggle to get their political footing. “These members are going to have to make their own determinations on how to balance these interests,” said Maryland Rep. Chris Van Hollen, chairman of the Democratic Congressional Campaign Committee and himself a representative of the affluent suburbs of Washington.

And finally, the Left is now miffed at Obama for failing to live up to netroots’ fondest dreams. They haven’t gotten gay marriage, a pullout from Iraq and Afghanistan, or repeal of the Patriot Act. They are grumbling that insufficient progress has been made on their extreme environmental agenda.

In sum, Obama is losing factions of his political coalition in record speed as these groups learn what his agenda is all about. His Democratic allies are likely to bear the brunt of that in 2010 — at a time when the economy has not yet recovered and unemployment is still high. This is why 2010 may, in fact, be a “wave” election and a bracing wake-up call for the White House.

As this report explains, the Obama coalition — made up of diverse groups with conflicting understandings of what he was all about — may be unraveling. There is the “specifically eroding support among young voters and independents — in part because of the president’s economic agenda.” Well, these groups and others have reason to be put off by Obamaism and the Democrats in Congress who have been enabling the lurch to the Left.

With unemployment sky-high among young workers and the prospect of a new mandate to buy health insurance they don’t want and can’t afford, younger voters (who aren’t inclined to turn out in off-year elections anyway) may stand on the sidelines in 2010. In August Michael Barone detailed the anti-youth aspects of Obama’s agenda, noting that even Obama’s cynical foreign policy and indifference to human-rights and democracy promotion don’t offer much for those who bought into the hope-n-change routine:

That leads me to wonder whether you were dismayed when Obama responded with stony indifference to the people in the streets of Iran protesting a fraudulent election and demanding freedom and democracy. Some called for the end of a regime that subordinates women and executes homosexuals, things I’m sure you don’t like at all. Although Obama eventually indicated some sympathy, he seemed to regard those demands as a nuisance getting in the way of negotiating with President Mahmoud Ahmadinejad and the mullahs.

Independents seem to be souring on Obamaism — huge spending, nasty partisanship, and massive debt. Then there are wealthy voters who are discovering just how expensive Obama’s economic agenda might be. In June the Wall Street Journal reported:

Recently elected Democrats from higher-income areas also have been cautious about legislation that would make it easier for labor unions to organize, and about legislation imposing tough new rules on banks. Republicans have savaged the new Democrats for supporting legislation to stem global warming by capping greenhouse-gas emissions, then forcing polluters to purchase and trade emissions.

The real kicker will be the Democrats’ insistence on a massive tax hike — allowing the Bush 2001 and 2003 tax cuts to expire. Combined with health-care taxes, marginal rates on the wealthy may return to pre-Reagan-tax-cut levels. That will be quite a wake-up call for the professional class that supported Obama in great numbers. Congressmen are not unaware of this:

“They’re just hanging themselves,” says Republican Rep. Sam Graves, who last year beat back a spirited challenge in his northwestern Missouri district, which includes suburban Kansas City, and said he is looking forward to a race on taxes in 2010.

The tax issue is presenting many new Democrats with a quandary as they struggle to get their political footing. “These members are going to have to make their own determinations on how to balance these interests,” said Maryland Rep. Chris Van Hollen, chairman of the Democratic Congressional Campaign Committee and himself a representative of the affluent suburbs of Washington.

And finally, the Left is now miffed at Obama for failing to live up to netroots’ fondest dreams. They haven’t gotten gay marriage, a pullout from Iraq and Afghanistan, or repeal of the Patriot Act. They are grumbling that insufficient progress has been made on their extreme environmental agenda.

In sum, Obama is losing factions of his political coalition in record speed as these groups learn what his agenda is all about. His Democratic allies are likely to bear the brunt of that in 2010 — at a time when the economy has not yet recovered and unemployment is still high. This is why 2010 may, in fact, be a “wave” election and a bracing wake-up call for the White House.

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New York Times, Meet Milton Friedman

Since John has awarded the prize for the most ridiculous headline to the Times, let’s make it a twofer and give the Times the dumbest opening paragraph as well.

The Senate voted Thursday to require health insurance companies to provide free mammograms and other preventive services to women, and it turned back a Republican challenge to Medicare savings that constitute the single largest source of financing for the bill.

Just as there are no free lunches, there are no free mammograms either. The insurance companies will pass the cost along to the policy holders in the form of higher premiums. These politically imposed mandates are a major reason why health insurance is so much more costly in states like New York and New Jersey than it is in neighboring states like Connecticut and Pennsylvania. A family policy that costs $12,250 a year in New York costs only $7,750 a year next door in Connecticut because that state does not have guaranteed issuance (get sick today, buy the policy tomorrow, and still be covered) and many fewer coverage mandates. New York has no fewer than 51 of these, including chiropractic treatment, acupuncture, and — a very big-ticket item — in vitro fertilization. Even if you think chiropractors are quacks, hate needles, and are at a stage in life when you don’t want to make babies even the old-fashioned way, you still must pay for coverage because politicians in Albany have decided you should.

As I have often pointed out, politicians cannot make economic decisions; they can make only political ones. That’s why socialism has never worked — and it never will. For socialized medicine, that goes double.

Since John has awarded the prize for the most ridiculous headline to the Times, let’s make it a twofer and give the Times the dumbest opening paragraph as well.

The Senate voted Thursday to require health insurance companies to provide free mammograms and other preventive services to women, and it turned back a Republican challenge to Medicare savings that constitute the single largest source of financing for the bill.

Just as there are no free lunches, there are no free mammograms either. The insurance companies will pass the cost along to the policy holders in the form of higher premiums. These politically imposed mandates are a major reason why health insurance is so much more costly in states like New York and New Jersey than it is in neighboring states like Connecticut and Pennsylvania. A family policy that costs $12,250 a year in New York costs only $7,750 a year next door in Connecticut because that state does not have guaranteed issuance (get sick today, buy the policy tomorrow, and still be covered) and many fewer coverage mandates. New York has no fewer than 51 of these, including chiropractic treatment, acupuncture, and — a very big-ticket item — in vitro fertilization. Even if you think chiropractors are quacks, hate needles, and are at a stage in life when you don’t want to make babies even the old-fashioned way, you still must pay for coverage because politicians in Albany have decided you should.

As I have often pointed out, politicians cannot make economic decisions; they can make only political ones. That’s why socialism has never worked — and it never will. For socialized medicine, that goes double.

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What Happened to Bending the Cost Curve?

Megan McArdle has a typically thoughtful post on bending the cost curve, or not, through the Democrats’ health-care reforms. She explains:

What passes for delivery reform consists mostly of slashing reimbursement rates to providers, and then putting Medicare Advantage on the same plan. There are two problems with this.  The first is that there’s no reason to believe that providers will find ways to efficiently provide care at the new, lower rates, rather than just stop serving Medicare patients. That was the core point of the recent report from the Centers for Medicare and Medicaid Services — and though a lot of bloggers developed sudden suspicions about the integrity of government reports, in fact, this pretty much jibes with the warnings that Doug Elmendorf has been issuing, and also, reality. . . The second is that the treatment cuts — and any further cuts recommended by the cost effectiveness commission — can be undone by Congress.

Well what about the tax on so-called Cadillac plans? Maybe that’s going to discourage overspending, but as McArdle points out, it’s also quite possible that it “ends up just being a heavy tax on a random group of people who happen to have expensive health insurance, [and] then it won’t cut health care costs, and also, will probably end up being repealed.”

There’s really nothing in sight that will influence the cost of health care, because the Democrats refuse to address two issues: tort reform (with the ensuing problem of defensive medicine and unneeded procedures) and expanding markets (e.g., interstate sales, changing tax treatment of individually purchased plans).

What we are doing here is spending gobs of money, raising hundreds of billions in taxes, slashing Medicare payments, and empowering government bureaucrats to influence health-care treatment all in the name of expanding coverage. It isn’t remotely what Obama promised, and it’s not what voters seem to want. But we may get it anyway.

Megan McArdle has a typically thoughtful post on bending the cost curve, or not, through the Democrats’ health-care reforms. She explains:

What passes for delivery reform consists mostly of slashing reimbursement rates to providers, and then putting Medicare Advantage on the same plan. There are two problems with this.  The first is that there’s no reason to believe that providers will find ways to efficiently provide care at the new, lower rates, rather than just stop serving Medicare patients. That was the core point of the recent report from the Centers for Medicare and Medicaid Services — and though a lot of bloggers developed sudden suspicions about the integrity of government reports, in fact, this pretty much jibes with the warnings that Doug Elmendorf has been issuing, and also, reality. . . The second is that the treatment cuts — and any further cuts recommended by the cost effectiveness commission — can be undone by Congress.

Well what about the tax on so-called Cadillac plans? Maybe that’s going to discourage overspending, but as McArdle points out, it’s also quite possible that it “ends up just being a heavy tax on a random group of people who happen to have expensive health insurance, [and] then it won’t cut health care costs, and also, will probably end up being repealed.”

There’s really nothing in sight that will influence the cost of health care, because the Democrats refuse to address two issues: tort reform (with the ensuing problem of defensive medicine and unneeded procedures) and expanding markets (e.g., interstate sales, changing tax treatment of individually purchased plans).

What we are doing here is spending gobs of money, raising hundreds of billions in taxes, slashing Medicare payments, and empowering government bureaucrats to influence health-care treatment all in the name of expanding coverage. It isn’t remotely what Obama promised, and it’s not what voters seem to want. But we may get it anyway.

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Flotsam and Jetsam

Marco Rubio is closing in on Charlie Crist in the Republican Florida Senate primary.

Two Republican congressmen have a theory as to why the recovery is tepid: “The source appears to be a growing fear that the federal government is retreating from the free-market economic principles of the last half-century, and in particular the strong growth policies that began under Ronald Reagan.” One big factor, they say, is tax policy: “Marginal income tax rates, capital gains rates, dividend rates and death-tax rates will increase — significantly. Hardest hit by these increases will be small businesses that file under the individual income tax code as sub-chapter S corporations, partnerships and proprietorships. Yet these are the very people whose investment and hiring decisions either drive or starve recoveries.”

Michael Goldfarb closes in on NIAC’s lobbying and efforts to silence journalists: “Keep in mind, this is an organization that claims on its tax forms that it DOES NOT engage in lobbying. Moreover, all of the group’s efforts seems focused on preventing additional sanctions, eliminating U.S. democracy funding initiatives, and destroying the Voice of America’s Radio Farda service. The regime couldn’t come up with a better set of priorities for NIAC, which may explain why so many people are wondering on behalf of whom NIAC is working.”

More bad polling for Obama in the latest Fox News/Opinion Dynamics poll: 46 percent approve and an equal percentage disapprove of his performance. Independents disapprove by a stunning 51 to 34 percent margin. By a 42 to 39 percent margin, respondents want to vote Republican in congressional races “to provide a check on Obama’s power.”

And from Quinnipiac: “Three-quarters of American voters — 74 percent — like President Barack Obama as a person, but only 47 percent like most of his policies, and voters disapprove 51-35 percent of the health care overhaul passed by the House of Representatives which he has endorsed, according to a Quinnipiac University national poll released today. Voters disapprove 53-41 percent of President Obama’s handling of health care. Obama’s endorsement of the House of Representatives–passed health care plan makes no difference to 44 percent of American voters, while 24 percent say it makes them view him more favorably; 30 percent less favorably.”

Meanwhile, the status quo has never looked so good: “As Congress debates a possible major expansion of health insurance in the United States, Gallup finds 38% of Americans rating healthcare coverage in this country as excellent or good, the highest (by eight percentage points) in the nine-year history of this question, and 12 points above last year’s level.”

Another weekend rush: “Senate Majority Leader Harry Reid said the first key test vote on his $848 billion health care bill will be taken Saturday, but he declined to say whether he has 60 senators lined up to vote yes. ‘We will find out when the votes are taken,’ he told reporters at a midday event. Reid also said he would not use a procedural maneuver known as reconciliation to pass the bill — a shift from previous statements when he would say all options are on the table.” And that’s 8 p.m. on Saturday for the vote. Get the sense they don’t want too much attention?

Meanwhile: “Democratic Sen. Ben Nelson (D-Neb.) said Thursday that he would prevent health reform from moving to final passage if restrictions on federal funding for abortion weren’t tightened during the amendment process. But, he added, ‘there are a lot of other things that could keep me from supporting it in the end as well.'”

Governors speak up: “Republican governors, meeting outside of Austin, sharply criticized the bill and a companion measure that has passed the House, claiming Thursday that they do nothing to contain rising medical costs and would shift significant costs to already fiscally strapped states.”

Wait, we were told to forget the tax problems because he was a genius: “Snowballing frustration about the economy burst into a political fracas Thursday, with several lawmakers calling on Treasury Secretary Timothy Geithner to resign over angst about unemployment and Wall Street bailouts. The criticism came largely from House Republicans, who have long been critics of the Treasury secretary. Mr. Geithner’s job status doesn’t appear to be in serious jeopardy and several Democrats at a congressional hearing leapt to his defense. But joining the anti-Geithner chorus in increasing numbers are more liberal Democrats who say the White House’s economic policies haven’t done enough to boost job growth.”

Marco Rubio is closing in on Charlie Crist in the Republican Florida Senate primary.

Two Republican congressmen have a theory as to why the recovery is tepid: “The source appears to be a growing fear that the federal government is retreating from the free-market economic principles of the last half-century, and in particular the strong growth policies that began under Ronald Reagan.” One big factor, they say, is tax policy: “Marginal income tax rates, capital gains rates, dividend rates and death-tax rates will increase — significantly. Hardest hit by these increases will be small businesses that file under the individual income tax code as sub-chapter S corporations, partnerships and proprietorships. Yet these are the very people whose investment and hiring decisions either drive or starve recoveries.”

Michael Goldfarb closes in on NIAC’s lobbying and efforts to silence journalists: “Keep in mind, this is an organization that claims on its tax forms that it DOES NOT engage in lobbying. Moreover, all of the group’s efforts seems focused on preventing additional sanctions, eliminating U.S. democracy funding initiatives, and destroying the Voice of America’s Radio Farda service. The regime couldn’t come up with a better set of priorities for NIAC, which may explain why so many people are wondering on behalf of whom NIAC is working.”

More bad polling for Obama in the latest Fox News/Opinion Dynamics poll: 46 percent approve and an equal percentage disapprove of his performance. Independents disapprove by a stunning 51 to 34 percent margin. By a 42 to 39 percent margin, respondents want to vote Republican in congressional races “to provide a check on Obama’s power.”

And from Quinnipiac: “Three-quarters of American voters — 74 percent — like President Barack Obama as a person, but only 47 percent like most of his policies, and voters disapprove 51-35 percent of the health care overhaul passed by the House of Representatives which he has endorsed, according to a Quinnipiac University national poll released today. Voters disapprove 53-41 percent of President Obama’s handling of health care. Obama’s endorsement of the House of Representatives–passed health care plan makes no difference to 44 percent of American voters, while 24 percent say it makes them view him more favorably; 30 percent less favorably.”

Meanwhile, the status quo has never looked so good: “As Congress debates a possible major expansion of health insurance in the United States, Gallup finds 38% of Americans rating healthcare coverage in this country as excellent or good, the highest (by eight percentage points) in the nine-year history of this question, and 12 points above last year’s level.”

Another weekend rush: “Senate Majority Leader Harry Reid said the first key test vote on his $848 billion health care bill will be taken Saturday, but he declined to say whether he has 60 senators lined up to vote yes. ‘We will find out when the votes are taken,’ he told reporters at a midday event. Reid also said he would not use a procedural maneuver known as reconciliation to pass the bill — a shift from previous statements when he would say all options are on the table.” And that’s 8 p.m. on Saturday for the vote. Get the sense they don’t want too much attention?

Meanwhile: “Democratic Sen. Ben Nelson (D-Neb.) said Thursday that he would prevent health reform from moving to final passage if restrictions on federal funding for abortion weren’t tightened during the amendment process. But, he added, ‘there are a lot of other things that could keep me from supporting it in the end as well.'”

Governors speak up: “Republican governors, meeting outside of Austin, sharply criticized the bill and a companion measure that has passed the House, claiming Thursday that they do nothing to contain rising medical costs and would shift significant costs to already fiscally strapped states.”

Wait, we were told to forget the tax problems because he was a genius: “Snowballing frustration about the economy burst into a political fracas Thursday, with several lawmakers calling on Treasury Secretary Timothy Geithner to resign over angst about unemployment and Wall Street bailouts. The criticism came largely from House Republicans, who have long been critics of the Treasury secretary. Mr. Geithner’s job status doesn’t appear to be in serious jeopardy and several Democrats at a congressional hearing leapt to his defense. But joining the anti-Geithner chorus in increasing numbers are more liberal Democrats who say the White House’s economic policies haven’t done enough to boost job growth.”

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The Devil Is in the Details

The AP reports:

Americans are worried about hidden costs in the fine print of health care overhaul legislation, an Associated Press poll says. That’s creating new challenges for President Barack Obama as he tries to close the deal with a handful of Democratic doubters in the Senate.

For months the president held dog-and-pony shows at the White House, refused to talk about specifics, and declined (still has) to put forth his own health-care bill. We know why. When it gets down to the details, the public hates what he is selling:

For example, asked if everyone should be required to have at least some health insurance, 67 percent agreed and 27 percent said no. The responses flipped when people were asked about requiring everybody to carry insurance or face a federal penalty: 64 percent said they would be opposed, while 28 percent favored that. … “I think it’s crazy. I think it infringes on our rights as a citizen, forcing us to do these things,” said Eli Fuchs, 26, of Marietta, Ga.

Likewise, support for a ban on denial of insurance coverage for pre-existing conditions drops dramatically when people find out that their own insurance costs will go up, and support for mandates on employer coverage plunges when voters hear there are fines for employers who don’t comply.

No wonder the president wanted to avoid getting into the nitty-gritty specifics for so long. Who wants to be the bearer of bad news? But it’s not easy to pass legislation that is exceptionally controversial without getting into the weeds and confronting criticism head on. If Obama is such a great orator and so persuasive, why didn’t he tell the public about the “trade-offs” that are now proving to be a stumbling block?

Obama kept telling us during the campaign that politicians — those old-fashioned pols he was going to replace — didn’t treat voters like adults and deliver them tough medicine. But he’s done precious little of that since being elected. And by avoiding a full and thoughtful conversation on what he really wants — much higher taxes, a raft of new regulations with stiff penalties, and more government control of health care — he has left the heavy lifting to Harry Reid (never a good idea), and left the American people feeling like he’s tried to pull a fast one (also never a good idea).

The AP reports:

Americans are worried about hidden costs in the fine print of health care overhaul legislation, an Associated Press poll says. That’s creating new challenges for President Barack Obama as he tries to close the deal with a handful of Democratic doubters in the Senate.

For months the president held dog-and-pony shows at the White House, refused to talk about specifics, and declined (still has) to put forth his own health-care bill. We know why. When it gets down to the details, the public hates what he is selling:

For example, asked if everyone should be required to have at least some health insurance, 67 percent agreed and 27 percent said no. The responses flipped when people were asked about requiring everybody to carry insurance or face a federal penalty: 64 percent said they would be opposed, while 28 percent favored that. … “I think it’s crazy. I think it infringes on our rights as a citizen, forcing us to do these things,” said Eli Fuchs, 26, of Marietta, Ga.

Likewise, support for a ban on denial of insurance coverage for pre-existing conditions drops dramatically when people find out that their own insurance costs will go up, and support for mandates on employer coverage plunges when voters hear there are fines for employers who don’t comply.

No wonder the president wanted to avoid getting into the nitty-gritty specifics for so long. Who wants to be the bearer of bad news? But it’s not easy to pass legislation that is exceptionally controversial without getting into the weeds and confronting criticism head on. If Obama is such a great orator and so persuasive, why didn’t he tell the public about the “trade-offs” that are now proving to be a stumbling block?

Obama kept telling us during the campaign that politicians — those old-fashioned pols he was going to replace — didn’t treat voters like adults and deliver them tough medicine. But he’s done precious little of that since being elected. And by avoiding a full and thoughtful conversation on what he really wants — much higher taxes, a raft of new regulations with stiff penalties, and more government control of health care — he has left the heavy lifting to Harry Reid (never a good idea), and left the American people feeling like he’s tried to pull a fast one (also never a good idea).

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New York State as a Model? Only in Pelosiland

If you were developing a plan to make health insurance more affordable, would you use as a model the state whose laws have made health insurance the most expensive in the country? That’s what Nancy Pelosi and the Democratic majority in the House have done.

David Gratzer points out that PelosiCare will force insurance companies to cover orthotics. Unless you are a doctor or have foot problems, you probably don’t know even what orthotics are, but you’ll be covered for them if this bill becomes law. New York State also mandates the coverage of off-label drugs, chiropractors, in vitro fertilization, and a host of other services. Each additional mandate inescapably raises the premium.

Orthotics, of course, is hardly the only mandate in the 1,992-page PelosiCare bill.

Even worse, New York, with “guaranteed issue,” requires that health-insurance companies sell policies to anyone who asks for one and to cover pre-existing conditions. This is the equivalent of requiring fire-insurance companies to sell policies to people whose house burned down the day before — and then pay to rebuild the house. Naturally, premiums on the shmoes who carry health insurance when they are healthy must go up to cover the shnorrers who only begin paying premiums when they have claims.

PelosiCare will require guaranteed issue.

And New York severely limits the ability of insurance companies to charge the young, who have a very low risk of serious health issues, lower premiums than those charged to the not-so-young, who have a much higher risk. Since the young are wildly overcharged in order to subsidize seniors in New York, many decide not to buy health insurance, knowing that if they are very unlucky and get seriously sick, they can always buy the insurance then and be covered.

PelosiCare will do the same. To be sure, the bill calls for those who do not buy insurance to pay a fine of $2,000. As New Yorker Andrew R. Heinze writes, that’s about what he is currently paying just for the coverage of hospital care today, thanks to New York’s economic-reality-be-damned health-insurance laws. He plans to drop his insurance if PelosiCare becomes law and depend on good luck (and guaranteed issuance).

Residents of New York City pay about five times as much for health insurance as those who live in, say, Columbus, Ohio, because of these mandates, guaranteed issue, and restricted premium differentials. PelosiCare will make sure that those who live in Columbus will see their health-insurance bills soar. Or it will cause a collapse of the private health-insurance market, making a government takeover of health care inevitable.

It’s hard not to think that the latter is exactly what they have in mind.

If you were developing a plan to make health insurance more affordable, would you use as a model the state whose laws have made health insurance the most expensive in the country? That’s what Nancy Pelosi and the Democratic majority in the House have done.

David Gratzer points out that PelosiCare will force insurance companies to cover orthotics. Unless you are a doctor or have foot problems, you probably don’t know even what orthotics are, but you’ll be covered for them if this bill becomes law. New York State also mandates the coverage of off-label drugs, chiropractors, in vitro fertilization, and a host of other services. Each additional mandate inescapably raises the premium.

Orthotics, of course, is hardly the only mandate in the 1,992-page PelosiCare bill.

Even worse, New York, with “guaranteed issue,” requires that health-insurance companies sell policies to anyone who asks for one and to cover pre-existing conditions. This is the equivalent of requiring fire-insurance companies to sell policies to people whose house burned down the day before — and then pay to rebuild the house. Naturally, premiums on the shmoes who carry health insurance when they are healthy must go up to cover the shnorrers who only begin paying premiums when they have claims.

PelosiCare will require guaranteed issue.

And New York severely limits the ability of insurance companies to charge the young, who have a very low risk of serious health issues, lower premiums than those charged to the not-so-young, who have a much higher risk. Since the young are wildly overcharged in order to subsidize seniors in New York, many decide not to buy health insurance, knowing that if they are very unlucky and get seriously sick, they can always buy the insurance then and be covered.

PelosiCare will do the same. To be sure, the bill calls for those who do not buy insurance to pay a fine of $2,000. As New Yorker Andrew R. Heinze writes, that’s about what he is currently paying just for the coverage of hospital care today, thanks to New York’s economic-reality-be-damned health-insurance laws. He plans to drop his insurance if PelosiCare becomes law and depend on good luck (and guaranteed issuance).

Residents of New York City pay about five times as much for health insurance as those who live in, say, Columbus, Ohio, because of these mandates, guaranteed issue, and restricted premium differentials. PelosiCare will make sure that those who live in Columbus will see their health-insurance bills soar. Or it will cause a collapse of the private health-insurance market, making a government takeover of health care inevitable.

It’s hard not to think that the latter is exactly what they have in mind.

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McCain Health Care Conference Call

Doug Holtz-Eakin, senior policy advisor, and Carly Fiorina, RNC Victory 2008 Chair and former Hewlett-Packard CEO, held a conference call today as part of John McCain’s healthcare rollout.

There’s good in the McCain plan. Both advisors stressed that McCain’s plan puts “patients in charge,” and they both emphasized that under the McCain plan drug importation would be permitted. McCain has broken with many Republicans and drug industry interests in pushing to allow drug imports from places like Canada.

But there are real problems with the plan as well. Skeptical questioners on the call asked how McCain is going to compete with Democratic plans that guarantee health insurance universally. This is an intractable problem. McCain will need to convince people that the Democratic plan is either unrealistic (see the Massachusetts example), too expensive, or will impair the good things in the American health care system (e.g. doctor choice innovation). And we have yet to see McCain get fired up on a domestic issue to the extent he can sell something like this, which is not at first glance better than what the Democrats are offering.

There is also a fair amount of fudging going on. Where are all the cost savings going to come from? In large part, says the McCain team, from innovation. But, as they revealed in response to a question, these are things that private companies (e.g. insurers or employers) do. So where is government going to get money to cover or subsidize all those hard-to-insure people in the GAP plan? Not clear.

And isn’t GAP really another entitlement? The McCain campaign said in response to my follow-up question after the call that the GAP plan is “an effort to work with states to develop approaches to establishing a market to assure coverage for higher-risk folks who find it hard to get insurance.” That is thin gruel for those advocating universal coverage, and ominous for fiscal conservatives concerned this will be a drain on taxpayers. So the McCain team has its work cut out for it. But it is best to start practicing healthcare salesmanship now, on a day when the media is consumed with Obama-Wright coverage.

Doug Holtz-Eakin, senior policy advisor, and Carly Fiorina, RNC Victory 2008 Chair and former Hewlett-Packard CEO, held a conference call today as part of John McCain’s healthcare rollout.

There’s good in the McCain plan. Both advisors stressed that McCain’s plan puts “patients in charge,” and they both emphasized that under the McCain plan drug importation would be permitted. McCain has broken with many Republicans and drug industry interests in pushing to allow drug imports from places like Canada.

But there are real problems with the plan as well. Skeptical questioners on the call asked how McCain is going to compete with Democratic plans that guarantee health insurance universally. This is an intractable problem. McCain will need to convince people that the Democratic plan is either unrealistic (see the Massachusetts example), too expensive, or will impair the good things in the American health care system (e.g. doctor choice innovation). And we have yet to see McCain get fired up on a domestic issue to the extent he can sell something like this, which is not at first glance better than what the Democrats are offering.

There is also a fair amount of fudging going on. Where are all the cost savings going to come from? In large part, says the McCain team, from innovation. But, as they revealed in response to a question, these are things that private companies (e.g. insurers or employers) do. So where is government going to get money to cover or subsidize all those hard-to-insure people in the GAP plan? Not clear.

And isn’t GAP really another entitlement? The McCain campaign said in response to my follow-up question after the call that the GAP plan is “an effort to work with states to develop approaches to establishing a market to assure coverage for higher-risk folks who find it hard to get insurance.” That is thin gruel for those advocating universal coverage, and ominous for fiscal conservatives concerned this will be a drain on taxpayers. So the McCain team has its work cut out for it. But it is best to start practicing healthcare salesmanship now, on a day when the media is consumed with Obama-Wright coverage.

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McCain’s Pivot

Most candidates face a challenge going from a primary (where they have appealed to their base) to the general election (where they must offer more centrist message). John McCain is fortunate in that his primary message is his general election message. No significant policy readjustments appear needed to capture moderates and independents. Indeed, the pressure on McCain has been to go back and become more conservative to satisfy disgruntled elements on the Right–a plea he so far has ignored.

The challenge McCain does face is beefing up his domestic policy positions. Many voters suspect, I think, that McCain lacks interest in domestic matters. The flap with Mitt Romney over whether McCain admitted his lack of economic expertise only re-enforced this concern. On Tuesday, McCain began to address this problem with a detailed speech on the housing crisis. He generally got positive reviews from market-oriented commentators and avoided sacrificing conservative economic principles in the rush to soothe nervous voters/home owners.

This speech cannot be an isolated set piece. In his stump speech and town hall meetings McCain needs to talk fluently and frequently on the economy, free trade, and healthcare. (As to the latter, he actually has a very interesting proposal that addresses affordability and access to health insurance without a government mandate.)

His choice of a VP might also help. While McCain cannot appear to be subcontracting out his economic policy responsiblities, it would be wise to select someone with economic expertise, especially in the regulation of financial institutions or in budget and trade policy.

But make no mistake: McCain must convince voters he is knowledgable and engaged on domestic policy. Having substantially assisted in promoting and defending the surge, he may now be a victim of its success. Voters are turning their attention away from Iraq (which is receding from the front pages, except for the occasional acknowledgment of “grim milestones” like the 4000th casualty last week) and looking for answers on domestic issues.

Most candidates face a challenge going from a primary (where they have appealed to their base) to the general election (where they must offer more centrist message). John McCain is fortunate in that his primary message is his general election message. No significant policy readjustments appear needed to capture moderates and independents. Indeed, the pressure on McCain has been to go back and become more conservative to satisfy disgruntled elements on the Right–a plea he so far has ignored.

The challenge McCain does face is beefing up his domestic policy positions. Many voters suspect, I think, that McCain lacks interest in domestic matters. The flap with Mitt Romney over whether McCain admitted his lack of economic expertise only re-enforced this concern. On Tuesday, McCain began to address this problem with a detailed speech on the housing crisis. He generally got positive reviews from market-oriented commentators and avoided sacrificing conservative economic principles in the rush to soothe nervous voters/home owners.

This speech cannot be an isolated set piece. In his stump speech and town hall meetings McCain needs to talk fluently and frequently on the economy, free trade, and healthcare. (As to the latter, he actually has a very interesting proposal that addresses affordability and access to health insurance without a government mandate.)

His choice of a VP might also help. While McCain cannot appear to be subcontracting out his economic policy responsiblities, it would be wise to select someone with economic expertise, especially in the regulation of financial institutions or in budget and trade policy.

But make no mistake: McCain must convince voters he is knowledgable and engaged on domestic policy. Having substantially assisted in promoting and defending the surge, he may now be a victim of its success. Voters are turning their attention away from Iraq (which is receding from the front pages, except for the occasional acknowledgment of “grim milestones” like the 4000th casualty last week) and looking for answers on domestic issues.

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George McGovern, Free Marketeer?

Who would have thought that George McGovern would write an eminently sane column on the dangers of government paternalism? It has gems like this:

Buying health insurance on the Internet and across state lines, where less expensive plans may be available, is prohibited by many state insurance commissions. Despite being able to buy car or home insurance with a mouse click, some state governments require their approved plans for purchase or none at all. It’s as if states dictated that you had to buy a Mercedes or no car at all.

He even looks at the unintended consequences of bans on “payday lending,” long a bogey-man of liberals, and finds the cure is worse than the disease. He concludes:

Since leaving office I’ve written about public policy from a new perspective: outside looking in. I’ve come to realize that protecting freedom of choice in our everyday lives is essential to maintaining a healthy civil society. Why do we think we are helping adult consumers by taking away their options? We don’t take away cars because we don’t like some people speeding. We allow state lotteries despite knowing some people are betting their grocery money. Everyone is exposed to economic risks of some kind. But we don’t operate mindlessly in trying to smooth out every theoretical wrinkle in life. The nature of freedom of choice is that some people will misuse their responsibility and hurt themselves in the process. We should do our best to educate them, but without diminishing choice for everyone else.

No, honest: George McGovern wrote that. Perhaps he could talk to Hillary Clinton and Barack Obama about their notions for solving the home mortgage crisis. I am sure he would advise Clinton of the unintended consequences of freezing rates on sub-prime loans, or warn Obama about the costs to taxpayers and consumers at large of a bail-out fund for affected homeowners.

All this raises a question: has McGovern become wiser as the years have passed or has his party has become dimmer? Perhaps both . . .

Who would have thought that George McGovern would write an eminently sane column on the dangers of government paternalism? It has gems like this:

Buying health insurance on the Internet and across state lines, where less expensive plans may be available, is prohibited by many state insurance commissions. Despite being able to buy car or home insurance with a mouse click, some state governments require their approved plans for purchase or none at all. It’s as if states dictated that you had to buy a Mercedes or no car at all.

He even looks at the unintended consequences of bans on “payday lending,” long a bogey-man of liberals, and finds the cure is worse than the disease. He concludes:

Since leaving office I’ve written about public policy from a new perspective: outside looking in. I’ve come to realize that protecting freedom of choice in our everyday lives is essential to maintaining a healthy civil society. Why do we think we are helping adult consumers by taking away their options? We don’t take away cars because we don’t like some people speeding. We allow state lotteries despite knowing some people are betting their grocery money. Everyone is exposed to economic risks of some kind. But we don’t operate mindlessly in trying to smooth out every theoretical wrinkle in life. The nature of freedom of choice is that some people will misuse their responsibility and hurt themselves in the process. We should do our best to educate them, but without diminishing choice for everyone else.

No, honest: George McGovern wrote that. Perhaps he could talk to Hillary Clinton and Barack Obama about their notions for solving the home mortgage crisis. I am sure he would advise Clinton of the unintended consequences of freezing rates on sub-prime loans, or warn Obama about the costs to taxpayers and consumers at large of a bail-out fund for affected homeowners.

All this raises a question: has McGovern become wiser as the years have passed or has his party has become dimmer? Perhaps both . . .

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Obama On Health Care

Although Hillary Clinton’s mandated universal health care plan may be a winner in the primary, Barack Obama’s responses last night on health care showed why he will be a more formidable general election candidate. He made two points that will resonate with independents and even aggrieved Republicans who remember the Clinton secret health care task force shepherded by Ira Magaziner. First, Obama explained:

It was also that Senator Clinton and the administration went behind closed doors, excluded the participation even of Democratic members of Congress who had slightly different ideas than the ones that Senator Clinton had put forward. And, as a consequence, it was much more difficult to get Congress to cooperate. And I’ve said that I’m going to do things differently. I think we have to open up the process. Everybody has to have a seat at the table. And most importantly, the American people have to be involved and educated about how this change is going to be brought about.

Now that does sound like a different approach than Hillary Clinton’s I-know-best-and-you-can-take-it-or-leave-it approach. (David Brooks brings it all back to life here.) Obama also showed himself to be a less authoritarian liberal than Clinton. He explained the downsides of a plan with individual mandates:

Number one, understand that when Senator Clinton says a mandate, it’s not a mandate on government to provide health insurance, it’s a mandate on individuals to purchase it. And Senator Clinton is right; we have to find out what works. Now, Massachusetts has a mandate right now. They have exempted 20 percent of the uninsured because they have concluded that that 20 percent can’t afford it. In some cases, there are people who are paying fines and still can’t afford it, so now they’re worse off than they were. They don’t have health insurance and they’re paying a fine. In order for you to force people to get health insurance, you’ve got to have a very harsh penalty, and Senator Clinton has said that we won’t go after their wages. Now, this is a substantive difference.

So, at least on this issue, Obama does seem to have both a stylistic and substantive approach less off-putting, less authoritarian, and frankly less scary for voters than what many Democrats have presented. That amounts to a considerable challenge for John McCain.

Although Hillary Clinton’s mandated universal health care plan may be a winner in the primary, Barack Obama’s responses last night on health care showed why he will be a more formidable general election candidate. He made two points that will resonate with independents and even aggrieved Republicans who remember the Clinton secret health care task force shepherded by Ira Magaziner. First, Obama explained:

It was also that Senator Clinton and the administration went behind closed doors, excluded the participation even of Democratic members of Congress who had slightly different ideas than the ones that Senator Clinton had put forward. And, as a consequence, it was much more difficult to get Congress to cooperate. And I’ve said that I’m going to do things differently. I think we have to open up the process. Everybody has to have a seat at the table. And most importantly, the American people have to be involved and educated about how this change is going to be brought about.

Now that does sound like a different approach than Hillary Clinton’s I-know-best-and-you-can-take-it-or-leave-it approach. (David Brooks brings it all back to life here.) Obama also showed himself to be a less authoritarian liberal than Clinton. He explained the downsides of a plan with individual mandates:

Number one, understand that when Senator Clinton says a mandate, it’s not a mandate on government to provide health insurance, it’s a mandate on individuals to purchase it. And Senator Clinton is right; we have to find out what works. Now, Massachusetts has a mandate right now. They have exempted 20 percent of the uninsured because they have concluded that that 20 percent can’t afford it. In some cases, there are people who are paying fines and still can’t afford it, so now they’re worse off than they were. They don’t have health insurance and they’re paying a fine. In order for you to force people to get health insurance, you’ve got to have a very harsh penalty, and Senator Clinton has said that we won’t go after their wages. Now, this is a substantive difference.

So, at least on this issue, Obama does seem to have both a stylistic and substantive approach less off-putting, less authoritarian, and frankly less scary for voters than what many Democrats have presented. That amounts to a considerable challenge for John McCain.

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Palestinians in East Jerusalem Say: Please Don’t ‘Liberate’ Us

An extraordinary admission from Palestinians living in East Jerusalem in advance of the Annapolis summit, as recounted by Ilene R. Prusher in the Christian Science Monitor:

Those feeling skittish about the city’s potential partition aren’t just Israelis – who traditionally take the position that Jerusalem should be Israel’s united capital – but also Palestinian Jerusalemites, who fear that their standard of living will fall if they come under the control of the Palestinian Authority (PA).

“I don’t want to have any part in the PA. I want the health insurance, the schools, all the things we get by living here,” says Ranya Mohammed as she does her afternoon shopping in Shuafat.

“I’ll go and live in Israel before I’ll stay here and live under the PA, even if it means taking an Israeli passport,” says Mrs. Mohammed, whose husband earns a good living from doing business here. “I have seen their suffering in the PA. We have a lot of privileges I’m not ready to give up.”

Nabil Gheet, a neighborhood leader who runs a gift and kitchenware outfit in the adjacent town of Ras Khamis, also resists coming under the PA’s control.

“We have no faith in the Palestinian Authority. It has no credibility,” he says, as his afternoon customers trickle in and out. “I do not want to be ruled by Abbas’s gang,” he says, referring to Palestinian President Mahmoud Abbas.

An extraordinary admission from Palestinians living in East Jerusalem in advance of the Annapolis summit, as recounted by Ilene R. Prusher in the Christian Science Monitor:

Those feeling skittish about the city’s potential partition aren’t just Israelis – who traditionally take the position that Jerusalem should be Israel’s united capital – but also Palestinian Jerusalemites, who fear that their standard of living will fall if they come under the control of the Palestinian Authority (PA).

“I don’t want to have any part in the PA. I want the health insurance, the schools, all the things we get by living here,” says Ranya Mohammed as she does her afternoon shopping in Shuafat.

“I’ll go and live in Israel before I’ll stay here and live under the PA, even if it means taking an Israeli passport,” says Mrs. Mohammed, whose husband earns a good living from doing business here. “I have seen their suffering in the PA. We have a lot of privileges I’m not ready to give up.”

Nabil Gheet, a neighborhood leader who runs a gift and kitchenware outfit in the adjacent town of Ras Khamis, also resists coming under the PA’s control.

“We have no faith in the Palestinian Authority. It has no credibility,” he says, as his afternoon customers trickle in and out. “I do not want to be ruled by Abbas’s gang,” he says, referring to Palestinian President Mahmoud Abbas.

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HillaryCare 2.0

The most interesting thing about Hillary Clinton’s rollout of her health care plan yesterday was not the substance of the plan—which is not much different from what John Edwards and Barack Obama have offered—but the cautious and defensive tone she and her campaign have taken toward it. Clinton constantly repeated, during the rollout, that this idea was different from the “HillaryCare” proposal of 1993. “This is not government-run,” she told a cheering audience, “there will be no new bureaucracy.”

The chief reason for Hillary’s circumspection, of course, is her leading role in the Democrats’ last health care debacle. In one respect it actually seems like she is probably over-reading the importance of that line on her resume—how many voters really remember the ‘93 debacle or think of it as a great shadow over Hillary Clinton? This seems like a Washington cliché that has taken on a life of its own.

In another respect, her caution is absurd and misleading. The notion that an entirely new scheme of nationalized health insurance regulation will involve “no new bureaucracy” is risible. The idea that the new public insurance options to be part of the menu on Hillary’s plan won’t expand government-run coverage is ludicrous.

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The most interesting thing about Hillary Clinton’s rollout of her health care plan yesterday was not the substance of the plan—which is not much different from what John Edwards and Barack Obama have offered—but the cautious and defensive tone she and her campaign have taken toward it. Clinton constantly repeated, during the rollout, that this idea was different from the “HillaryCare” proposal of 1993. “This is not government-run,” she told a cheering audience, “there will be no new bureaucracy.”

The chief reason for Hillary’s circumspection, of course, is her leading role in the Democrats’ last health care debacle. In one respect it actually seems like she is probably over-reading the importance of that line on her resume—how many voters really remember the ‘93 debacle or think of it as a great shadow over Hillary Clinton? This seems like a Washington cliché that has taken on a life of its own.

In another respect, her caution is absurd and misleading. The notion that an entirely new scheme of nationalized health insurance regulation will involve “no new bureaucracy” is risible. The idea that the new public insurance options to be part of the menu on Hillary’s plan won’t expand government-run coverage is ludicrous.

And more importantly, Clinton’s approach (and that of the Democrats generally) will create increasingly government-run care in more profound ways over time. Their response to the growth of health insurance premiums is to introduce new regulations and a new payer into the system. But introducing a new payer into the system does not reduce costs (on the contrary, as Medicare shows us, it tends to increase them), and Clinton has not offered any other serious way to reduce costs. She has offered, in the end, only a way to shift some costs to the government—and yet she still claims that would not shift control to the government.

He who pays the piper calls the tune. The emerging Republican approach to health care would have patients (rather than employers) pay—and would offer some aid to those who can’t. Hillary’s approach would have the government pay, and whether she wants to acknowledge it or not, would therefore have bureaucrats call the tune.

She is right to worry that government-managed health insurance will scare voters. But she is wrong to insist that her plan doesn’t qualify for the title.

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Counting the Uninsured

The annual Census Bureau report on income, poverty, and health insurance coverage was released yesterday, and set off the usual flurry of confusion and bad ideas on the last of those three subjects. The number of Americans without health insurance increased last year to roughly 47 million Americans, or 15.8 percent of the population. The raw number is less important than the percentage: in a growing population the raw number of both those without insurance and those with insurance is likely to grow (and indeed, the number of insured Americans increased by about 800,000 last year, while the number of uninsured increased by about 2 million.) But at 15.8 percent, the proportion of the uninsured matches its highest level ever (last reached in 1998).

In looking at this figure, though, a great deal of caution is warranted. As Eric Cohen and I pointed out in the February issue of COMMENTARY (and as the Census report itself notes) the number masks much nuance.

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The annual Census Bureau report on income, poverty, and health insurance coverage was released yesterday, and set off the usual flurry of confusion and bad ideas on the last of those three subjects. The number of Americans without health insurance increased last year to roughly 47 million Americans, or 15.8 percent of the population. The raw number is less important than the percentage: in a growing population the raw number of both those without insurance and those with insurance is likely to grow (and indeed, the number of insured Americans increased by about 800,000 last year, while the number of uninsured increased by about 2 million.) But at 15.8 percent, the proportion of the uninsured matches its highest level ever (last reached in 1998).

In looking at this figure, though, a great deal of caution is warranted. As Eric Cohen and I pointed out in the February issue of COMMENTARY (and as the Census report itself notes) the number masks much nuance.

For instance, a family that loses its health coverage will, on average, become insured again in about five months. 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 so could not 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.

This is not to say that there aren’t a great many Americans going without health insurance, or that their plight doesn’t merit attention and action. It does, however, mean that unqualified use of the 47-million figure as a political rallying cry is not responsible.

Health insurance is, indeed, too expensive, for too many families. But the private health insurance system does work well for the great bulk of those who can afford it (a 2006 Kaiser Foundation poll found that 88 percent of those with health insurance rated their coverage good or excellent, and almost 60 percent were even satisfied with its cost). A sensible solution to the problems of the uninsured would help them afford access to private coverage, rather than replace the entire American health insurance system with a government funded single-payer approach. This approach—if we are to judge it by the experience of many nations that have tried it—is likely to reduce doctor and patient freedom, increase wait times, hurt quality, and (as we can already see from Medicaid and Medicare) threaten to bankrupt government budgets.

The Census figures show only that the uninsured are in need of help getting access to our (mostly) free-market health care system, not that America needs a huge new health insurance bureaucracy.

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A Crafty Health Care Move

Earlier this summer, when Senate Democrats (with significant support from some Republicans) offered a bill that would expand federal subsidies for children’s health insurance , conservatives accused them of trying to bring government-funded health care in through the back door. Now, as if to prove the point, House Democrats this week are preparing to introduce a much more ambitious plan to fortify and expand the government’s role in health care.

The New York Times reported that the plan, slated to be made public in the coming days, would not only vastly expand the scope of the State Children’s Health Insurance Program (SCHIP), it would also reduce the incentive for private health plans to participate in the Medicare program, and eliminate the requirement in current law to limit Medicare’s reliance on general revenue for its funding.

Two points about why this bill is a smart play by the Democrats. First of all, it’s intended to make the Senate plan (which would increase SCHIP funding by more than $35 billion) appear to be the most moderate of three alternatives, mediating between the White House’s proposal of a $5 billion increase and the House’s $50 billion.

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Earlier this summer, when Senate Democrats (with significant support from some Republicans) offered a bill that would expand federal subsidies for children’s health insurance , conservatives accused them of trying to bring government-funded health care in through the back door. Now, as if to prove the point, House Democrats this week are preparing to introduce a much more ambitious plan to fortify and expand the government’s role in health care.

The New York Times reported that the plan, slated to be made public in the coming days, would not only vastly expand the scope of the State Children’s Health Insurance Program (SCHIP), it would also reduce the incentive for private health plans to participate in the Medicare program, and eliminate the requirement in current law to limit Medicare’s reliance on general revenue for its funding.

Two points about why this bill is a smart play by the Democrats. First of all, it’s intended to make the Senate plan (which would increase SCHIP funding by more than $35 billion) appear to be the most moderate of three alternatives, mediating between the White House’s proposal of a $5 billion increase and the House’s $50 billion.

Secondly, and more importantly in the long term, by tying together politically appealing cases for coverage—for the very old and very young—the Democrats are making a concerted effort to move toward government-funded health insurance. Historically, Medicare has been seen as a crucial foot in the door for advocates of government health insurance, and the SCHIP program, created in 1997, was very consciously conceived of as a step in this direction as well. By explicitly tying the two together in one bill, House Democrats can both gather a powerful coalition behind them (the AARP will mount a national campaign for the bill, for instance), and begin to press in on America’s private health care market from both sides.

Advocates of nationalized health care may, oddly enough, have learned a lesson from the pro-life movement: the way to achieve revolutionary goals in American politics is by taking one small step after another, each carefully designed to be emotionally appealing and hard to oppose.

Although President Bush has promised to veto both the House and Senate versions of the bill, the Democrats’ new strategy makes it more likely that the Senate bill might, in time, gain the votes to override such a veto. Fiscally, socially, politically, and practically, this would be a bad idea. But you have to admire the Democrats’ craftiness.

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Hillary’s Changing Plumage

Much has already been said about Hillary Clinton’s shifting positions on Iraq. Having once criticized President Bush for not sending enough troops, she now has announced her intent to vote to block war funding. But Hillary’s zigzagging is nothing new. It has been the stamp of her last fifteen years.

She began her political life in the radical student movement of the 1960’s, summarized by her commencement speech at Wellesley College in 1969, in which she declared that the “prevailing, acquisitive, and competitive corporate life . . . is not the way of life for us. We’re searching for a more immediate, ecstatic, and penetrating mode of living.” (Husband Bill seems to have taken this quest to heart.)

Her New Leftism was not soon outgrown. In 1987, her profile raised by Bill’s status as governor of Arkansas, she assumed the chairmanship of the New World Foundation, a funder of radical Left, pro-Communist, and PLO-linked causes. The foundation had a history of such activities before Hillary took it over, but as I showed in a 1993 article for COMMENTARY, the number of extremist and Communist front groups funded by the foundation multiplied under her leadership.

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Much has already been said about Hillary Clinton’s shifting positions on Iraq. Having once criticized President Bush for not sending enough troops, she now has announced her intent to vote to block war funding. But Hillary’s zigzagging is nothing new. It has been the stamp of her last fifteen years.

She began her political life in the radical student movement of the 1960’s, summarized by her commencement speech at Wellesley College in 1969, in which she declared that the “prevailing, acquisitive, and competitive corporate life . . . is not the way of life for us. We’re searching for a more immediate, ecstatic, and penetrating mode of living.” (Husband Bill seems to have taken this quest to heart.)

Her New Leftism was not soon outgrown. In 1987, her profile raised by Bill’s status as governor of Arkansas, she assumed the chairmanship of the New World Foundation, a funder of radical Left, pro-Communist, and PLO-linked causes. The foundation had a history of such activities before Hillary took it over, but as I showed in a 1993 article for COMMENTARY, the number of extremist and Communist front groups funded by the foundation multiplied under her leadership.

In 1992, Bill ran for President as a “new Democrat,” code for not-a-liberal, and his emissaries successfully wooed my support. In discussions with leaders of the centrist Democratic Leadership Council, I was assured that Hillary, far from tugging Bill leftward, was using her weight to keep the campaign in the middle of the road.

Not long after she and Bill moved into the White House, Hillary turned back to the Left, leading the effort to install some form of national health insurance and inviting Michael Lerner, the unreconstructed 1960’s radical then parading as a “rabbi,” to the White House to give her guidance. Hillary embraced Lerner’s Oz-like “politics of meaning,” even using the phrase in her speeches.

When she set up shop in New York and ran for the Senate, Hillary swung back toward the center, becoming an especially vocal supporter of Israel and, later, a hawk on Iraq. Now she has shed her hawk’s plumage for the white of a dove. All of which leaves us to ponder this question as she runs for President: would it be worse to be governed by Hillary the opportunist or Hillary the true believer?

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French Health Care for All?

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

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

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

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

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

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

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

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

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

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

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

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Bush’s Health-care Vision

This year’s batch of controlled leaks building up to the State of the Union address has included a lot of talk about health-care proposals. It looks as if the President will offer two new health-care ideas in the speech: one involving a reform of the tax code and the other supporting state efforts to help the uninsured get private health insurance.

The President seems set to propose replacing the long-standing system of tax exemption on employer-purchased health insurance. This system makes it more expensive for Americans not covered through their job to get health insurance on their own and creates an incentive for employer-based plans to grow ever more costly (as Eric Cohen and I point out in the February issue of COMMENTARY). The President wants to put in its place a standard deduction for health insurance of $15,000 for families and $7,500 for individuals.

Anyone who has private health insurance, regardless of how it was purchased, would qualify under this plan. About 80 percent of workers who are now covered at work have plans that cost less than $15,000 and so would see their taxes go down or stay the same under this proposal, but the other 20 percent of those with employer-based coverage would end up paying more taxes. The money brought in by this measure would help cover the cost of allowing families who buy their coverage themselves to get in on the tax deduction. This would lower their health costs, and would be a major incentive for the uninsured who can afford it to purchase their own coverage.

The trouble is that those 20 percent are not just fat-cat CEO’s with extravagant health plans, but also some unionized workers, whose unions have negotiated particularly good coverage. The new Democratic majority in Congress is very unlikely to stand for a tax increase on its union constituency. And many Democrats also fear such proposals would reduce the pressure for a government-run system, their preferred health-care solution.

In the face of such opposition, the second proposal under discussion may be both more significant and more realistic. The President apparently intends to propose means of helping states turn the Medicaid funds they now use to pay hospitals for caring for the uninsured into direct assistance to uninsured individuals to buy their own private health insurance. Eric and I lay out the benefits of such an approach in our article, but we also point out that neither the Left nor the Right wants to discuss the real looming fiscal crisis in health care: the costs of care for older Americans. If what we see in the papers is right, that won’t change this year.

This year’s batch of controlled leaks building up to the State of the Union address has included a lot of talk about health-care proposals. It looks as if the President will offer two new health-care ideas in the speech: one involving a reform of the tax code and the other supporting state efforts to help the uninsured get private health insurance.

The President seems set to propose replacing the long-standing system of tax exemption on employer-purchased health insurance. This system makes it more expensive for Americans not covered through their job to get health insurance on their own and creates an incentive for employer-based plans to grow ever more costly (as Eric Cohen and I point out in the February issue of COMMENTARY). The President wants to put in its place a standard deduction for health insurance of $15,000 for families and $7,500 for individuals.

Anyone who has private health insurance, regardless of how it was purchased, would qualify under this plan. About 80 percent of workers who are now covered at work have plans that cost less than $15,000 and so would see their taxes go down or stay the same under this proposal, but the other 20 percent of those with employer-based coverage would end up paying more taxes. The money brought in by this measure would help cover the cost of allowing families who buy their coverage themselves to get in on the tax deduction. This would lower their health costs, and would be a major incentive for the uninsured who can afford it to purchase their own coverage.

The trouble is that those 20 percent are not just fat-cat CEO’s with extravagant health plans, but also some unionized workers, whose unions have negotiated particularly good coverage. The new Democratic majority in Congress is very unlikely to stand for a tax increase on its union constituency. And many Democrats also fear such proposals would reduce the pressure for a government-run system, their preferred health-care solution.

In the face of such opposition, the second proposal under discussion may be both more significant and more realistic. The President apparently intends to propose means of helping states turn the Medicaid funds they now use to pay hospitals for caring for the uninsured into direct assistance to uninsured individuals to buy their own private health insurance. Eric and I lay out the benefits of such an approach in our article, but we also point out that neither the Left nor the Right wants to discuss the real looming fiscal crisis in health care: the costs of care for older Americans. If what we see in the papers is right, that won’t change this year.

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