Empty Words and Conundrums on Health Care

Regular readers of this blog may start to wonder – especially after this post – whether I’m in some way obsessed with conservative moderate David Frum. As much as I’d like to be able to tell you that no, I’m not…I worry it may be true. It may seem a bit strange to you, since Frum is far from the worst ranter on the right side of the American political aisle currently. In fact, if anything, it’s just the opposite: David Frum is one of the few high-profile conservative pundits who has bucked the tide of what, for lack of a better term, I’ll call Limbaugh-ism that’s been sweeping the GOP and the ranks of conservatism for at least fifteen years. I’m referring to the seemingly endless, ever-rightward march of the political ideas of the right, coupled with the equally endless-seeming increase in the nastiness of the rhetoric they employ towards anyone they perceive as an adversary (“enemy” is probably the word most of the Limbaugh-led would use) and the inflexibility of their positions. Such increasing conservatism, inflexibility and vitriol is hardly limited to just the AM talk radio hosts, either. Would that it were. But when the Senate minority leader says candidly that his party’s main goal for the next congress that’s about to start is nothing more than to defeat the President in the upcoming election two years hence, that virus – wherever it started – has become both epidemic and systemic. Against that backdrop, David Frum tends – probably partially by his own design – to stand out like a sore thumb, precisely because he doesn’t resemble that all-too-recognizable mold of the modern Republican/conservative. He’s usually polite, thoughtful, and willing to express ideas that break with the conservative cant-du-jour.

Except when he isn’t.

Frum’s got a new column up over at The Week, in which he argues that the GOP is in a pickle on health care reform, and not just because of their recent, ridiculously gimmicky non-repeal of what they derisively term “Obamacare.” As usual, Frum is an incisive enough thinker to correctly discern the basic outline of one of the problems the GOP finds itself facing. Namely, that America is a “harsh enough society” (his words) to allow large numbers of people to go without insurance, but not a harsh enough society to let large numbers go without actual care. It’s what Frum suggests should be done about it that compelled me to respond to him, yet again, at the risk of appearing obsessed.

Frum observes that the result of the GOP’s strategy to date of either tacitly opposing universal health insurance coverage or trying to avoid the question altogether while still ultimately backing the notion that everyone will eventually get care somehow, has resulted in both a growing number of uninsured in America and a much more inefficient health care delivery system for those uninsured, a system which is also far costlier for the rest of us. Why? Because in such a system, the uninsured wind up getting care far later and at tremendously higher cost – often at emergency rooms – than would have been possible if they’d received proper (and far cheaper) preventative care through an insurance policy.

Frum correctly points out the contradiction in opposing (or at least not supporting) universal care while arguing that everyone in America can get care if they need it. But his big idea for the GOP to solve this problem amounts to: be more honest with people. Frum envisions himself prepping a hypothetical GOP front-runner for upcoming Presidential debates in 2012 by imagining the candidate he’s advising being asked the following question: “Governor/Senator: Do you believe that the federal government should ensure that all Americans can buy an affordable health-insurance policy?”

Now, it’s true that for a party like the GOP who profess to be about efficiency, fiscal discipline and frugality, it makes no sense to deliver care in such an unwieldy and costly manner. Frum knows it, and he knows any Democratic opponent can use it as a very effective point against the GOP contradiction on this issue. So Frum solves this thorny dilemma by telling his imaginary candidate (and, by extension, the GOP in general) to simply stop opposing universal coverage. The sub-title of Frum’s article is: “Coverage for all: We do it, why not say it?” I couldn’t agree more.

So why hasn’t some savvy GOP candidate already realized Frum’s wisdom and taken his advice? They had ample opportunity to do so during 2008, yet strangely, none did. In his article, Frum admits that once a GOP candidate crosses that Rubicon of supporting universal coverage, any plan they come up with will inevitably be something that looks a lot like “Romneycare” – the Massachusetts health care plan signed into law by Mitt Romney when he was the pro-choice governor of a liberal state, instead of the deeply anti-choice candidate who’s trying to get elected President today. It ought to give us – and it should have given Frum – pause, to notice that the Romney of today doesn’t like to talk about how similar his plan for Massachusetts is to the Affordable Care Act which Congress passed last January. As I’ll explain, Romney’s reasons for the switch get to the heart of the matter. For now, though, back to Frum’s article. In order to come out in favor of universal health insurance coverage, any candidate would have to put forth a plan which includes some combination of these three components in order to make it work:

…regulation to define what insurers must cover, a mandate on individuals to buy insurance, subsidies for those who cannot afford insurance.

Again, Frum is right: if we know we’re going to provide everyone care eventually anyway, even if it’s at great expense in an emergency room, then it makes sense to pursue universal coverage, thereby eliminating the enormous costs that come from caring for 45 million uninsured people in emergency rooms. He’s also right that any health care proposal which strives for universal coverage (or mandates it) would have to make coverage affordable for people, in order for them to be able to purchase it. That would be accomplished either by giving subsidies to people to help them to purchase coverage affordably, or by mandating that the insurance companies charge no more than certain amounts for coverage, or some combination of both these ideas. In any event, such a plan would also include additional cost-saving regulations on the insurers to eliminate the practice of cherry-picking only the healthy in order to maximize profits, eliminate recission, etc. Also, such a plan would define minimum acceptable coverage insurers would be required to offer. Finally, any such proposal to reform the health care system that put such new restrictions and mandates on insurers would also have to mandate that individuals be required to purchase coverage. Without that “individual mandate,” healthy people – usually the young – would avoid purchasing comprehensive coverage, and insurers would be burdened with only covering those most in need of care: the elderly and already-ill.

Would a program thusly designed actually work? Would it save enough money to be feasible? Obviously, the answer would depend upon the specifics of the plan in question, but in general, the answer is: of course it would. If Frum didn’t agree that it could, he wouldn’t be proposing this idea. In fact, as you’ve probably already figured out, what I just described – and Frum described

in less detail – is exactly what President Obama and the 111th Congress passed, which the GOP is now derisively calling “Obamacare.” Obama’s solution wasn’t the only possible one, of course, but it unquestionably fits within the definition Frum gives. Frum optimistically and cheerfully advises the GOP:

…why not build our policy on what we are actually going to do? Answer the question “yes:” Everybody should have insurance. Don’t be the party that wants to take coverage away. Be the party that makes coverage work better.

Making coverage work better? Sounds great! Yet, if I were the hypothetical GOP candidate Frum was advising (a very weird thought, LOL), I’d reject his fairly ambiguous advice that I should just sort of “man up” and announce publicly that I support universal coverage. Why? For probably the same reason that the last time the GOP had control of both houses of Congress and the White House, from 2002-2006, they didn’t even mention health care reform, let alone attempt to do anything substantive about it. Frum, in one of the understatements of the year, gives the reason: “answering such a question in the affirmative “…carries other risks for a Republican.” (my emphasis)

Gee, Sparky – ya think?

In reality advocating such a thing isn’t just “risky” for a Republican Presidential hopeful, it’s outright political suicide. Essentially, every single one of the combination of ways one could structure a health insurance reform plan that provided universal coverage and also included the components Frum mentions, would inevitably wind up enraging – permanently – one or another of the power-blocs that candidate (or any GOP candidate) will require to get elected. It’s just that simple.

Need examples? Well, to start with, as Anthony Weiner says whenever I see him on TV discussing health care, the GOP are a wholly-owned subsidiary of the health insurance industry. The health insurance lobby likes the idea of an individual mandate – forcing everyone to purchase health insurance or face a penalty – because it would give insurers access to a captive marketplace that would be required by law to purchase their products. But insurers’ desire for such a captive marketplace would be negated if it was accompanied by what would be contained in the rest of Frum’s (and Romney’s, and Obama’s) equation, such as the restrictions on the rates insurers can charge and/or on certain practices (like recission and cherry-picking). Insurers aren’t unhappy with things just the way they are; any changes of the type Frum is discussing would only earn them less money than they already make. And they’d be virtually certain to oppose any candidate, GOP or otherwise, who proposed they make smaller profits.

Even if a GOP candidate’s health care policy plan could somehow be drafted to avoid the wrath of the insurance lobby – one of Washington’s most powerful – it would still fall afoul of other traditional GOP backing interests. Namely, the GOP’s base voters themselves. GOP voters, especially with recent trends towards tea-tinged “government should get its hands off”-type sentiments, will be immediately furious with the idea of an individual mandate. Indeed, they already are: look no further than the explosion of rage from all quarters of conservatism against the individual mandate provision in the Affordable Care Act. And if a GOP candidate told the base of his party that not only will they be forced to buy insurance, but that in addition, the plan was to give taxpayer-funded subsidies to lower-income people to make coverage affordable for them to purchase? Well, let’s just hope any candidate making such an announcement had the good sense not to do so at a town hall meeting, standing face-to-face with these base voters – otherwise, (s)he might be in physical danger.

I’ve said before that David Frum isn’t a dumb guy. I’ll repeat that now. So why would an acknowledged smart guy like Frum urge GOP Presidential candidates to propose health care plans which, while they might sound sensible to you and I, would almost certainly end the White House aspirations of any candidate proposing it – at least for that election cycle, and maybe forever?

The answer to that question is a little trickier, and requires some guesswork on my part. But it begins with the fundamental contradiction that started Frum’s post in the first place: that Americans “are willing to allow people to go without insurance. We are not willing to allow them to go without care.” This isn’t a problem for Democrats in the way that it is for Republicans because Democrats (in general) have a consistent position on this. Most liberals and Democrats would solve the problem by first acknowledging it as a problem and suggesting that we should indeed cover everyone as a remedy – along with adopting all those other regulations and subsidies which would make such a plan work. That’s why all us liberals mostly supported and voted for “Obamacare.” Many of us would have gone even farther to solve the problem, by proposing that we adopt the public option or even some form of single-payer or a French-style system. There are arguments to be made against our position, obviously, but the position itself doesn’t suffer from the internal contradictions that the GOP position to date has. That’s because Democrats have traditionally viewed – and are increasingly coming even more to view – health care as a basic human right. David Frum recognizes that in reality, such a position is not merely a liberal or Democratic one. In fact, most Americans feel this way…that’s why we continue to provide care for the uninsured even through the horribly costly mechanism of allowing them to go uninsured and wait until their conditions are severe before seeking treatment at emergency rooms.

Although Frum is aware of the policy liability it presents for Republicans to remain silent or tacitly oppose universal coverage, the reason GOP candidates don’t support it – and in fact, the reason Frum himself doesn’t offer any ways for GOP candidates to overcome the problems they’d create for themselves by supporting it (as he suggests they should) – is because the majority of Republican power blocs don’t support universal coverage, and don’t view either health insurance or health care itself as a basic human right. Frum knows this, he’s just not sure what to do about it. Insurers don’t want their profits cut or to be told what business practices they can’t engage in, and GOP voters don’t want their taxes raised, nor to be told by the government that they must purchase a product.

Once we understand that, it becomes clear that there IS a solution Frum could have advocated which would erase the inconsistency in the current Republican position on universal coverage without alienating any of the traditional GOP power-blocs. I can’t tell whether Frum overlooks this solution, or is simply too embarrassed to point out. Of course, the solution to which I’m referring would be for Frum to urge his hypothetical candidate to embrace the positions of the GOP power-blocs by simply declaring that health care is NOT a fundamental human right, but instead a privilege and a commodity to be bought – if you can afford it – and that universal health insurance coverage is therefore a goal which is desirable only if it can be achieved without costing either insurers or taxpayers any money or freedom. Any GOP candidate who boldly announced such a platform regarding health care would reassure insurance companies that the GOP was on their side. It would reassure skittish and angry libertarian-leaning base voters that the candidate proposing it would never try to force them to buy a product they didn’t feel like they needed or wanted to buy. And it would reassure all GOP voters, rich people included, that their taxes wouldn’t go up one dime to pay for subsidies for anyone who couldn’t afford insurance on their own. Because in the minds of these conservative GOP-supporting power-blocs, it’s a problem, not a point of pride, it’s a bug, not a feature, that we as Americans don’t just tell the uninsured: “too bad, suffer.” Any GOP candidate willing to boldly declare outright that they support such a view would ensure his or her good standing with the power-blocs I described.

So why doesn’t David Frum’s imagined scenario of advising a potential 2012 GOP Presidential candidate include this advice: “tell them you support people being entitled to exactly – and ONLY – as much care as they can pay for out of pocket?” Because the American public already agrees that isn’t who we are as a country. How much easier it would be for capitalists and for detached, cerebral libertarian ideologues if we were such a country! But we’re not, and Frum knows it. So he’s left trying to figure out ways for his hypothetical client/candidate to rectify or gloss over this glaring GOP inconsistency of providing care to everyone while still somehow supporting economic policies toward health care which result in over 45 million uninsured. That’s why Frum’s there’s such a jarring disconnect in proposals, between his analysis of the problem, which always seems razor-sharp, and his prescription for how to proceed, which is embarrassingly muddled and toothless. Frum doesn’t offer his candidate the advice of urging him or her to say (essentially) “screw the uninsured,” because he knows that any GOP candidate espousing such rhetoric would have to face hostile general-election voters, having told them that people should have to pay for their own care, which would result in a near-certain loss. And Frum knows any GOP candidate will face the dilemma of either choosing that strategy (and likely losing), or supporting a plan that includes universal coverage, which would alienate enough powerful GOP backers to also all-but-ensure the candidate will never even get to face general election voters because he or she would have been eliminated long before, in the primaries or even earlier, by powerful interests who would rather condemn the uninsured and underinsured to suffer than have their taxes raised or be told what to do by the government.

I agree, it’s a pretty pickle for any GOP candidate. Perhaps it’s an even bigger pickle for a pundit like Frum who seems to want to save the GOP, and even conservatism, from itself; to drag it kicking and screaming into at least the 20th century, if not the 21st. David Frum knows the vast majority of Americans’ view their country as a compassionate and well-off place where people are not left to starve in the streets, old people are not put “out to pasture” but can live out their golden years in dignity and peace, and the sick are cared for – even if they cannot pay the full retail cost of such care. Sometimes, when I read posts of Frum’s like the one that inspired this post, I think Frum himself agrees with such notions. But then I begin to doubt myself on that point, because if Frum agreed with the idea that these things are moral imperatives, that health care is a basic human right – at least more so than fealty to the almighty free market is, or keeping taxes low is – it would be intolerable to him that there are 45 million uninsured in his country, the richest in the world. In short, if Frum believed that, he’d be a Democrat, not a Republican. He’d be a liberal (or at least a centrist), not a conservative. So the fact that Frum’s observations center around his realization that it’s incongruous or hypocritical for Republicans to tacitly support everyone having access to care even if it’s through costly emergency rooms, while not supporting universal health insurance coverage which would lower costs. And his advice centers entirely around trying mightily to find ways for GOP candidates to get around or explain away that vulnerability and inconsistency while keeping the base voters and the corporations satisfied by not upsetting the applecart too much. That’s why Frum speaks fondly yet vaguely of wanting to be “the party that makes coverage better” without offering any thoughts on how that might be accomplished: because he knows there aren’t really any good ways to square that circle. Frum attempts weakly to conjure up some vision of a combination of innovative new “market-based” approaches to the problem by paying lip-service to the notion of tinkering with the balance between subsidies, regulation and the mandate, but it’s all sad kabuki. It leaves the reader empty because Frum’s rhetoric itself is empty: there aren’t any solutions in it. Not even any workable suggestions. There is only Frum’s realization of the problem the GOP has in discussing health care, and a wish that GOP candidates could come up with a better angle on it.

Sadly, there are plenty of solutions, real-world solutions, to the problem Frum observes. Single-payer is one. The Affordable Care Act was another. I just can’t decide whether the reason Frum doesn’t propose any is because he knows all too well how futile it would be for any GOP candidate to truly support such things in the current political climate among their base (and the insurance industry), or whether Frum actually agrees with those GOP power-blocs in their overall philosophy of – as Bill Murray put it in Where The Buffalo Roam – “fuck the doomed.” That question – whether Frum just sees the problem keenly and wishes it were different, or whether he’s as much of a profits-before-people guy as the Limbaughs and Dick Armeys of the world but is simply trying to put a more palatable face on such a widely unpopular philosophy.

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