Senate Bill Passed
Conference here we come.
UPDATE: Or not. Anyone for ping pong?
A Conundrum at the Heart of Health Reform Politics
Old people tend to be conservative. Conservatives don’t like government-financed health care. But old people fiercely defend government-financed health care (Medicare).
What’s going on here? How are we to understand this contradiction? It seems there are only two possibilities.
1) Medicare is a good deal for old people, and they defend it out of self-interest. Other conservatives tolerate it out of respect for their elders, or fear of their elders’ political power.
2) Conservative opposition to government-financed health care is a mirage. That is, conservatives do not actually oppose government-financed health care. They may think they oppose government-financed health care, and say they oppose it, but they actually oppose other things that they mistakenly designate with the label “government-financed health care.” What they are actually opposed to is some kind of dystopian future under a totalitarian socialist regime, or some such.
Under option #1, there is rampant duplicity and bad faith. Under option #2, there is a kind of mass delusion. Is there any other explanation available? And if not, which one of these is it?
The Limp Platitudes and Inconsistent Nonsense of Strunk & White
In my first semester of law school, I got into a brief classroom contretemps with an instructor over a matter of grammar. The instructor believed that a sentence of the form ‘there is a controversy about x’ is in the passive voice. Opining that good writing avoids passive constructions whenever possible, she stated her preference for the appalling formulation ‘a controversy exists about x.’ I interjected that ‘there is x’ is not a passive construction, and that there is nothing generally wrong with the passive voice anyway.
The instructor derisively awarded me a “gold star for the day,” trivializing my challenge to her usage dictatorship (while leaving it unclear to all whether she was admitting I was right). She then renewed a prior demand of absolute conformity.
I sat back, withdrew to somewhere inside Wernicke’s area, and silently counted the times she violated her own capricious rules. I may be a snoot, in David Foster Wallace’s sense (pdf), but I am not bullheaded.
This year, 2009, was the 50th anniversary of the publication of The Elements of Style by Strunk & White. Linguist and grammarian Geoffrey Pullum wishes it would rest in peace.
The Elements of Style does not deserve the enormous esteem in which it is held by American college graduates. Its advice ranges from limp platitudes to inconsistent nonsense. Its enormous influence has not improved American students’ grasp of English grammar; it has significantly degraded it.
Zing! There is a common malady among Americans of the English-class-high-performer type—people who are otherwise attitudinally permissive, but who inexplicably submit themselves to the total embrace of certain stodgy precepts of grammar, syntax, and diction. This malady is viral. And though none can say whether we would suffer from it had this book never been written, it is clear that The Elements of Style sits at the vector origin of this particular memeplex.
More from Pullum:
The book’s contempt for its own grammatical dictates seems almost willful, as if the authors were flaunting the fact that the rules don’t apply to them. But I don’t think they are. Given the evidence that they can’t even tell actives from passives, my guess would be that it is sheer ignorance. They know a few terms, like “subject” and “verb” and “phrase,” but they do not control them well enough to monitor and analyze the structure of what they write.
* * *
What’s wrong is that the grammatical advice proffered in Elements is so misplaced and inaccurate that counterexamples often show up in the authors’ own prose on the very same page.
Read Pullum’s whole piece and be absolved of needless anxiety over the passive voice, split infinitives, and interchangeable use of ‘which’ and ‘that’ to introduce relative clauses. It’s ok. There are no rules against those things. And there never have been. They were the product of the dogmatic and uninformed imaginations of William Strunk and E.B. White, “a pair of idiosyncratic bumblers who can’t even tell when they’ve broken their own misbegotten rules.”
Via Austin Frakt.
Constitutional Crisis Averted!
A minor constitutional crisis was narrowly averted today. It seems the House of Representatives was in jeopardy of being out of session for more than three consecutive days without leave of the Senate as required by the Constitution. Article I, Section 5, Clause 4:
Neither House, during the Session of Congress, shall, without the Consent of the other, adjourn for more than three days, nor to any other Place than that in which the two Houses shall be sitting.
The House had last adjourned on Wednesday evening. But what with snowfall being an “imminent impairment of the place of reconvening,” the House gavelled in for a minute or so at noon in case no one could make it at the appointed hour of 6 p.m. Whew. Crisis averted. System of government in perfect working order.
Story via CongressMatters.
The Procedural Road Ahead
With Senator Ben Nelson (D-NE) pledging his support today, the Democrats have reached the magic number (60) to approve a cloture motion and end debate on the health reform bill, the Patient Protection and Affordable Care Act. Actually, three successive cloture motions must be approved to get to three separate votes: one to substitute the reform bill for the “shell” bill, HR 3590; one to pass the manager’s amendment that Majority Leader Harry Reid released today; and one more to pass the final bill. So that’s 6 votes: three for cloture, each requiring a 60-vote supermajority; and three “up-or-down” votes requiring a simple majority. Between each cloture vote and its corresponding simple-majority vote, the Republicans can force 30 more hours of “debate.” The first cloture vote will be held at 1 a.m. on Monday.
That puts the final vote on Thursday evening, 12/24. Maybe Santa will recognize senators’ efforts by upgrading their stocking stuffers to lumps of “clean” coal.
60!
Will there be an adverse selection death spiral without the individual mandate?
It’s not really disputed amongst health-policy experts that adverse selection exists in voluntary insurance markets, or that it may be exacerbated by pure community-rating requirements.
However, it turns out there is not a general consensus about how serious the problem really is, and it is difficult to find a clear example of anything deserving the fear-inspiring appellation “death spiral.”
A death spiral, if the term bears objective definition, is something more than the predictable escalation of premiums resulting from adverse selection. I understand it to connote something like market collapse—which, in turn, I understand to designate a situation in which a large portion of insurance carriers defect from the market, i.e., stop offering individual insurance policies.
There are a few examples of market collapse in the wake of individual market reforms. Kentucky in 19941 and New Jersey in 19932 (among others) both saw big increases in premiums, declines in overall coverage, and rampant insurer defection. But it is not certain in either of these cases that community rating was the culprit, as other factors were present that may have both caused and aggravated market chaos. Also, other states that have implemented community rating in the individual market have not seen disaster ensue. Notably, New York has a strong community-rating requirement, and though its premiums are significantly higher than the national average, the market has been stable. (See KFF 50-state comparison of rating restrictions in the individual market, and AHIP survey of premiums.)
So, in the end, as leading healthcare economists Mark Pauly and Len Nichols have written, it could be that “[i]nsurers’ fear of adverse selection may be more important than the actual extent of observed adverse selection.”
- See Len M. Nichols, State Regulation: What Have We Learned So Far?, 25 JOURNAL OF HEALTH POLITICS, POLICY AND LAW 175, 192-94 (2000). [↩]
- See Alan C. Monheit et al., Community Rating and Sustainable Individual Health Insurance Markets in New Jersey, 23 HEALTH AFFAIRS 167, 170-71 (2004). [↩]
Individual Mandate Re-Revisited
Commenters are clamoring for facts, studies, and evidence!
Len asks about the evidence that significant numbers of people will choose not to have insurance even when they can afford it.
There are probably lots of interesting studies out there that attempt to answer this question under current law, but none of them would be relevant under the new statute.
If you think about the new regulations like a behavioral economist, you’ll see why. Insurers will be required to issue a policy to anyone who wants one, regardless of health status, and to charge the same price to everyone (though prices may increase with the age of the policyholder). Exclusions for preexisting conditions will not be allowed. Under this regime, you would be a fool to have insurance before you got sick. Because under the new law, you will be able to get insurance at the same price as everybody else even after you have been diagnosed with cancer, diabetes, and AIDS. Your incentive to pay into the system while in good health is basically zero.
So, I don’t think we really even need studies and data to know that the people seeking to buy insurance under the new regulations would be disproportionately unhealthy if there were no individual mandate.
This is known as the problem of adverse selection, and its consequences are the subject of Lee’s question about the spiral deathtrap loop theory. I’ll take that one on in the next post.
The Individual Mandate Revisited
The new opposition to the Senate bill emerging from the left has taken aim at the individual mandate as a kind of giveaway to profiteering insurance companies.
In response, Kevin Drum noted yesterday that the bill is built atop an intricate mass of concessions to various industry interests. Among those concessions is the individual mandate, which is construed as the political price of securing the support—or, at least, the uneasy lack of adamant hostility that we’ve seen—of the insurance industry.
I do not doubt that the individual mandate has been an important part of the political calculations that have staved off industry opposition. But I don’t think, as a matter of policy, the mandate is uniquely or even primarily for the benefit of insurers. It is the conceptual linchpin to a system of universal coverage (or near-universal) with private payers.
Without the mandate, the regulations requiring insurers to cover everyone regardless of health status (“guaranteed issue”) and to charge everyone in the community the same premiums (“community rating”) would inevitably lead to adverse selection and a feedback loop (“death spiral”) of higher premiums that would drive healthy, risk-subsidizing people to drop their coverage. Adverse selection, the bete noire of insurance markets, can’t be avoided without universal coverage, and it’s pernicious effects are too profound to ignore. And there are only two ways to get universal coverage: automatically enroll everyone or require them to enroll themselves.
So, the importance of the individual mandate is not so much that it is a necessary evil that will mollify powerful political interests. Rather, the mandate is an essential ingredient of reform’s consumer protections. It is a necessary condition of success for policy reasons every bit as much as for political reasons.
Quote of the Day
From Ezra Klein, amidst an explanation of why liberals should support the healthcare bill, even if they believe that the absence of a public option is a serious defect:
Social Security excluded African Americans originally. As, come to think of it, did America.
There is absolutely no upside to the idea of killing the bill. Public option, Medicare buy-in, higher subsidies, and raising the medical-loss ratio are all good ideas, but their absence is not important enough on balance to scuttle the whole bill. Shifting to a reconciliation strategy now would require starting over virtually from scratch, would completely undermine the momentum for reform, and would introduce enormous risks and innumerable new opportunities for failure.
Senator Obama v. President Obama
Len makes another good point here about the inconsistency between Obama’s position on drug importation as Senator and his opposition to it as President:
A senator has a responsibility to propose laws he thinks will be good for the country and can be fairly administered and enforced. The president’s job is enforcing the statute. When his agency head says, Mr. President, we can’t do this drug reimportation and our other things unless Congress also gives us XYZ. When congress fails to supply all the agency needs, then the President rightfully can change his opinion on a particular bill. He’s now administering, not lawmaking, and those two functions can have legitimate disagreement on the worthiness of a bill.
I’d add that, as President, it’s no small matter to hold together a deal on a massive overhaul of policy in an area sensitive to such heavyweight political interests as doctors, hospitals, unions, old people, the insurance industry, and big Pharma. Unfortunately, our politics has reached a stage where the President gets blamed for congressional failures, and so the President must secure support sufficient to win 60 votes. Does anyone doubt that there’s a vote or two to be lost in the Senate if the drug companies wanted to play hardball against the bill?
No Canadian Drugs for Us
Yesterday the Senate voted down the Dorgan amendment, a proposal to allow reimportation of pharmaceuticals. I asked my friend Len, a long-time regulatory affairs consultant for drug companies, what he thought about the issue. Here’s his response (lightly edited):
Here’s a healthcare proposal that many Democrats and Republicans support for vastly different reasons. Democrats like the idea that consumers could get cheaper drugs, so they support it. But reimportation would effectively gut the FDA’s enforcement ability, and Republicans like that. I oppose it for the reason that Republicans like it.
There are many regulations that together require that manufacturers, wholesalers, distributors, and pharmacies keep records of where drugs come from and where they go. This makes it easier to keep counterfeit drugs away from the consumer and if a recall is needed to find all those affected drugs and get them out of the stream of commerce. They also make it possible for FDA to inspect the plants where drugs are made, because in order to get past the border all drugs must be listed by the FDA in a particular database, and all manufacturing facilities must be registered.
I have not read the current drug importation proposal. In the past proposals have relied on the regulatory agencies of other countries to do much of the inspecting and tracing that FDA does today. An importer then would just show that it purchased the drug from some permitted seller in the other country, and that would be sufficient to get the drug into the US. If this type of drug importation were allowed it would shut FDA out of the drug manufacturing compliance business in reliance on those agencies in other countries. Many other countries have good regulatory agencies, but with the US free-riding on them, those countries’ agencies could be overburdened to the point where their enforcement capacity would break down. In fact, some Canadian politicians have said that they would try to block exports to the US for this reason.
For many years the FDA enabling statute has allowed importation if the commissioner certified that importation presents no additional risks to US consumers above those already inherent in the system. No FDA commissioner has done it because either any proposal by an importer is not as good as the current system or a complying system with appropriate safeguards would add to the price of the drugs so that there would be no savings.
This whole proposal is really hypocritical. Drug prices are lower in many other countries because the governments of those countries buy the drugs and negotiate good prices. Now if we really want to have low prices and safe drugs then we should have the US government negotiate the prices and buy the drugs, as happens in the countries with low prices.
— Len
The Folly of the OPM Plan
From the Department of Looking on the Bright Side of Death. It’s a good thing that the OPM-administered public-option substitute is dead. It would never have worked.
The idea was that OPM—the Office of Personnel Management which administers the Federal Employees Health Benefits Plan, sort of like the HR department for 9 million federal employees—would contract with national non-profit insurers to offer a policy that would be available on the exchanges nationwide.
There are lots of reasons, as Jacob Hacker explains here, that this is not a plausible substitute for a public plan. Mostly the reasons don’t matter anymore, but there is one underappreciated point to make that remains relevant to any proposal that calls for allowing people to purchase insurance “across state lines.”
Health insurance is not just an arrangement between the insured and the insurer. There is a crucial third element to the arrangement, as Bob Laszewski points out: access to a provider network.
Besides buying health insurance to cover expensive health care (pure insurance), what is the most important thing you buy when you buy a health insurance policy?
Answer: The provider network. Without an in-network discount from an HMO or PPO you might pay 30% or 40% more for your health care–in higher premiums or higher out-of-pocket costs. You definitely never want to pay retail at your doctor’s office or hospital.
Beyond the discounts, agreements between providers and health plans also establish managed care protocols that save lots of money and keep the cost of insurance down.
By definition an out-of-state health plan–one that does not operate in a given state–does not have a local network. If it did, it would already be doing business there.
There are some tricky economics in the health care/insurance markets, because transactions in those markets are not simply between buyers and sellers of goods, but are rather complex arrangements between consumers, providers, and payers—not to mention consumers’ employers. That trickiness gives rise to some tough legal issues…a subject for another time.
Don’t Forget The Real Public Option
It’s worth remembering that the bill’s real public plan, the one that matters most, is still intact: Medicaid expansion. CBO estimates that extending Medicaid eligibility to everyone under 133% FPL will insure 15 million people who would otherwise be uninsured. The public option, by contrast, was projected to cover between 3 and 4 million people who could just as easily buy a private plan. We don’t have numbers on the Medicare buy-in yet (if we ever will), but it is probably in the ballpark of 3 million people.
So remember that. Expanding Medicaid is a much, much bigger deal than the “public option” in the exchanges. It helps more people, and it helps the people who need it most. That’s no reason to be disconsolate. This is an epic victory for liberal America.
And one more thought: what’s to stop the Congress from taking up a reconciliation bill with a robust public option (pegged to Medicare reimbursement, as originally conceived) within the next year or two? Let the public option and Medicare buy-in be the goal posts for the next bill.
Medicare Buy-In Sold Out
Well, Senate Democrats have conceded defeat to the Senator from Lieberman. Right out of the jaws of victory. But Lieberman is now on board to vote for the bill, assuming no further fringe antics by the 59% majority to resurrect liberal desiderata. And House Majority Leader Steny Hoyer believes the House will pass a bill without a public option.
I’ve thought for some time now that the public option should have been renamed after it had been so thoroughly watered down with compromise that it no longer had a chance to fulfill its promise. But it’s probably better to lose the public option altogether—for now—than to pass one that is ineffectual and winds up discrediting the whole idea.
At this point we have a huge bill that will save thousands of lives, save families from bankruptcy, reduce the deficit, and make meaningful headway on cost reforms. We’re losing a tiny part of that bill. The public option had, and still has, great potential, but in this bill it’s value is mostly symbolic. Let it live to fight another day.
About Me
- I write this blog.
-
My twitter feed:
