Wednesday, January 19, 2011

Telling the Truth about Health Care

I admit that I couldn't get through all seven hours of the House debate on HR2, the Republicans' bill to repeal the Affordable Care Act. I had to give up during hour four (two and a half hours yesterday and nearly two today) when the talking points were simply repeating themselves. We'd entered that point where everyone had to give their one-minute speech that would get them on the local news. (For all the talk about changing the filibuster rules in the Senate to allow better decision making, we really need an approach to "debate" in the House that gets to more than dueling talking points.)

The bill passed the house by a vote of 245 to 189, with Republicans voting 242 to 0 and Democrats voting 3 to 189. It stands little chance of coming up in the Senate, less chance of passing if it does come up, and faces a sure veto by President Obama.

With that behind us, we can go back to remembering what is true about ACA. I've posted these things on Facebook before, but thought it would be good to put them all in one place.

ACA is NOT a government takeover of Health Care. This was determined as "the big lie of 2010" according to Politifact. Talk about "putting bureaucrats between you and your doctor" is the status quo. The federal government creates incentives for states to establish exchanges for those people not on employer-based insurance. It's true the states represent governments, but this certainly isn't a national takeover (Reagan called it "New Federalism").

It is NOT a "budget buster". It actually saves money in the long run based on CBO estimates. It begins to slow the growth curve on costs, which increased 131% between 1999 and 2009. It is true that costs have gone up since the passage of ACA in March, but the full implementation doesn't occur until 2014. The costs have regularly been increasing. There is an additional piece I've been thinking about. One of the new restrictions is that insurers must spend 85% of their revenues on actual medical care. I believe the cost increases this year are an attempt to maximize what the base is before the 15% overhead limit kicks in. It's not a sustainable growth curve but more of a one-off.

The "American People" HAVE spoken on the Law and they DO NOT support repeal. Recent data  demonstrates that there are significant partisan divides on the question. According to the Kaiser Family Foundation, 55% of Republicans do support repeal. But only 26% of all those polled think so. The remainder want some parts adjusted, think it's a good thing, or are unhappy because it didn't go far enough. This may indicate that our political discourse has gotten so one-sided that we only listen to our most ardent supporters and think they represent the people as a whole. When you look at the individual components of the law, they are very popular even among those calling for repeal.

Medical malpractice reform WILL NOT solve the cost issues. I don't think it would hurt the Democrats to give in on this one, but it's not significant. In response to a request by Sen. Orrin Hatch in the fall of 2009, the CBO estimated that fixing frivolous lawsuits would reduce medical costs by one half of one percent. To put that in context, if you spent $300 per month on insurance you'd only have to spend $298.50. It may be true that doctors practice defensive medicine (additional tests, etc) to protect themselves against lawsuits, but the Effective Measures review (that gets called a door to rationing) would likely provide tremendous protection against those lawsuits.

The law has NOT been declared unconstitutional. One judge is opposed to the individual mandate (and there are legal scholars who challenge his logic) but left the law standing. The other judges to review constitutionality upheld the law. The commerce clause allows the regulation of proper interstate business. (By the way, the Republican strategy is to require shopping across state lines, which besides creating a "race to the bottom" would apply the same logic.) This will be determined in the Supreme Court and "if" the decision is made on established law, it will be upheld.

So what is this about? It's a major philosophical disagreement over the nature of health care. This morning, one of the new Representatives from Indiana, Todd Rokita, stated his position clearly -- "Health Care is Not a Right". Position like his see health care as a commodity that one purchases from the private sector. If you have sufficient means, you get better care (which is why there's been a big fight over "Medicare Advantage" or "Cadillac plans"). This is why the Republicans are concerned about individuals being forced to purchase care "against their will". I really don't understand why folks worried about immigrants using public services are comfortable with the uninsured getting care from emergency rooms and relying on the pro-bono write offs of local hospitals.

Democrats like me look at this differently. I'm concerned about those who gamble with their health for financial reasons until the situation is chronic. Then they get care too late so that the costs are much higher. Those costs get factored into everyone's health costs (the hospitals aren't giving stuff away). So caring for the poor and sick represents the common good. More importantly, it becomes a moral imperative because of our expectations about what a healthy society looks like.

The Republicans will now try to limit the implementation of ACA, as is their right. As they say, elections mean something. Of course, the 2008 election is why ACA was legitimately made law and will remain so since they didn't win the Senate. Republicans do appear to be in favor of the reforms people like (portability, no limit on pre-existing conditions, children on parents' insurance, etc.) but have no plan for how to get there or how to finance it.

There is much to address in ACA going forward. The exchanges will need to be evaluated. Adjustments will be made this year to the 1099 reporting requirements for small businesses. It will take time to move from chronic response to preventative care. It may take a decade for the deployment of medical professionals to match the need. And there are still nearly 30 million people uncovered. But it's the right direction, as Ezra Klein explained the other day in the Washington Post. In the end, that's all we can do in terms of finding the balance between individual freedom, states rights, crisis management, and fiscal health, while pursuing that "more Perfect Union."

Monday, January 17, 2011

Jeopardy Hodgepodge, An Apology, Martin Luther King, and Cylons

If you're a faithful Jeopardy viewer, you know that "Hodgepodge" is the category they use when there are a bunch of not-very-related answers in the category. Keep that in mind, since today's thoughts are loose ends I want to tie up.

Rules for Discourse: Like many viewers, I was moved by the president's remarks Wednesday night in Tucson. His challenge to raise the bar on our discourse, not because it causes violence, but because it's a way forward that would be true to Christina Taylor Green's beliefs about democracy. It may seem hard to determine what kind of discourse would meet that heightened bar, but I'm not sure it's hard at all. The following comes from the Washington Post's "User Discussion and Submission Guidelines" that should govern postings on their webpage:

By submitting content, you are consenting to these rules:
  1. You agree not to submit inappropriate content. Inappropriate content includes any content that:
    • infringes upon or violates the copyrights, trademarks or other intellectual property rights of any person
    • is libelous or defamatory
    • is obscene, pornographic, or sexually explicit
    • violates a person's right to privacy
    • violates any local, state, national, or international law
    • contains or advocates illegal or violent acts
    • degrades others on the basis of gender, race, class, ethnicity, national origin, religion, sexual orientation, disability, or other classification
    • is predatory, hateful, or intended to intimidate or harass
    • contains advertising or solicitation of any kind
    • misrepresents your identity or affiliation
    • impersonates others

While the Post doesn't have the staff to monitor all comments, these are excellent guidelines we can use to monitor our own discourse. I have started copying these guidelines and posting them on comment pages when the dialogue has descended into the name calling that is too common in all of our discourse. If we all agreed to avoid these infractions, we could work together toward common understandings. I will avoid libel and defamation, I will not intimidate or harrass, and I would include "political party" in the limitation against degrading others.

The Apology: A review of websites over the last week shows a tremendous amount of victimization. Sarah Palin, Pat Buchanan, and the Washington Times believe that there is a "pogrom" against conservatives. (Now in addition to having to apologize to Jews for the "blood libel" line, they need to consider their apologies to all who have endured forced migration.) When challenged that the "socialist" and "take back our country" rhetoric has a negative effect, they respond that Candidate Obama said, "If they bring a knife to the fight, we'll bring a gun." No one has actually accused the president of inciting violence in that remark.

I really want to make a defense that we're talking about the repetition of messages over an extended period of time in a variety of media sources. And President Obama's claim was something made in a speech in June of 2008. Or that when liberals said that President Bush "lied to go to war in Iraq" that it was a fair response to the misreading of intelligence data.

But to engage in such a defense would suggest that violating principles of civil discourse is best measured by frequency or magnitude. In fact, violating the principles is a one-time thing. Once the line is crossed, doing it by a lot or doing it many times doesn't change the fact that the line was crossed. I'm reminded of a wonderful passage in Donald Miller's Blue Like Jazz. Miller and his friends go to largely secularlized Reed College and apologize for the times in the history of the Christian faith where the Church was the source of pain and suffering. They don't make excuses. They just apologize.

So, at least for me, I'm sorry for flippant remarks that demeaned others, accused them of acting on self-interest, or of seeking political gain over common good. I crossed the line and I apologize. Norms of reciprocity would suggest that the other side do the same, but I apologize even if it only changes MY future behavior.

MLK: Today is the Martin Luther King, Jr. Holiday (at least in most places). It's where we want to celebrate the significance of dreams of a better society, of the value of nonviolence over armed conflict, and how our religious values can promote the common good. But King's "I Have a Dream" speech teaches us some important lessons about civil discourse.

When I taught Race and Ethnic Relations, I would use the speech in the opening class. While most people know the line where he wants his children judged "not by the color of their skin but by the content of their character", the speech actually demonstrates the difficulty of progress in American society. King starts the speech, describing how the great ideals of the Declaration of Independence had been given to citizens as a "promissory note" but that for blacks the note had come back marked "insufficient funds". In the middle of the speech, he argues that his "white brothers" who had marched alongside, "realize that their freedom is tied up with our freedom". He argued in other speeches that the system that so limited blacks limited whites as well. He argued for true democracy when he said, "We cannot be satisfied as long as a Negro in Mississippi cannot vote and a Negro in New York believes he has nothing for which to vote." When we can recognize the past, and own together the present, only then will we see the day when "justice rolls down like water." When that day comes, it will be common to see the children judged by their character.  We can't simply start with the character line. Understanding race relations in America requires us to hold all these thoughts together, as King did.

Here's the lessons I take for Civil Discourse. First, we have to be able to tell the truth about the past. We haven't always lived according the values we espouse. Admitting that doesn't weaken the values, it pushes us deeper. Second, we are a complex society committed to the constitutional principle of "promoting the general welfare". Not for the folks like me or the folks that agree with me -- the welfare of all. Third, we have a bias toward justice. That means addressing inequality where we see it. If a system works well for most people, we should be concerned about those for whom it doesn't work. Only then, are we free to focus on individuals as if race, class, religion, region, gender, or ethnicity doesn't matter.

Back to Jeopardy: You may have read that an IBM computer has been programmed to play Jeopardy against the two biggest winners. It will be televised in February. There was a practice game last Thursday where Watson competed in a practice game. "He" easily handled the competition.

What happens when we start using computers as pundits? Will they be able to fact check? To combine a variety of competing perspectives and find a policy proposal that meets the best solution for the most people? Can we raise our game to keep competing or will we sit idly by while Hal from 2001 quietly turns off the life support systems? 

Makes me really miss Battlestar Galactica: "The Cylons were created by man. They rebelled. They evolved. They look and feel human. Some are programmed to think they are human. There are many copies. And they have a plan".

Sunday, January 9, 2011

Reflections the Day After the Tucson Shootings

So, I'd hoped my first blog of 2011 would be an upbeat piece about the possibilities inherent in a new year. But the events of yesterday morning at a Safeway knocked all sense of happy new year out the window.

Like most people, I've been trying to find news updates about the shooting of Congresswoman Giffords and those who were with her. It's impossible to understand what was in the mind of the shooter, but the picture that is emerging is one of paranoid delusions and a significant amount of premeditation. Jared Loughner may well be a deranged individual actor like previous actors who shot Ronald Reagan or George Wallace. And legal responsibility rests with the shooter, not the people whose careless rhetoric creates an unstable atmosphere.

The sheriff in Pima County, Clarence Dupnik, made comments yesterday about how "vitriol and hatred" had become a part of our culture and that Arizona might be a centerpiece for such rhetoric. He did make clear that "unbalanced people" will react in ways that we don't expect.

Comments by Speaker Boehner and Senator McCain make Loughner out to be significantly abnormal. Boehner's comments referred to "an inhuman act". McCain said that Loughner was "a wicked person who has no sense of justice or compassion." Not that any of these leaders had ever met the shooter -- but to call him "other" makes clear that normal people aren't affected by harsh rhetoric. Megyn Kelly challenged Sherif Dupnik that he should focus on the facts of the case and that it's not the time or the place of a sheriff to critique rhetoric (but it's okay for a commentator/newsperson to opine!).

Commentators and politicians were trying to get the sheriff to back off his statement. Jon Kyl argued that such comments weren't the job of law enforcement officials. Sarah Palin's staff tried to argue that the bulls-eyes on her election map weren't meant to look like targets (a claim that has already been easily "refudiated" by one of Sarah's tweets).

David Gergen has an excellent piece on the CNN website arguing that we need to avoid recrimination and finger pointing. He also reminds us that when this day passes, we need to do some reflection on the nature of discourse and "pledge to each other that we will struggle for a more civil and decent America."

Here's what I've been pondering. The reason we need to scale back our heated arguments is not primarily because they might inflame unbalanced individuals to acts of unimaginable violence. There will always be characters like John Hinkley (who shot Reagan) and Arthur Bremer (who shot Wallace). It's possible our rhetoric provides a rationale for misguided, wrongheaded, irrational, or absolutist people. As much as it pains me to say this, I kind of agree with Megyn Kelly -- these folks are out there.

The real issue, as Gergen makes clear, is what the rhetoric does for the rest of us. There are internet rumors circulating that Loughner once had "liberal leanings" and others that he's connected to "anti-government groups". What's happening is that Being Right and Scoring Political Points has become so important that we'll use the actions of a deranged individual to get Our Side to Win. That's not crazy behavior by an inhuman actor. That's us, getting sucked into a style of rhetoric that only has winners and losers.

It has been pointed out that just three days ago, Congresswoman Giffords took to the well of the House to read the First Amendment to the Constitution. It makes clear that the government "will make no laws abridging the freedom of speech." That has gotten distorted to the point that anyone suggesting that a sentiment not be shared is denying free speech rights. But just because you're free to your opinion doesn't mean that you shouldn't be careful about how it's expressed. I'll defend anyone whose voice is silenced by the government. But "bearing false witness" isn't a matter of freedom of speech. This isn't about legality, but is about our moral commitments to truth-telling and expressing common decency and compassion for fellow human beings. It's a higher bar to clear but it's really how we want to live.

Happy New Year anyway.