One Final Comment on Healthcare

Healthcare reform has largely dropped out of the news since passing. Although I believed that as a political matter, it should have been made to vest, there was one potential policy advantage in waiting till 2014.

People like Sarah Palin and Michelle Bachman insist that it will lead to death panels in the sense that if everyone has access to healthcare, it will have to be rationed and people will be denied essential services. The obvious retort is that if some people don't have access to healthcare at all, they are by definition being denied essential services. In effect, what Palin and Bachman are saying is don't let anyone else get access because it will take services from me. Not a very edifying argument, but one with a certain appeal.

But is it true? For life-threatening conditions or serious illness, no. We already have mechanisms in place to ensure that no one is left to die in the street. Most of the uninsured entering the system will be reasonably healthy. But what the Massachusetts experience has shown is that, although critical care will not be much affected, primary care will be severely strained. The influx of 32 million people, fairly healthy, but without regular care up till then, will be a serious strain on our primary care system.

That is the advantage of a four-year lag. It will give us time to prepare by training a large number of primary care providers to cope with this sudden influx. We should be working on that between now and then. For instance, we should vastly increase scholarships to become nurse practitioners and physician assistants. (These two categories are qualified to give primary care to a generally healthy person, but they are less expensive and quicker to train than family doctors). We should be advertising, urging people to follow these two careers because they will be growth industries in a few years. And if we are unable to train enough primary care providers on our own, we should start admitting more immigrants who can offer primary care.

So, what are we doing now to prepare for the influx? So far as I can tell, nothing.

What about the Individual Mandate?

Of all the provisions in the proposed healthcare bill, none has aroused such hostility as th individual mandate. It is denounced on the right as forcing people to buy a service they don't want. Opponents on the left rather hypocritically denounce the individual mandate in similar terms, although their real objection is that payments have to go to a profit-seeking insurance company. And the thought of having such a requirement forced on them angers and offends most people.

The essential counter is that the individual mandate, however, unpopular, is necessary as a matter of risk pooling. If insurance companies are not allowed to deny coverage for a pre-existing condition, they will have greater expenses and need more revenue. Besides, people will be tempted not to buy insurance until they get sick, further increasing insurance costs while undermining revenue. Insurance is, in effect, a system whereby the (currently) healthy subsidize the sick.

As a matter of policy, I am not sure this is absolutely necessary. One might allow insurance companies to charge as much as necessary for premiums to sick people and just provide and adequate subsidy to make them affordable. But whatever the policy merits, the whole risk pool argument will never fly as a matter of politics. For one thing, people hate being told that they have to do something because it is their duty to society. But beyond that, if you are trying to sell the idea to Republicans/libertarians, you will never get anywhere pushing the idea of risk pool. The problem is not just that the idea is too complex and wonky for Republican/libertarians to understand. It is that they don't want to understand it or, perhaps, that they understand it perfectly well and are morally opposed.

The problem with risk pooling to a Republican/libertarian is that it is collectivist. The healthy are being asked to pay in to subsidize the sick. That is redistributionist and therefore violates their most basic moral principles. To be told that is your duty to pay into a pool while healthy so that the sick can have access to healthcare looks like a case of robbing Peter to pay Paul -- even if everyone can expect to become Paul some day.

But that leaves an alternative that might be a more acceptable way of looking at it. Healthy people are not being asked to buy insurance to subsidize the sick. They are being asked to pay their dues now, when they are healthy, so they can collect the benefits later when they are sick. When people develop a medical problem, their rates will go up, so they will almost certainly need a subsidy to buy insurance. People who try to cash in on the benefits when they're sick without paying their dues when they're well are a bunch of free riders the system should not support. (Of course, many people will need subsidies to pay for insurance even when well, but we'll sort of gloss over that). So, if instead of having an individual mandate, you simply make the rule that anyone who doesn't buy insurance now when they are healthy will not qualify for a subsidy later on if they get sick, that will be an approach highly agreeable to conservatives.

The problem, of course, is that it will not be acceptable to liberals. Liberals will ask what if someone is too ill-informed, short-sighted or just plain poor to buy health insurance. Are we to leave them to die in the gutter? So far as I can tell, the answer from a libertarian is that this is not a legitimate concern so far as public policy goes. If people don't pay their dues and run into trouble, there is always private charity. We conservatives pay much more to charity than you liberals. If you really cared, you would pay as much as we do. But how much to pay is strictly a private matter and not any business of the government. Not letting government rob Peter to pay Paul is a whole lot more important to a libertarian than what becomes of Paul if he can't pay his doctor bill.

Nonetheless, if anyone wants an individual mandate with any chance of getting past a Republican filibuster, this is the only possibility I could see.

Reflections on Breaking up the Healthcare Bill

One of the proposals for dealing with the new 41-59 Republican "majority" in the Senate is to break the healthcare bill into pieces and pass them one by one, daring the Republicans to vote against them. This proposal has been much criticized. From a policy perspective, it is criticized because the popular and unpopular parts of the bill are mutually indispensable and an attempt to separate them would just send premiums skyrocketing. From politics perspective, Republicans may do anything from automatically filibustering anything to supporting the pieces and then claiming credit. ("Look, we blocked the dreaded Obamacare and gave you this wonderful (if mostly the same) system instead.") Nonetheless, I would like to give my analysis, both in terms of politics and policy, of the separate parts.

Standardizing of benefits and premiums.

One of the Democratic proposals was a standardization of health insurance packets. All policies will offer the same basic benefits packet, the only difference being how much of the tab the insurer versus the insured pays. Likewise, insurance companies will be required to risk pool to offer similar rates to everyone throughout the community. To be honest, I don't have a clear sense of the merits of how this compares to the current, immensely varied system.

But regardless of the policy merits, as a political matter, Republicans will fight this tooth and nail and invoke the filibuster over it. It goes against their basic principles at two levels. First of all, having government dictate benefits packages and rates violates their sense of free market capitalism (and, by extension, freedom). Second, many Republicans propose bare-bones policies as a cost-control measure. If patients bore more of the cost of healthcare, the theory goes, they will consume less of it. Many Republican would like to encourage policies that cover only routine, preventive care and major, catastrophic care.

As a policy matter, this may not be such a bad idea. My big problem with it is there are some things too big to be routine care and too small to be catastrophic that may fend off later catastrophes. A woman who receives an abnormal Pap smear having the abnormality burned out before it becomes life-threatening cancer would be a classic example. My advice would be to allow bare bones policies, but require them to cover any intermediate condition the doctor certifies and a matter of life and death. As a political matter, my guess is that it will be embarrassing for Republicans to vote against that, and that were are unlikely to see Tea Parties demonstrating, demanding that their insurance be allowed to exclude life-saving treatment.

Pre-existing conditions, rescission, and lifetime caps.

As a matter of politics, these are the most popular part of the healthcare bill, and Republicans will probably not want to face a 30 second ad accusing them of voting against them. Nor are we likely to see too many Teabaggers out protesting demanding their insurance companies' right to drop them if they get sick and offering to die as martyrs to free enterprise.

More realistically, both Republicans and Tea Parties may resist these measures on the grounds that they will make premiums skyrocket. And, of course, that is true. As a policy matter, it is the big reason many on our side oppose breaking the bill into its constituent parts. We do recognize the basics of the market and that there is no free lunch. If insurance companies are to be forces to incur all these additional costs, they have to be allowed additional revenue.

If Republicans resist banning pre-existing conditions and lifetime caps (I can't imagine anyone defending rescission), they will undoubtedly argue that these will make insurance more expensive. Democrats should freely acknowledge as much -- and then call for subsidies to help people pay for the increased rates. Personally, though, I believe this is worth passing even if subsidies don't pass. After all, what will happen if we do force insurance companies to take on so many more costs but don't offer subsidies? Insurance rates will skyrocket. The public will be outraged. And Congress will face one of three choices: (1) do nothing; (2) change the law to allow the bad old practices; (3) create a subsidies to help people buy insurance. Granted, the Teabaggers will probably be outraged at the subsidies and call for repealing the law instead, but I am guessing they will be in the minority, and the pressure for subsidies will be too strong to resist.

Subsidies

As a matter of policy, there is no doubt that if we are going to ban denials based on pre-existing conditions, rescission, and lifetime caps, we will need subsidies to cope with the increased rates. (Really, we need them anyhow). As a matter of politics, Republicans and the Tea base will no doubt be outraged and see the subsidies as "socialism," "a complete government takeover of healthcare," and something that calls for taxes. So there will be considerable resistance to such subsidies. On the other side, there is the threat of 30 second ads that "Senator So-and-So cast the deciding vote that blocked assistance to individuals and small businesses buying health insurance." And there is the specter of public wrath when premiums skyrocket and no help is at hand. So we may be able to pry loose a few Republicans to vote for subsidies to help buy insurance.

The other question is how to fund such subsidies. Republicans have an inflexible principle: No tax increases, even, no matter what the circumstances. That's going to be a tough one to overcome. No doubt even Republicans who do agree to subsidies will insist on financing them by cutting other spending. Here's my only suggestion. There is generally less resistance to taxes if people are assured that a particular tax goes into a particular fund to support a particular program. It feels more accountable that way. I personally think this is generally a bad system and that programs should be paid for from the general fund and all compete on an equal basis. The other problem is that whatever the revenue source for the fund, there is no way to ensure that it matches actual need for subsidies. But no matter. If creating a separate tax to pay for a "trust fund" is the only way to get subsidies enacted, I say go for it. (Of course, Republicans might just filibuster anything that raises taxes anyhow, regardless of skyrocketing premiums).

Cost control.

There are three cost control measures Republicans favor: (1) limiting malpractice claims; (2) allowing insurance companies to compete across state lines; and (3) bare bones policies. Everything else is "rationing," "government control of health care," "government bureaucrats coming between you and your doctor," "pulling the plug on granny" and even "death panels," "euthanasia of seniors" and perhaps even T-4. Republicans will not yield one inch on this. It is a matter of basic principle to them. Free markets, not government, must be in charge of controlling costs.

Notice that they have been sure there were death panels in there somewhere even before the healthcare bill was proposed in the first place. Republicans began to be alarmed over the subject ever since the stimulus bill included funds for comparative effectiveness research. That alone was enough to set off their alarm bells, even though it was only research and had no authority to mandate at all. Ever since the healthcare bill was proposed, Republicans have been sure there are death panels (by one name or another) in some part of it somewhere, even if their location constantly migrates. This is a huge, HUGE issue to them; anything that may suggest government restricting access to healthcare, or rationing it.

It's useless to point out that comparative effectiveness research is something the Mayo Clinic does that allows them to deliver top quality healthcare at well below average rates. It's pointless to argue that insurance companies deny people treatment all the time. It's useless to point out that pricing people out of healthcare altogether (which is what the free market approach will do) is ITSELF a form of rationing. None of those matter. What is important to Republicans is that all those are part of the private sector. Any cost control measure in the bill will be work of the Evil Government.*

So no cost controls other than tort reform or competition across state lines will be in any bill that can get through the Senate. But don't despair. Republicans do favor "entitlement reform." "Entitlement reform" is a euphemism for cutting Medicare, something they have denounced this bill for doing. But they fear openly taking responsibility for it and want to appoint a commission to make recommendations. Maybe, with luck, we can appoint some people to the commission who will make reasonable cost control recommendations.

Next post: The most controversial issue of all: Individual mandate.

___________________________________
*And, to be fair to Republicans, their fears are not entirely crazy. Larger organizations do indeed tend to be more bureaucratic and rigid than smaller ones. It may be true that what works well at the Mayo Clinic would become overly rigid and bureaucratized if done by a large insurance company, let alone the government.

Memo to the Democrats

OK, nothing very original in this post, but hey, I'm a busy law student. I don't have time.

To the Democrats: No, it wasn't because you moved too far too fast or pushed too far to the left. No, you wouldn't have gotten bipartisan cooperation if only you hadn't asked so much. And no, having a different order of priorities would not have made the slightest difference. And, finally, no, the Republicans are not going to be the least bit more cooperative now that they've tasted blood and are closing in for the kill.

What did you do wrong. Two things. (1) You were Democrats. (2) You were in power. In that you violated the 28th Amendment that every Republican knows was passed during the Reagan Administration by Bruce Ackerman's informal Amendment process: "Republicans shall at all times be in power."

What could you have done differently? Well, you might have had a come-to-Jesus moment, changed your registration to Republican, and reported to Fox News for your marching orders. Short of that, nothing. No matter what you did, no matter how moderate or restrained, you would still have been denounced as wild-eyed leftwing extremists. It's a standard formula they trot out every time. They used it against Bill Clinton, the junkfood-eating Arkansas hillbilly from the centrist DLC, and they'll use it on you. Stop being a battered wife and trying to figure out you offended the abuser. And don't get silly ideas like that he'll change now, or it's different this time. Go out and take a self-defense class instead.

Granted, I may be overreacting. The news cycle is very short sighted and tends to project current trends indefinitely into the future. Why, just a year ago, conventional wisdom had it that the Republicans were divided, demoralized, and headed for decline. And I remember very well in 1995 people were writing epitaphs for the Clinton Administration as a failure and assuming that the Republicans has a complete free reign to pass anything they wanted, even though they didn't have a veto-proof majority.

It didn't work that way. Republicans did a great job of attacking Clinton and his agenda as dangerously radical, but when they actually tried to enact their own agenda, it turned out not to be very popular. Clinton reinvigorated his presidency by challenging the Republicans to a showdown and winning. Both came away from the encounter chastened and were able to work together to some degree. I actually thought the Republicans would conclude from that that there was such a thing as being too right wing. We all get these foolish delusions sometimes. But you have a lot more experience than I do, and less excuses.

So, maybe you'll have the chance to do it again. If so, the time to start is right now. Conventional wisdom already holds that when Senate Democrats outnumber Republicans 60-40, they hold a razor-thin advantage," and that when it shifts to Dems 59, GOP 41, Democrats have lost the "majority." Folks, I know that pundits have to keep their mouths moving or their brains may start working, but doesn't it indicate that something is the matter when holding a wide majority in the House, a 59-41 majority in the Senate and the Presidency are all dismissed as inconsequential compared to the Republican's 41-59 Senate lead?

For starters, don't fumble on the 5-yard line. No one respects a team that does that. Then, start offering up a lot of popular legislation and dare the Republicans to block it. Better yet, choose legislation that will be popular with independent swing voters but not the Tea Party base and force the Republicans to choose which group to piss off. Alternately, you could completely give up and let them sweep the 2010 election. I'm guessing that the Tea Party's message of taking a chainsaw to government will be wildly popular until they win elections and actually start to do it.

Of course, it that's your strategy, you'd better be prepared to actually roll up your sleeves and clean up the mess they make. This post (much repeated across the Left Blogosphere) rather strongly indicates that you are much too afraid of responsibility ever to actually stand up for your principles and try to govern.

If that's the case, then why on earth should anyone vote for you? Granted, the Republicans don't seem that interested in governing either, but at least they have the courage of their convictions and are ready to say so.

But if all you are interested in doing is tiptoeing around, trying to avoid offending the Republicans or taking any sort of responsibility, I would suggest changing your name. To the Cheese-Eating Surrender Party.

The Obligatory Healthcare Post

The school year is over, as is Christmas, so it is really time for me to start posting again before school resumes. So, healthcare has passed the Senate and awaits reconciliation. My comments on the subject:

No, this isn't perfect. You don't get everything you want. Deal with it. Instead of a single payer, we get something like the Swiss healthcare system, in which everyone is required to purchase health insurance, insurance companies are required to offer the same basic services to everyone regardless or age or condition, and the government offers subsidies for people who can't afford premiums. To throw the whole system out and stick with the status quo because it isn't everything you wanted is a classic exercise in cutting off your nose to spite your face. Senators Feingold and Sanders understand this; so should the left blogosphere.

Whatever emerges out of conference committee will not have a public option and will disallow federal funds for abortion. That's the price of getting it passed. Deal with it. As for other contentious issues, the houses will doubtless find some sort of compromise on expenditure formulas. I do not pretend to know enough to judge the relative merits of the different financing systems. I am mostly interested in two issues. The long-term survival of the system could depend on either.

The first is whether exchanges should organized by the federal government or the states. As a law student, I can confidently say by the federal government. Why? Certain conservative have long denounced the whole system as an unconstitutional extension of federal power. Mockers have answered, so what do you plan to do about it, nullification. The obvious answer is no, a Supreme Court challenge. If the federal goverment requires states to set up exchanges, the current Supreme Court might, indeed, find that provision unconstitutional. In the case of New York v. United States, the Supreme Court has held that the federal government may not "commandeer" states do administer programs it sets up, but must do so itself. Requiring states to set up interchanges sounds very much like unconstitutional "commandeering" and could very well be struck down. And without interchanges, the whole system will fail.

The other critically important issue is when the whole thing is implemented. The delay in implementation is basically an accounting gimmick to conceal the true costs of the bill because Blue Dogs are afraid to vote for anything too expensive, but accounting gimmicks are not a good method of fiscal responsibility. To delay relief to someone in need of health coverage now for the sake of an accounting gimmick is lousy policy. It is even worse politics. In the end, if there is one thing the public hates more than deficits, it is any serious attempt to get rid of them.

But above all else, the benefits under the system would do well to vest before the 2012 election if Democrats want the whole reform to survive. Republicans will pull out all the stops and unleash all hysteria in the 2010 elections. Undoubtedly they will pick up seats. They may very well repeat 1994 and win majorities in both houses. But barring truly extraordinary events, it is unlikely that they will win 2/3 majorities in both houses. That means Obama will be able to veto any attempt to repeal the health care bill.

Granted, passion on the subject will probably die down after a while when the bill passes and nothing catastrophic happens. But if the benefits do not vest by 2012, Republicans can always ramp up the hysteria in that year by warning that the bill is about to take effect and only we can stop it. Consider what the 2012 election could sound like. Republicans will warn that if the Democrats win, healthcare reforms will vest next year lead to the end of liberty as we know it, complete government takeover of healthcare, Communist tyranny, death panels, euthanasia of seniors, T-4, Soviet tanks in the streets, cats and dogs living together, etc. Democrats will warn that if Republican win they will block health care reform from vesting and you won't get all those benefits we promised you back in 2009. It isn't hard to see which is the stronger argument.

By contrast, if the exchanges are actually up and running in 2012, it will be extremely difficult for Republicans to convince anyone that liberty has ended, death panels are murdering seniors, Soviet tanks are occupying the country, cats and dogs are living together, etc. Instead, Democrats will tell people that Republicans want to take away their health insurance. It will be a tad bid awkward for Republicans to tell people who have purchased policies with government subsidies that their doing so has ended liberty as we know it, and that if we don't take away their insurance, the country will degenerate into a Communist tyranny. More likely, they will issue unconvincing and easily refuted denials that they ever saw the whole thing as a problem.

And if this doesn't convince Democrats, consider an alternative scenario. Republicans take power in 2012 and do nothing at all to stop the exchanges and subsidies from vesting. When people without insurance start buying coverage, Republicans will take credit for the program and say it proves they are so much better at delivering healthcare than Democrats. Don't put it past them.

Polarization: It's Not Just Fox's Fault

Let's face it. Although I continue to be disturbed at the degree of polarization we are experiencing, when our own side starts shouting down speakers at town halls, biting off fingers and killing abortion protesters, it is time to realize that we are not blameless. Yes, the other side started it with their talk of "death panels" and other such lies, but we, quite simply, are taking the bait and allowing ourselves to be provoked. This has two dangerous effects -- it encourages the right wing's martyr complex, and it escalates the polarization further, and from both sides. This is what we must not do.

I blame the media. For the polarization on both sides. Two excellent Washington Post columns explain the twin problems at work.

One problem is that the public is poorly informed. Obviously Fox News and talk radio tell a lot of lies. That's what Fox News and talk radio do. Nothing we can do about it. But mainstream news outlets have been falling down on the job of explaining what is really going on. By that I mean not just explaining that there are no death panels being proposed (they have at least made the attempt there), but a failure to explain what is being proposed. Andrew Alexander, Washington Post ombudsman, reports that 72% of all the Post's front page articles since the beginning of July have been about the politics, rather than the policy of health care reform. Policy-oriented articles are often too wonky for most readers to follow. Authors tend to assume that readers know what terms like "single payer" or "public option" mean. Alexander proposes that newspapers make policy issues accessible to non-wonks by features like "glossaries explaining basic terms, easily digestible Q&As, short sidebars that summarize complex concepts and graphics that decipher complicated data." He also proposes more stories on what reform means to the average citizen.

Of course, none of this will sway people who automatically discount everything in the "liberal media" and believe only Fox News. But it is a mistake to exaggerate their numbers, and therein lies the other problem. Alexander reports that an article about healthcare systems in other countries was among the most popular items published by the Post. The hardcore Fox crowd would never link to such an article. Columnist E.J. Dionne reports the constant bias toward sensationalism. In fact the angry crowds shouting speakers down, the Obama as Hitler signs, the talk of "death panels," and other such hysteria made up only a small fraction of all such meetings. We should have suspected as much when Obama went looking for such a crowd to work and couldn't find one. Dionne even quotes a network reporter as telling one Congressman, "Your meeting won't get covered unless it blows up."

The result is obvious. While Fox News stokes right wing paranoia with reports of "death panels," mainstream outlets stoke liberal paranoia with tales hysterical mobs shouting down speakers and comparing Obama to Hitler. Liberals denounced such things, in turn feeding the anger and fear of more reasonable protesters who then felt unfairly demonized. And so the polarization grows and the health of democracy suffers.

No one will hear me writing on this obscure blog, but if they did, I would not waste time trying to convince Fox News, talk radio or Republican leaders to be more reasonable. It is obviously not in their nature. But to the mainstream media, I would say, follow Andrew Alexander's advice. Write more about policy, geared to the non-wonk, so that the general public will understand what is being debated. This is not to suggest that everyone who understands the proposed reforms will favor them, only that there will be more room for rational debate. And when debate becomes irrational, follow Dionne's advice. Yes, irrationality is news and deserves to be reported. But give us some perspective. If the vast majority of meetings are not blowing up, show some of them, too, and give us relative numbers. Your bias toward sensationalism is contributing to the polarization that is most deadly to democracy.

And to Democratic leaders. Barney Frank's approach can be tempting. Yes, when people are being irrational, it can be tempting just to mock them. But it will just be met with either counter-mockery or a sense of martyrdom. Al Franken has it right. Rationally engage whoever is engageable, be wonky but not patronizing, treat your constituents like adults. Be Franken, not Frank. And we may cool things off yet.

Anti-Healthcare Protests: Why They Are Nonetheless Alarming

Although I emphatically do not consider the Republican Party fascist, I do consider its behavior since the 1990's both disturbing and dangerous to the future of democracy. Sarah Robinson's mistake was her exclusive focus on fascism. One of her top readers makes the same mistake, saying that the fascist analogy is flawed and we are really more like the Roman Republic.

The problem here is that all historical events are individual and unique. Exact parallels do not exist. Many popular governments have failed throughout history. Only two have become full-fledged classical fascist regimes (although fascist movements may have played a role in the downfall of others). To recognize when there is danger, it is better to move from the narrow issues of classical fascism (a unique event unlikely to repeat) to the broader issue of how democracies fail in general, to see what overall patterns recur.

Occasionally a foreign power is to blame. The Thirty Tyrants in Athens were installed by the Spartans. The French Third Republic fell to the German Army. Nascent democracies in Eastern Europe after WWII were undone by the Red Army.

But in the absence of an overwhelming foreign power, for all the individual variations, there is almost always the same underlying pattern. Rival factions become increasingly polarized. At least some factions come to value their own power over any sort of procedural fairplay. Indeed, such factions may be openly contemptuous of procedural fair play. Strife between factions escalates. Political violence becomes increasingly common, and grows. Democratic institutions are unable to contain the ever escalating factional strife and eventually break down.

The outcome is not always the same. Sometimes one faction comes to power through semi-legal channels and uses the state to suppress its opponents. That was the pattern for the classical fascists in Germany and Italy, as well as in Portugal. But democracies can fail in other ways as well. Sometimes the collapse into civil war and anarchy (Lebanon, the United States). Sometimes the military takes over to end the factional strife by force (Chile). Sometimes there is a complex combination of these outcomes (ancient Rome, modern Spain). But the basic pattern of escalating polarization, factional strife, and political violence recurs every time, whether in ancient Rome, Germany, Italy, Spain, Portugal, Chile, Lebanon, or even the United States. (Let's face it, when democratic institutions fail to resolve the leading issue of the day and a civil war ensues with 600,000 dead, that has to count as a serious failure of democracy, even if both sides in the war maintained their committment to democracy throughout).

To date we are still far from being a failed democracy. A strong democratic heritage and consciousness, and a tendancy across the political spectrum to equate democracy with national identity make it just about impossible for anyone to reject at least the outward forms of democracy. But polarization is reaching a fever pitch. Republicans are refusing the recognize Democrats as real Americans or legitimate political players. Willingness by prominent, respectable Republican leaders to liken Obama to Hitler and spout flagrant lies about his policies, anti-health care demostrators shouting down speakers and seeking to shut down debate are all signs that our traditional notions of fairplay are being abandoned. No political violence so far, but people are bringing guns to political demonstrations. Militias are returning. Death threats against Obama are four times the volume of death threats against Bush.

Overall prognosis: It looks bad, but could be a lot worse.

So what do I recommend?

First, don't be intimidated. Pass a healthcare reform. It may escalate polarization in the short run, but Republicans made a mistake in telling so concrete and easily falsifiable lie as death panels killing granny. If healthcare reform passes and death panels do not, in fact, kill anyone's grandmother, it is going to be difficult to convince people that they did.

Second, when Republicans fight dirty, don't adopt the same techniques. That will just escalate the polarization further. Call them on it. Every time a Republican of any prominence equates Obama to Hitler, introduce a resolution in Congress condemning the characterization. Point out that our side honorably voted for a resolution condemning MoveOn.org for a similar offense. When militia types bring guns to a demonstration, point out, as E.J. Dionne has that "[A]n armed citizenry is not the basis for our freedoms. Our freedoms rest on a moral consensus, enshrined in law, that in a democratic republic we work out our differences through reasoned, and sometimes raucous, argument. Free elections and open debate are not rooted in violence or the threat of violence. They are precisely the alternative to violence." Shame is the appropriate remedy for shamelessness. Let's start using it.

Third, expect this to happen next time and prepare in advance. Keeping in mind that (1) Republicans will try to shut down any significant Democratic initiative and to make Democratic success impossible, and (2) whoever speaks first and most aggressively controls the media narrative, what is the obvious conclusion? That every time the Democrats launch an initiative, it must be introduced with huge media blitz, explaining over and over, in terms understandable to an ordinary, low-information voter, WHAT THE HELL WE ARE PROPOSING. I am not suggesting lying or blatant propaganda, though over simplification is inevitable. My point is simply the earlier and more often voters get hit over the head with WHATEVER THE HELL WE ARE PROPOSING, the more difficult it will be to distort later on. Consider the following polling statistics. When asked simply whether they favors or opposed the proposed healthcare bill, respondents opposed it 42% to 36%. When the pollster explained WHAT THE HELL WAS IN IT in accessable terms, the results shifted to 53% in favor to 43% against.

Finally, in addition to the depressing study of democratic governments that failed, we should also study ones that became dangerously polarized, but ultimately pulled back from the abyss. The French Third Republic during the Dreyfus Affair and the transition between Fourth and Fifth French Republics immediately come to mind. No doubt there are many others as well. Not being xenophobes, we are not afraid to learn from other countries, even the French. Let's see what they can teach us about how democracies avoid failure.

UPDATE:
I cannot recommend highly enough this post by Glenn Greenwald. He encapsulates perfectly everything I want to say about Republicans. In particular, the attacks on Obama are not, in the end about race. They are about Republicans being unwilling to recognize any Democratic President as legitimate.

Anti-Healthcare Protests: Why They Are Not Fascist

It is not only Republican lies and hysteria about healthcare reform that deserve to be condemned. Our own side has committed its own share of alarmism with talk of "Brownshirt tactics." In particular, I am belatedly responding to Sarah Robinson's claim at Orcinus that Republicans have gone full-on fascist over healthcare. Taking historian Robert Paxton as her source, Robinson argues that the Republican party has gone fascist because we are no longer seeing any daylight between conservative elites and the right-wing mob.

All through the Bush years, progressive right-wing watchers refused to call it "fascism" because, though we kept looking, we never saw clear signs of a deliberate, committed institutional partnership forming between America's conservative elites and its emerging homegrown brownshirt horde. . . . America's conservative elites have openly thrown in with the country's legions of discontented far right thugs.

The fact that "brownshirt thugs" have not engaged in any actual violence so far, certainly nothing on the scale that, say southern racists deployed against Civil Rights workers in the 1950's and '60's is less important to Robinson than that conservatives have openly aligned themself with them.

I see several problems with this analysis. For one thing, while it is true that both Mussolini and Hitler came into power by forming an uneasy alliance with the conservatives, it is also true that, contrary to the common Marxist analysis of the day, it was not the conservatives who were using the fascists to achieve their goals. It was the fascists who were using the conservatives. Granted, one may argue today that the GOP has been taken hostage by its wingnut base, and that sane conservatives have little choice but either to join the Democrats or to go along for the ride. But I see no evidence that the truly insane members of the GOP have the sophistication to manipulate the conservative elite. The manipulating lies over healthcare looks pretty one-sided to me.

The tactical differences between (German and Italian) conservatives and their fascist counterparts are also significant. Both parties shared many goals such as crushing the left, ending strikes, and restoring national greatness. But fascists did two things that should scare the hell out of any right-thinking conservative (and did alarm German and Italian conservatives). They whipped up the ugly passions of the mob, and they used street thugs and mob violence to achieve their goals. Now obviously the leaders of the GOP and their allies in Fox News and talk radio are showing themselves eminently willing to whip up the ugly passions of the mob. But so far I see no evidence, none whatever, that they are willing to condone actual violence and street thuggery. Some have even gone so far as to condemn taking guns to protests (especially while carrying signs urging some human sacrifices to the tree of liberty). Granted, telling armed men that Obama wants to kill your grandmother is the sort of thing that tends to invite violence. But so far I have every reason to expect that if any violence did break out, conservative elites would take alarm and seek to reign it in.

And finally, Robinson, following Paxton, strains too hard for paralells, trying to force today's situation to match intra-war Germany and Italy. (Mussolini's Blackshirts broke up a farmworker's strike. Republican nativists threaten Mexican farmworkers. This is starting to look almost Goldberg-esque). I prefer to take a broader and more general definition of fascism and see how well today's Republican party fits. This conservative historian offers a fairly decent definition of fascism, "a paramilitary party that has taken over the state and claimed an effective monopoly of political activity."* Or, aspirationally, a paramilitary party seeking to take over the state and claim an effective monopoly on political activity. That is something sufficiently alien and odious to our American political tradition that any open attempt would arouse intense resistence and rejection.

Can it happen here? Has it? Robinson quotes Paxton as suggesting that it has, that the Reconstruction Ku Klux Klan was the first authentically fascist movement. Was the Klan "a paramilitary party . . . claim[ing] an effective monopoly on political activity"?

Well, the Democratic Party during the Reconstruction clearly did not acknowledge the legitimacy of the Republican Party and sought (successfully) to make the South a one-party state. Whether the Democrats would have accepted a rival party that was not associated with the hated North and did not advocate racial equality is an open guess.

Could the Klan be considered a paramilitary adjunct of the Democratic Party? Well, it was paramilitary in the sense that it used violence and intimidation, and an adjunct of the Democratic Party in the sense that it wanted to (and ultimately did) suppress the Republicans. But the Klan was neither paramilitary nor an adjunct to anyone in the sense that it had no hierarchical command structure and was not really under anyone's control. Also, the Klan differed from Mussolini's Blackshirts or Hitler's Brownshirts in that it basically dissolved once it achieved its goal. While Mussolini and Hitler, once in power, set up organized secret police to take the place of their street thugs, Southern Democrats, once in power, did not maintain it with a paramilitary, unless one counts ad hoc lynch mobs even less organized than the Klan.

So, what about Republicans? Does the latest outburst of hysteria make them "a paramilitary party . . . claim[ing] an effective monopoly on political activity"? Only by stretching those terms beyond any reasonable definition. Yet at the same time, it has just enough tendancies in that direction to be disturbing.

It has been apparent since 1992 that Republicans are not willing to accept any Democratic President as legitimate. Bill Clinton was a junkfood-eating Arkansas hillbilly who belonged to the conservative Democratic Leadership Council that sought to attract votes by bringing the Democratic Party toward the center. Yet throughout his term of office, Republicans denounced him as a wild-eyed radical, invented talk radio and Fox as weapons against him, dug constantly into his tiniest indiscretions, and ultimately impeached him over a blow job. Howard Dean was denounced as a deranged radical in the 2004 primaries until Democrats became so alarmed that they chose the presumably more electable John Kerry -- only to see the hostility almost seemlessly transfer. For 16 years, Republicans have been working themselves into a frenzy of hatred of Hillary Clinton in preparation for the day she ran for President. Yet the moment it became clear that Obama would be the nominee, they once again promptly and seemlessly transferred their hostility, actually discovering a belated respect for Hillary.

This is linked to the belief that only conservatives are "real Americans" and the quest for a permanent Republican majority. Yet a true one-party system would never be tolerated in the United States. The words permanent Republican majority make the point clear -- Democrats will be tolerated and allowed to run for office at all levels, so long as they do not exercise any actual power.

As for a paramilitary party, that, too, is completely unacceptable in this country (the Ku Klux Klan notwithstanding). Crowds at town halls who shout down the speakers and spout outrageous lies not paramilitary -- they are neither violent nor have a command structure.

That leaves the militia movement, which is once again reemerging. Now obviously the militia movement is not a paramilitary arm of the Republican Party. In fact, in the 1990's, in could plausibly deny being partisan. It got its first stirrings under the senior Bush, who alarmed them with talk of the "new world order" and offended them by fighting the Gulf War through the UN instead of unilaterally. The Ruby Ridge incident took place under Bush's watch. The destruction of the Branch Davidians at Waco was genuinely shocking. And the Clinton Administration really was seeking gun control measures. In short, the militias could claim to be upset over more than just having a Democrat in the White House. And the demise of the militia movement could be attributed at least as much to 9-11 as to the election of Bush Junior.

But the return of the militias coinciding exactly with the election of a Democrat, together with the absence of any proposed gun control legislation or anything else that could reasonably be taken as provocation makes their real agenda clear. They are angry that a Democrat won the Presidency and cannot accept him as legitimate. Now, obviously this does not make the militia movement a paramilitary adjunct of the Republican party, as opposed to independent individuals who think that a Democrat in the White House is reason enough to prepare for armed resistence. But when Fox and talk radio keep spouting, and Republican leaders keep implicitly endorsing, outrageous paranoid lies that inflame and encourage militia types, it gets harder and harder to deny a certain indirect collusion.

That being said, the militias have never used violence and intimidation to sway the outcome of an election, which makes them unlike Blackshirts, Brownshirts, or the Klan. It is also no doubt true that in case Republicans achieve Karl Rove's goal of a permanent majority, the militias will go away, rather than serve as their paramilitary arm. To the extent Republicans dream of a one-party dictatorship, it is a soft dictatorship on the Mexican model, not the totalitarian variety.

In short, calling Republicans fascists is both false and dangerous. But Republican behavior in the healthcare debate is also dangerous and alarming. My next post will discuss what I see as the real danger.
____________________________________________________________
*To this s/he adds militaristic policy, the abrogation of the procedures of liberal democracy, the actual militarization of society, the successful penetration of the state into the everyday life of the individual, and a very significant degree of actual state regulatory control over the economy. But right now I am less interested in what fascists do once in power that how they seek to get there.

When Politics Eclipse Policy

I had planned a belated post on the Torture Memos, but it will have to be even more belated, because the whipped-up hysteria over healthcare reform is becoming more and more disturbing. In fact, mendacity and sheer insanity of the protests is becoming so disturbing and so far out of bounds of what was formally acceptable debate that the tone of the protests is beginning to eclipse the issue itself.

What is so disturbing and out of bounds here?

Certainly not the existence of the dispute. I do not doubt that Republicans have sincere, principled disagreements with the Democrats' proposal. Nothing wrong with that. That is politics as usual and might, by itself, even be amenable to compromise. Two factors prevent compromise. One is a matter of policy -- Democrats and Republicans and ideologically incompatible views of how to handle rising health care costs -- regulate more versus regulate less. The other is political -- the opposition party wants to thwart the ruling party to keep it from looking successful. Ideologically, Republicans fear that universal health care will go badly. Politically, they fear it will go well. But this dilemma, too, is nothing new or, by itself, especially disturbing.

What is disturbing is the outrageousness of the lies being told about this proposal, how broadly they are being spread, the willingness of the senior Republican leadership to go along with them, the the hysteria they are whipping up. Yes, a certain degree of spin, distortion and deception is a normal part of political debate. When Bill Clinton came out with his own health care proposal, there was a great deal of discussion among opponents about the horrors of single payer, but no acknowledgement that he was not, in fact, proposing a single payer. But there was nothing at the time like accusations of "death panels" pulling the plug on Grandma, comparisons to Hitler, and even remote insinuations that the elderly, the sick and the handicapped would be murdered. Yes, there have always been fringe groups of paranoids who held beliefs like this, but these are views being propagated, not by fringe groups, but by mainstream channels like talk radio and Fox News, and being pushed (well, usually hinted at in such a way as to maintain plausible deniability) by mainstream Republican leaders. The Republican leadership quite simply has decided to sever any ties to real world fact and just shriek out any lie that serves their purpose. Such a breathtaking level of cynicism is both new and alarming.

Also alarming are the angry crowds showing up, believing these outrageous lies, shouting down anyone who disagrees with them and even packing heat. Granted, there have not been actual outbreaks of violence. But telling an armed man that Obama wants to kill your grandmother is playing with fire.

Even more disturbing is that shrieking blatant lies seems to be working. One might dismiss a recent poll saying that support for the bill before Congress has fallen to 36% in favor an 42% opposed. More disturbing is that fully 45% of all respondents at least partially believe in the "death panels." And, although respondents are about evenly divided in their opinion on the protests themselves, the critical independents say 50% to 34% that the protests have done more good than harm. The protests, in other words, are swaying, rather than repulsing, swing voters. As one commentator remarks, "[I]t creates an enormous incentive to lie, blatantly and repeatedly, to the public. There are no real penalties, and the number of Americans who'll believe nonsense skews the debate in the liars' direction." This means that whenever any other major Democratic initiative comes up, Republicans will repeat the tactic.

So what is the agenda? Well, in the short run, presumably to shut down a Democratic Congress, to make it impossible for Democrats to pass any major initiative. Presumably the goal is to drive the base into a frenzy and associate Democrats in the mind of swing voters with ineptitude and inability to get anything done. The short run goal is presumably to win Congress in 2010, just as the Republicans did in 1994, and to win the White House in 2012.

But there is a problem here. Whipping the base into a frenzy and turning swing voters off of Democrats as inept is not really a good long-run strategy. Frenzies are exhausting and not sustainable. And if the Republicans do win a majority in 2010, they would do well to remember the lessons of 1995. Upon taking over Congress, Republicans promptly overreached. Demonizing Democrats can win elections and turn voters off of the Democratic agenda, but it will not win any converts to the Republican agenda. No one much liked what Gingrich and his crowd were trying to, and Bill Clinton rebuilt his Presidency by standing up to the Republican Congress.

The long-run goal, presumably, is to continue working on Karl Rove's project for a permanent Republican majority. Needless to say, the 2008 election was a setback to that goal, but to judge from the level of hysteria the Republican Party and its media allies are seeking to whip up, it apparently has not been abandoned.

From the very start, Rove's plan was not structurally sound. Permanent* control of the government by one party is stable only if that party enjoys a strong majority of popular support. And over the long haul, that sort of support is sustainable only by enacting sound policies and competently implementing them. Rove wanted to take a country fairly evenly divided between the parties, muster 51% support for Republicans, and exclude the other 49% from power entirely. To do this, he focused on ignoring moderate swing voters, rallying the base, demonizing nearly 49% of the population, and enacting policies based on their appeal to favored constituencies, without much regard to their effectiveness. The result was a general ineptitude that turned an evenly divided population sharply against Republicans and their ideas. Yet the Republicans show no intention of changing their policies.

So how do you build a permanent Republican majority when your party does not command majority support and your ideas are widely unpopular? To judge by the hysteria currently being whipped up, the answer appears to be to undermine and delegitimize the Democrats, by fair means or foul. Demonize any Democrat who has the unmitigated audacity to usurp the Presidency. Turn their presidency into a frenzy of accusations and ugliness. Proclaim the Big Lie on Fox and across talk radio. Make it impossible for Democrats to pass any significant legislation. Whip up the mob if they appear to be succeeding. And explain that given the level of oppression underway, you completely understand the returning militia movement.

Granted, none of this will actually make Republican ideas or their implementation any more palatable. But it may at least be more palatable than the paralysis and orgy of recrimination accompanying a Democratic government. What we are seeing now looks like an attempt at permanent Republican majority by blackmail -- vote for us, or we'll shut the country down.

You think the hysteria in the Clinton years was bad? You ain't seen nothing yet.
_________________________________________________________________
*By "permanent" here I do not actually mean until the end of time, and do not think Rove meant it that way either. Beyond the lives of the present generation is a fair definition of permanent in a this context.

Healthcare Tradeoffs: We Don't Like the Ones the Market Makes

Moving past the hysteria about "death panels" and "pulling the plug on granny" to written columnists there are some serious conservative critiques of the proposed healthcare plan. My local newspaper ran one by John Stossel that perfectly reasonable point. Healthcare proposals are claiming to be able to do three incompatible things -- extend coverage to more people, control costs, and not interfere with people's freedom of choice. To achieve any two of these things, the third must give way. It's a fair point. I would like to have a serious discussion of how to find the appropriate balance. But the current atmosphere makes such a debate impossible.

Consider the hysterical screaming. Death panels will pull the plug on granny! A government bureaucract will come between you and your healthcare! (Anything that reduces freedom of choice is out). How are we going to pay for it all! Will this increase my taxes? (Costs must be contained). They're going to cut Medicare! The old, the sick and the handicapped will suffer most! (So much for excluding more people).

So what does Stossel propose? Well, other than saying that the market knows best, he is careful not to say. In an earlier column, Stossel warns of the monstrous despotism that will occur if the proposed bill pases. Evil government bureaucrats and social engineers make our medical decisions for us. Innovation will cease. Monstrous distortions will enter into the system. We will all end upon a Hayekian road to serfdom. Carefully ignored in the earlier column is that we already have such a system for everyone ever 65 -- it's called Medicare. If all these horrible things will come about under universal healthcare, shouldn't there be at least some sign of them under Medicare. Unfortunately for Stossel, he is able to point to only one -- it has cost a great deal more than originally anticipated.

In his current column, Stossel makes clear that current Medicare rates are unsustainable. Government will have to do one of three things -- cut Medicare spending, raise taxes, or start limiting what it will cover. Stossel takes great care not to say which one of these options he favors. But he makes clear that raising taxes will be disasterous and interfering with patient decisions will be despotic. Cutting payments he merely regards as politically unpalatable. This gives a hint of which approach he truly favors.

Ultimately, Stossel has only one answer to give -- let the market decide. Given his way, he would undoubtedly eliminate Medicare and Medicaid as unwarranted government interference with the free market. Lamenting American's failure to fear the threatened despotism, Stossel complains that he gets comments like, "I guess the 47 million people who don't have health care should just die, right, John?" Significantly, he does not answer that question. But from a strict free market perspective, the answer is yes. If you take a gamble not buying health insurance, you should face the consequences of losing it.

Stossel's proposal -- let the free market decide -- will undoubtedly give theoretically unlimited choices to consumers, restricted only by their ability to pay. It will definitely cut costs. But it will do so at the cost of excluding much greater numbers of people, including many otherwise uninsurable people now on Medicaid or Medicare. A whole lot more people will die. Many others will have chronic, painful conditions untreated. The free market, quite simply, will control costs by excluding more and more people, rather than by limiting choices. To someone like Stossel who regards preserving free market choices as the supreme good, this is acceptable. To most of us, it is not.

Healthcare -- A Word of Advice No One Will Hear

Not surprisingly, Republicans have moved into full-on fearmongering mode about ObamaCare. (Much worse than they were under the Clinton Administration because this time it might actually pass).

We have been warned in the most apocalyptic terms possible about the consequences of any sort of healthcare reform passing. Possible dangers invoked include government controlled healthcare, a government bureaucrat coming between you and your doctor (aren't insurance company bureaucrats much better?), loss of right to choose your own doctor, sub-third-world levels of care, euthanasia of seniors to save on health care costs, horrendous despotism, Americans reduced to Egyptian slaves building the Pharoah's pyramids, dogs and cats living together, etc, etc.

How do you argue with that level of fearmongering? It certainly won't do to point out that Canada and most of Western Europe have varying types of universal healthcare without any such apocalyptic consequences, for two reasons. For one thing, most opponents of healthcare reform already think Canada and Western Europe provide sub-Third World levels of care and are horrendous despotisms. For another, the mere suggestion that some other country might have a good idea worthy of emulation is enough to set off a lot of right-winger's inner xenophobe. (Oh my God, they think other countries are better than us! They want us to stop being Americans and turn into Canadians!)

A better approach would be to point out that here in the USA we already have a major government-controlled health insurance. It's called Medicare. All people over 65 are eligible to belong and so far no one has noticed the government doing them in to save on costs. In fact, life expectancy has increased quite a bit since we adopted it.* If government involvement in healthcare were altogether as catastrophic as you claim, wouldn't we see at least some sign of it with Medicare? And, better yet, dig up some of the fearmongering that occurred when Medicare was first proposed to show just how similar it was to the fearmongering at work today.
__________________________
*That is not meant to suggest that the adoption of Medicare caused the increase in life expectancy. Proving or disproving that would require going back in time with a time machine, stopping Medicare, and seeing what happens. But it clearly proves that government-controlled health insurance is compatible with vast increases in life expectancy.