Taking Care

I still lack the heart to get into the nitty-gritty of the healthcare summit; other than to say it went pretty much exactly how I thought it would: the Republicans' last experience of live TV discussions with the President persuading them to come far better prepared this time.

However, since S. Spielbergo has spent some time discussing the overall situation over at his own blog, I thought I'd take a big risk and actually start tearing up online articles by people who are actually liable to respond.

For us Europeans the American system just boggles the mind – we just can’t begin to fathom why they don’t have a similar system to us. I mean as much as we complain about it, we basically love our NHS (well your NHS and my small island equivalent). We like that we never need to be concerned about having the right cover, or that our insurance premiums will go up, or getting a long term condition or any of that rubbish the Yanks have to deal with on our daily basis.

We’re basically used to what we have, and we like it so it’s hard to understand why those “evil” Republicans are so hell bent against the idea…

At this point it is worth pointing out that in my view the Democrats aren’t a lot better and most of their suggestions are just improvements on a broken system rather than the complete rebuild it actually needs.

Actually, it's not at all hard to understand why those evil Republicans don’t want the idea, any more than it’s hard to understand why they don’t want people’s inheritance taxed, corporate money into their coffers limited, illegal immigrants given medical care, and so on: it’s predominantly a combination of dogmatically insisting freedom is exclusively determined by what the law doesn’t prevent combined with a pathological fear of people getting money the GOP thinks they don’t deserve.

And make no mistake, my deletion of Spielbergo's scare quotes is deliberate. The Republicans as a party are evil, or at least their actions are evil, if you'd rather think of it that way. There is simply no other way to describe people who ask their countrymen to elect them so as to serve their interests and then turn round and argue that it isn't worth trying to save the lives of 18 000 to 45 000 citizens every year.

I have no doubt that if the Republicans had brought a bill to the summit on Thursday, I would have despised it. There would already be thousands of posts up across the blogosphere about how terrible it was, and one would probably be mine. But at least at that point the Republicans could argue they were aware of the problem, and had an idea how to solve it, even if I thought that idea was ridiculous.

Instead, they said they had no intention of even considering the problem, and just tried to dodge the issue each time it was raised.

You can't do that, and it not be evil. These people volunteered to take responsibility for the general public, and then flat out refuse to even admit the existence of the problems that are quite literally killing many of those same people. Not only that, but they've actively argued the methods for saving lives the other side have suggested will lead to the government killing people. It takes a certain sort of moral vacuum to try and protect a status quo that kills people by stating that the changes will kill people and knowing damn well that you're lying. It's attempting to justify your willingness to let people die by pretending you care too much about them for you to risk them dying.

This goes back to my long-term problem with many conservatives; it's impossible to conclude that these people have an ounce of empathy for those failed by the system when all they do is insist those people don't exist. It's one thing to listen to a story about a woman forced to wear her dead sister's dentures because she couldn't afford to visit a dentist and then argue that hard choices have to be made in a society and we can't protect everyone; it's quite another to start mocking the idea that this mightn't be something we should put up with in one of the most affluent nations in the world. For sure, many people who do that sort of thing aren't evil, just appallingly callous (and bollocks to their complaints that they were "only joking"; you only get to claim you were joking when the rest of your behaviour makes it clear you didn't believe what you're saying). It only becomes evil when one has the direct ability to do something about it, and instead mocks the very idea that one should feel obliged to try.

Anyway. With that point aside, think there’s some conflation going on here in Spielbergo's argument. I do, as Spielbergo says, love the NHS. Crucially, this is not because I am European, it is because I am British. I’m sure plenty of French people love the French system and plenty of Swiss people the Swiss system. This is an important point because all three systems are very different. It does no-one any good to compare America's system to "Europe's".

Spielbergo is entirely right that the Democratic proposals are too timid to fix the current system. This is not because the system is fundamentally flawed, however. It’s only fundamentally flawed if you assume the US needs a specifically NHS-style system; a system to which the States is indeed probably institutionally (to say nothing of ideologically) incapable of applying. Choose something like, say, the Swiss system instead, however, and the degree of large-scale changes needed becomes far, far less. Those who know far more about these things than I do have been suggesting the Swiss model be adopted precisely for that reason; it works far better than the US model and is sufficiently structurally similar to make implementing it theoretically feasible with a minimum of fuss. I’m not sure I'd even would recommend anyone else following the NHS model at all, actually, since as far as I can determine it's chiefly noteworthy for the fact it manages to operate pretty well despite us putting so little money into it.

Anyway when you stop and think about it from the Republicans perspective you can kind of (well kind of) get what their problem is with the idea. They have a system already in place that the majority of Americans are happy with – yes there are some holes (and some pretty big ones at that), but the system by and large seems fairly popular. First point for a conservative is therefore why rock the boat? If it isn’t broke don’t fix it and all that jazz.

There are three problems with arguing that the system is fairly popular. The first is the most obvious: the fact that people are happy now does not mean they'll be happy in a few years following the massive increases in insurance premiums heading down the pipe (and which have already been announced in some states, like Maine and California). Arguing that a system isn't broken yet is embarrassingly short-sighted, and doesn't deserve to be considered as a sensible objection unless those people arguing it can suggest how to fix it at a later date. Certainly, anyone who argues we need to do something about global warming must immediately recognise the foolishness of this argument, since right now, the planet isn't exactly in dire straits. So why worry, huh?

The second problem is that this argument only tracks following the most superficial consideration of the statistics. Yes, the vast majority of Americans list themselves as very or somewhat satisfied with their healthcare. Of course, it would be tempting here to argue that there was probably a time when the vast majority of Americans were OK with slavery too. I'm not going to, because the comparison would be unfair, but it does highlight the important truth that it is meaningless to cite the percentage of people happy with a situation without considering the damage being done to those not happy.

In any case, a closer look at the data suggests a different story. Fully two thirds of those who have had recourse to their insurance claims describe their bills as having a major adverse effect on their lives. Almost a quarter state they put off seeking medical help for lack of funds. More than half are concerned that losing their job will cost them their insurance (which raises another important point: being happy with what an system has allowed you is not the same as being happy with the system itself ). A fifth state they have had difficulty persuading their insurers to pay up.

Given this, the question is not "Why change a system so many people are happy with" so much as "How can a system with such drawbacks still lead to people being satisfied". My own personal take on this would be Occam's Razor; these people are satisfied because have no experience of alternative medical systems under which they'd be better, and because the nature of the current system is such that you can be rejected or bankrupted by insurers at the drop of a hat, which means many people are probably satisfied at least in part because they've escaped the worst case scenario.

Regardless of how close to the mark that speculation is, I'd argue it would be far more sensible to look at the stats regarding how insurance claims have affected people, rather than how much those people feel they're hard done by in comparison to others.

Lastly, and related to the above, the problem with this kind of appeal to the will of the masses is that never actually seems to account for that will properly. Sure, majority of American’s prefer their own healthcare, but a majority of them also believe the system should be changed. A wide margin more people (9%) support rather than oppose the Democratic HCR proposal once they know what is in it. This after over a year of being told the bill would explode the deficit and kill your Grandmother.

So it seems strange to argue that if most people like their current insurance it shouldn’t be changed, even if most people think it should. I know cherry picking polls and stats is hardly a practice limited to Republicans, but it doesn't make them right to do it.

The second issue is they are quite firmly behind the idea of small government – Now the NHS in the UK comprises £119bn in costs – which means to add it on (if we didn’t already have it) would increase spending by about 30%. You ask any proponent of smaller government if they want to take a system out of the private sector and increase government spending by 30%, I’m pretty sure they are going to turn around with a very large NO!

The problem with this argument is that the current cost of American healthcare to the taxpayer is already higher than ours. Nor is anyone suggesting taking a system out of the private sector, this is about regulating that part of the private sector more stringently. Now, a "small government" conservative can certainly still object to the increased regulation, but make no mistake; said conservative would be making that argument despite a reduction in the tax burden, not in addition to it. Moreover, as I've said, comparing the proposed changes in the US system to the NHS is pointless, because no-one has proposed aping the NHS in any case.

Of course, the Republicans have spent a good deal of the last year pretending that is what’s been proposed, which should be the latest in a long line of clues that trying to fairly determine where they stand on this issue is liable to be a waste of one's time.

And yes Squid I know all those 50 million uninsured and 18,000 dying each year should be a good argument – But well it hasn’t worked so clearly it isn’t.

This is, needless to say, entirely backwards, if not out-and-out insane. First of all, this implies that an argument is only good if it works, and that it works only if the other side immediately capitulates based on its quality, which is so far away from the way politics works I’m amazed anyone could possibly suggest it. Whether or not an argument works depends not on the opposition agreeing with it (and just how often do you see that happen?), but on how well it drives public opinion, shoring up the poll numbers that might just persuade someone (in this case the Democrats) to stop cowering and get something done. Getting the Republicans to admit they're wrong has never been the objective. Persuading the public the Republicans are wrong is the name of the game.

Second, when this particular argument fails, it isn’t proof the argument itself is bad, it’s proof that the Republicans are so far away from any position that can be squared with concern for their constituents, interest in carrying out their responsibilities, or a desire to negotiate in good faith, that every single word put down in a paragraph that starts with “Looking at it from their perspective...” is tragic waste of vowels and consonants that might otherwise have been used to describe a good movie or craft a dick joke.

What Spielbergo means, as far as I can discern, is that the only way a political argument can be good is if the other side is either forced to agree with it in public, or pretends not to agree with it but changes their stance anyway. As a general rule, I would agree that those are the arguments that could certainly be considered the most successful within political circles (outside of the court of public opinion, though of course that's still relevant because it's only when they're paying attention that it matters that a party has been forced into admitting the other side have a point). In this case, though, it doesn’t matter, because Obama is coming at the Republicans with their own arguments, and they’re still pretending they don’t agree. There are any number of provisions within this bill that Republicans still in Congress are on the record for having supported. Last year, the general feeling amongst the GOP was that 80% of the HCR bill was in line with their philosophy, it was just that that wasn’t enough. Fast forward to now, though, and all of those Republican ideas included in the hopes of getting them to sign on are now repeatedly decried as offences against democracy.

So even if we did make the mistake of believing an argument is only good if the other side will confess to agreeing with it, there quite simply isn’t such a creature left in the rhetorical world. Because using the HCR bill (or anything else) to sink Obama’s presidency is the only thing, literally the only thing, the GOP cares about right now.

Now, you can argue that such is their role as the opposition. I would disagree, I think the role of opposition is to keep the party in power honest rather than to thwart its ability to govern – the will of the people, and so forth - but you could make the case, though you'd have to explain to me how it's OK to, say, block appointees to high-level military positions in the middle of two wars whilst confessing no having no idea whether or not they're qualified.

Regardless of your position on what the minority party should consider itself entitled to do, what the current behaviour of the Republicans clearly demonstrates is that Spielbergo is looking for a method of persuasion that quite simply does not exist. The thought process by which one assumes that method must exist - and I see no other way to read Spielbergo's argument other than that he believes this, unless he's prepared to argue there exist literally no "good" arguments for reform - and so any that fail must have been flawed in some way, is the same one that leads to people like David Broder arguing that any time the Republicans filibuster a bill it must be the Democrat’s fault for not giving them enough of the things they want, and that the only way “bipartisanship” can fail is if the side more willing to compromise isn’t prepared to compromise enough.

Not that I think Spielbergo is the next David Broder, of course. I mean, I may be telling everyone I think his arguments are wrong, but I don’t want to insult the guy.

Now onto the main point I wanted to make – and the one that surprises me the Republicans don’t seem to have cottoned onto – We Europeans get to buy all these drugs and things, but we don’t spend anywhere near the amount the Americans spend.
...
US dollars subsidise our Healthcare.

And more specifically every American Citizen paying for health insurance is helping us over in Europe and Canada get better drugs cheaper than we should otherwise have it.

This, at least, I agree with entirely, in so much as I’m sure the Republicans probably do hate this (Democrats, too), though I suspect many of them can console themselves with endless whiskey sours at the next banquet a drugs company throws for it’s – ahem - “friends” in Congress. Having said that, though, it’s far from clear to me how reforming the US health care system would in any way help, at least in the way it's currently considered. Firstly, the drugs price issue is currently essentially separate to that of HCR. I get why it shouldn't be: if drugs were cheaper so would insurance tariffs, but at present the Democrats have shied away from confronting the pharmaceutical industry as much as possible. Crucially, though, whilst you can lower drug prices and thus improve the insurance issue, I don't see how reforming insurance will make one iota of difference to the cost of drugs, which makes it hard to see how Spielbergo expects there to be a reduction in costs.

None of this matters, though, since it's not remotely the case that the Republicans would want it at all. What exactly is being proposed here? Forcing the drugs companies to reduce their prices? How will that help? Research costs what it costs. Reducing what the Americans pay to what we pay isn't going to do any good for those who make the pills, and I simply don't see anything the Americans can do to force us to pay more. Certainly I don't see any way they can do that by enacting entirely internal changes.

So what would the Republicans suggest? Replacing the money individuals pay for the drugs with government money for research? The GOP is already screaming (incorrectly) about the bill costing too much. Forcing a cap on the amount a pill can cost? That's fundamentally at odds with the way Republicans do things that it could never happen even if so many of them weren't receiving healthy amounts of cash from those same companies.

Certainly it seems clear to me that the search for this entirely mythological “good argument” is going to have to go a good deal further than “If you let us reduce costs in every other way, we’ll allow you to reduce the amount of subsidisation powerful pharmaceutical businesses will receive.” In truth, that might actually theoretically work if the Republicans were suggesting that to the Democrats (though realistically I very, very much doubt it would), but the suggestion that the best way to get the GOP to sign on with the Democrat’s agenda is to include provisions that will hobble major donors to Republican campaigns strikes me as pretty unpersuasive, however much the Republicans might agree that letting the rest of the world pay less for US drugs is a bad idea.

In fact, Spielbergo may not have seen this particular topic come up during the HCR discussion, but I have, or at least a couple of things that were very close. There were several abortive discussions generated on whether to introduce amendments to the bill that would allow the US government to either directly force pharmaceutical companies to reduce their prices for American consumers, or start buying American drugs back off the Canadians, since that would still be cheaper than buying them first hand.

Anyone want to guess which party was interested in reducing American drugs costs? And which party immediately labelled the idea as socialism in action?