27 March 2012

Etch sketches and court appointed lawyers

First, I don't plan on voting for Romney. I still expect, as I've always suspected, that he will ultimately be the GOP nominee. But the idea that somehow the campaign made a major gaffe by using an etch-a-sketch analogy to describe the typical campaign's pivot from primary to general elections is a serious error in logic. It is at best a minor hiccup on the pathway to the nomination. There's a couple reasons

1) Romney already has a reputation as a flip-flopper. Some of this is just that he's not a very skilled politician. Newt Gingrich has reversed course on numerous policy positions within days or weeks of each other repeatedly. He does not have Romney's reputation. The reason is that Romney's principle position that has shifted, or is perceived to have shifted over the course of a decade (not weeks or months) is more significant among Republican/conservative primary voters: abortion, and that this shift was very public and prominent. Santorum for instance, despite being known now as the most uber-ridiculous social conservative, was perfectly fine with abortion as recently as the late Reagan years. Yet he loses no ground on it because most people aren't aware he shifted his positions once he began running for office (eg, out of the most transparent basis to say things in order get elected, just as Romney is accused of doing). What this means in an electoral sense is that people who already thought of Romney as a flip flopper, and who thought of this character as a serious flaw, likely already weren't voting for him in the primaries or perhaps the general elections. His base of support is elsewhere and thus something like this does not matter. Coverage of this as an issue is amusing, and clearly good for the Etch-a-sketch people. But it's not something that will be looked back on as significant. Were Gingrich or Santorum skilled or promising candidates as alternatives, they would already be consolidating power. Not trying to dig into Romney's through bizarre campaign strategies. 

2) EVERY campaign always does this in national elections especially, it pivots to the center of the voting population to appeal to a broader constituency. The transgression of Romney's strategist was to admit that they were doing so. Very, very few political figures have firmly held opinions and principles that guide their public policy positions that they must take other than that which is politically necessary to keep them in office or in contention for office. Consider all the Republicans who were for TARP or health care mandates before they were against them. Or in the case of people like Santorum, were fine with medicare part D (a massive expansion of government) and NCLB when these things were popular with his base voters, and are now having to backtrack on them because they are less popular. Politicians change their minds, or appear to do so, all the time, and they indicate focus issues that they think will interest more voters than they will annoy or put off. The extreme social conservative vision shared by agitated conservative voters, or the misguided belief that government will do anything about deficits and deficit spending under conservative leadership, and so on, are generally not popular views outside of the conservative voters who already have some incentive to vote for putatively conservative political figures. So such figures need to present views which are more suitable to voters who might vote for such figures but don't care about these issues. Or find them less pressing than other concerns and may be willing to overlook disagreement on them. I think these voters are misguided, in that it seems pretty clear what happens to legislatures when things like this determine elections (it provides power to pre-existing blocs of incumbents that have little interest in serving these goals but rather furthering their own limited goals), and that voting on things that aren't likely to actually change, or are likely to change in real terms in a very different way from voter preconceptions of what will change and how, is a bad and even irresponsible way to decide how to vote. But politicians are aware that voters do this. That's why they pivot. And, outside of the most extreme activists who only care about their issues, most people want them to do so on the theory that they will hear something they like when they start paying attention (and again, most people utterly ignore politics except during for elections, so politicians can say more or less whatever they want and few people will call them on it).

Second, the ACA is finally up for debate in the Supreme Court. There's a lot of potential outcomes, only some of which are interesting. 
1) The government wins, the law is upheld as constitutional, remains law, Obama wins re-election, law goes into effect, world doesn't really end as the law isn't a huge shift in status quo. Health care costs continue to grow
2) The government wins, Romney wins election, law goes into effect. Health care costs continue to grow.
3) The government wins, Romney wins election, law is somehow repealed or not enforced. Health care costs continue to grow.
4) Government loses, portion of law is repealed by court (most likely the mandate if any part is to be turned back), Obama wins re-election, portions go into effect. Health care costs continue to grow, possibly somewhat faster.
5) Same as 4 except Romney wins. The more popular portions are less likely to be repealed by either the court or Romney/Republicans. Health care costs continue to grow.
It goes on like that for a while.

These are my thoughts.
1) I think the ACA was a fairly weak shift in health care coverage for Americans. Whether or not it is overturned, very little will change in the landscape moving forward for Americans and their rising demand for more health care spending both in the private market and through government programmes (especially the latter). This is also true regardless of which major party is in office. I view a significant legislative repeal as extremely unlikely (the Senate makes it difficult to remove pre-existing laws as passed and a shift toward one-party control is not likely) and a significant executive repeal as a remote possibility in the near term. Running an election with this repeal or support of the bill as a central issue is basically bullshit as far as I'm concerned. Not only is it not likely to happen, I don't think it is likely to matter very much to the underlying problems of our system one way or another.
2) I think individual mandates of some kind are appropriate economically speaking. I favor models like that of Singapore which relies in part on such mandates. I am not certain whether this is constitutionally legal or not, though I lean toward the interpretation that says it likely is legal based on case law (but probably shouldn't be except under the more Hamiltonian vision of federal powers that we presently operate under). One way around this would be to do as we did with the 16th or 18th amendments and pass a new amendment providing this power explicitly to the government, and only this power (or a directly related power, mandating private retirement accumulation or taxes levied for educational provisions, all of which have some expensive economic free rider problems associated with them that mandates help alleviate)

3) Government mandates using employer benefits rather than individual coverage of choice, or government mandates more broadly over what shall and shall not be a covered insurance event are ridiculous. In that they mandate what type of insurance you may buy and what you cannot. If that's the case, you might as well make the government the provider rather than bother with the 3rd and 4th party version we use now. A large part of the appeal of the Singapore model to me is that it places a somewhat larger burden of cost and transparency on the consumer, rather than on a third party, by mostly providing catastrophic coverage and mandating that the public save a portion of money for health care expenses (and providing care to the poor through subsidies and public hospitals). There are some unappealing elements (like using price controls), but given the state of patents and medicines in this country, and given the emphasis on specific treatment models instead of general preventive care, I'm not sure what process is to be used to get people toward different ways of dealing with providing themselves "health".

4) Studies have shown that the top 1% of all health care spenders account for 30% of all health care spending, and the top 5% account for 50% (the bottom 50% of spenders account for less than 1% of spending). What's interesting about the 5% group is that over 50% of that group indicates they feel "good" or better about their health. Not their health care, their health. What reason, pray tell, are they spending 50k a year on it then? Largely this is possible because they are not spending their own money, and that they have expended this amount is not obvious (even the true cost of their insurance is hidden, as employers don't have to fully disclose it until the provisions in the ACA kick in on that one and most people still won't add in lost wages to the cost of providing this as a benefit instead). Presumably they received expensive but successful intervention care for some ailment or injury, and presumably they recovered. But to me the fact that one had to have a significant health care intervention would be an indication that one's health was, in that year, not as good as someone in "good" health. I think this, combined with the general lack of using living wills and consultations on end of life care, is a clear indication that a) the public thinks that spending more money on health care ought to make them healthier or extend life for an ailing family member and b) they're probably wrong about that assumption but that this means that they will continue to spend a lot of money on health care, especially in the absence of having to draw on their own funds (ie, having someone else pay for it) or in the absence of price transparencies and competitive markets. Or both as we have now.

 5) Very few reforms as proposed address any of this. The ACA does at least deal with some transparency and electronic record keeping as problems, but ultimately preserves and even entrenches the employer-benefit model and 3rd party payment structure with a heavy government footprint that is disguised from the public (or which the public has disguised from itself, as in the case of the "keep your hands off my medicare" type screeds). This will do little to resolve the problem, since those are, in the view of many informed observers of all ideological stripes, the source of the problems. To use a medical analogy, we are treating some secondary infections but not the disease itself. The massive attention both in media coverage (despite the public's lack of informed status of reforms, alternatives, the condition of the status quo, and the provisions of the bill itself, coverage itself was and is fair to decent on this issue) and court battles with court-appointed lawyers making arcane side arguments over tax incidence and when issues concerning tax may come before a court, it all seems like further indications that people don't seem aware of how sick the patient (the country and ourselves) really is. And that they probably don't want to know. But that they will still complain when they get the bill.
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