Most accounts of what’s going on in the Senate Finance Committee on health care reform view the various amendments being offered as a buffet of Republican efforts to derail the legislation, and Democratic efforts to make the Baucus bill more like the versions already approved by the House committees and the Senate HELP Committee. And that’s generally the case.
But as TDS Co-Editor William Galston points out at The New Republic, there’s one big exception: Sen. Ron Wyden’s “Free Choice” amendment.
Under the previously approved reform blueprints, and in the Baucus bill, participation in the new “exchanges” that would establish a competitive system of health insurance plans offering federally-established minimum benefits is very limited: basically, they are for the uninsured who do not qualify for public programs, the self-employed, and small businesses. People already covered by employer-sponsored plans are barred from participating. That approach is designed to reassure those who fear the new system will discomfit people happy with their current insurance (other than, perhaps, rising premiums), and to avoid abandonment of employer-based insurance by younger and healthier folk who make coverage affordable for older and sicker employees.
But as Galston argues, the same logic greatly limits the ability of reform to hold down future costs, or for that matter, to satisfy consumer. Wyden’s amendment would require employers who do not offer a choice of affordable plans to offer employees vouchers that could be used on the exchange, and even converted to cash if low-cost alternatives were chosen. And that would have a powerful effect:

Wyden’s plan would offer more choice for both workers and employers, and it would encourage cost containment by encouraging consumers to select lower-cost options. CBO scores the plan as roughly deficit-neutral; the Lewin Group believes that it would actually lower the deficit by reducing the amount of revenue the federal government foregoes because of the tax exclusion for employer-provided health benefits.

So Wyden offers another way to reduce the revenues lost to the vast tax subsidy for employer-sponsored health coverage, while expanding individual choice. But at a time when Democrats are largely committed to a different approach, and Republicans are largely committed to the goal of killing reform altogether, it’s hard to see where Wyden will get any votes.
Perhaps a reformed system could move towards the Wyden approach in the near future, once the exchanges are set up and fears about costs gradually overcome fears about the disruptive effect of changing the employer-based system. But as Galston notes, the issues raised by Wyden can not be avoided perpetually.

Talk to a conservative about health care reform, and nine times out of ten he or she will quickly get around to a rap on medical malpractice insurance, tort reform, and the evil, evil trial lawyers that are responsible for high health care costs and that have bought political protection from the Democratic Party. Having heard this a million times, most progressives simply close their ears when the very subject comes up.
Via Ezra Klein, there’s a very good fact-based summary piece on this subject from David Leonhardt of the New York Times.
Here’s an excerpt:

The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.
The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.
At the same time, though, the current system appears to treat actual malpractice too lightly. Trials may get a lot of attention, but they are the exception. Far more common are errors that never lead to any action.
After reviewing thousands of patient records, medical researchers have estimated that only 2 to 3 percent of cases of medical negligence lead to a malpractice claim.

The usual GOP method for dealing with this issue is, of course, simply capping damage awards for malpractice suits, which might somewhat reduce “defensive medicine,” but at a hard-to-estimate cost in even greater medical errors. The other issue, of course, is that other elements of the health care system encourage unnecessary tests and procedures as much as fear of lawsuits. As Leonhardt notes:

The problem is that just about every incentive in our medical system is to do more. Most patients have no idea how much their care costs. Doctors are generally paid more when they do more. And, indeed, extra tests and procedures can help protect them from lawsuits.
So the most promising fixes are the ones that don’t treat the malpractice system as an isolated issue.
Imagine if the government paid for more research into which treatments really do make people healthier — a step many doctors don’t like. Such evidence-based medicine could then get the benefit of the doubt in court. The research would also make it easier to set up “health courts,” with expedited case schedules and expert judges, which many doctors advocate.

In other words, medical malpractice reform is not a substitute for health care reform, and in fact, the best way to deal with “defensive medicine” may be through health care reform.
That’s a better answer than the usual Kabuki Theater back and forth on this issue.

You often hear conservatives say that if alternative energy sources were feasible, they’d be cheaper. And many conservatives favor an approach of subsidizing every energy source through tax breaks, as opposed to making a conscious choice to limit or at least boost the price of the fossil fuels that contribute so much to climate change while perpetuating our dependence on unstable global oil markets.
That’s why it’s important to understand that producers of fossil fuels current benefit from a large variety of federal subsidies that are much more extensive than anything offered on behalf of clean and/or renewable energy sources. Via Grist’s David Roberts, there’s a new study by the Environmental Law Institute and the Woodrow Wilson International Center for Scholars that puts a price tag on U.S. subsidies for various energy sources during the years 2002-2008.
It’s a pretty bad picture. Over this period, fossil fuels received $79 billion in federal subsidies, while renewable fuels received $29 billion. And among the renewables, over half the subsidies actually went to just one politically connected source, corn ethanol, which is controversial because of its impact on agriculture, and because its production typically requires extensive use of fossil fuels.
As Roberts notes, the figures for fossil fuels subsidies are conservative:

It did not include any number of things that could be considered indirect or implicit subsidies. It didn’t include military spending to defend oil in the Middle East, spending on the electricity grid, or transportation spending. Those things don’t go exclusively to fossil fuels, but if there was a way of including the share that goes to fossil fuels, the fossil subsidy number would go way, way up. Infrastructure spending has more or less exclusively supported fossil fuels for decades now.

Just yesterday, President Obama told the United Nations that subsidies for fossil fuels around the world need to come to an end. That’s certainly a goal that needs to be embraced by the United States.

Mike Lux is a very pragmatic and unity-minded member of the self-conscious progressive wing of the Democratic Party. So it certainly got my attention when he published a post at OpenLeft today threatening that adoption by Senate Democrats of Sen. Olympia Snowe’s “public option trigger” would create a “Democratic Civil War.”
Mike’s primary substantive argument is that Snowe’s “trigger” involves a Catch-22 mechanism whereby the “affordability” of private health insurance that would avoid a public option in any given state is judged according to prices that include federal subsidies defined as making coverage “affordable.” Thus, he reasons, there will be no public option anywhere private insurance is offered. I doubt that’s right, but not having seen any actual legislative language for the Snowe “trigger,” I can’t say with certainty it’s wrong, either. This may be a case where perception matters as much as reality, particularly if progressives suspect they are being sold a pig in a poke.
The general “insider” view on the end-game for health care reform has been that in the end, public option advocates would unhappily accept a “trigger” as far preferable to the co-op structure embedded in the Baucus bill. Indeed, the main appeal of the “trigger” idea, as Ezra Klein has explained, is that it accomodates the wildly different empirical assumptions that supporters and opponents of a public option hold about what would happen to the price and availability of private health insurance in a competitive system. If progressives are right that effective competition would not occur–one of the main arguments for a public option in the first place–then a public option would arise, at least in theory.
Now Mike is saying that’s all a sham, and you’d have to expect that many public option opponents would say the same thing from the opposite perspective, arguing that the “trigger” will always be pulled. As Ezra Klein also noted in his piece on the “trigger,” there’s not much of a constituency for compromise on this issue. And that’s why offers of a legislative “fix” for the flaw that Mike is focusing on won’t be very warmly welcomed.
But here’s the realiity: As a practical matter, if Senate Democratic leaders reject both co-ops and a “triggered” public option, then they probably have to move health care reform legislation via the budget reconciliation route. It’s not just a matter of giving up the pursuit of Olympia Snowe (and perhaps the one or two Republicans she might be able to bring with her); enough “centrist” Democrats have heartburn over a “robust” public option, over a purely partisan bill, or over what will eventually emerge from a conference committee, to all but guarantee that Democrats will fall short of the 60 votes necessary to kill a filibuster, even now that Massachussets is supplying Democrats with a 60th senator.
As I noted earlier this week, there are legitimate concerns about how the use of reconciliation would play out. Maybe that really is the way to go, and maybe it will produce a 50-plus-one vote margin for a bill that not only has a strong public option, but that’s pretty close to what the House is likely to pass, which simplifies this whole process considerably.
But in cases like this, a Plan B would be advisable, and public option supporters might want to give some serious thought as to whether there is a version of the “trigger”–in which “affordability” is better defined, and a larger scale for competion is provided than the state-by-state approach Snowe is promoting–that might be acceptable if push comes to shove. This really isn’t a great time for a “Democratic civil war.”

DemFromCT has an informative Kos post on support for the President and health care reform, among other issues. He quotes from Jonathan Weisman’s Wall St. Journal report on On the latest WSJ/NBC News poll conducted 9/17-20 by Hart/McInturff:

…The president has shored up eroding support for his top domestic priority, with the survey showing he has arrested the slide in support for his health-care plan following this month’s speech to Congress.

On the same poll, from MSNBC’s First Read:

According to the poll, the president’s health-care numbers have slightly increased, although that increase remains within the margin of error. Thirty-nine percent believe Obama’s health-care plan is a good idea, which is up three points since August. Forty-one percent say it’s a bad idea.
In addition, 45% approve of Obama’s handling of health care, while 46% disapprove, which is up from his 41%-47% score last month. By comparison, just 21% approve of the Republican Party’s handling of the issue…And who will get blamed if health care doesn’t get passed this year? Per the poll, 10% say Obama, 16% say congressional Democrats, and 37% say congressional Republicans.

From the poll’s PDF:

Do you think it would be better to pass Barack Obama’s health care plan and make its changes to the health care system or to not pass this plan and keep the current health care system?
Better to pass this plan, make these changes 45
Better to not pass this plan, keep current system 39

The poll indicates 73 percent of respondents agree that it is “extremely important” or “quite important” to give people a choice of a public plan administered by the federal government and a private plan for health insurance.” When asked however, “Would you favor or oppose creating a health care plan adminsitered by the federal government that would compete directly with private health insurance companies?”, 46 percent favored the idea, with 48 percent opposed. DemFromCt notes that only 15 percent of respondents said they understood the legislative proposals being debated in congress “very well,” and he adds:

What they do understand is that they want something that requires that health insurance companies cover people with pre-existing medical conditions (63% say “absolutely must be included”, another 26% “would prefer” it be included), but people don’t want mandates to buy insurance (23% don’t want that included, and another 34% say it absolutely must not be in there).
…We’ve reached a stabilization of opposition and support of Obama’s health care policies for now, along with job approval. Obama continues with strong personal approval numbers.
The fate of the Congress rests with health reform and until that’s settled, the public is likely to take a dim view of Congress, especially on the R side. But that won’t stop voters from taking it out on Democrats… the generic D vs R congressional number in this poll is only +3 for Dems. If I were them, I’d take this as a strong signal to produce something on health reform. Failure is not an option.

As the Senate Finance Committee takes health care reform amendments and proposals, this poll indicates that there is a fair amount of ambivalence in public attitudes toward some of the particulars of health care reform, but not about the need for reform — and who is expected to lead the way forward.

In recent months not only Democrats but many other Americans as well have become increasingly dismayed by the growing irrationality and even downright delusional thinking that appears to be taking hold among many conservatives and Republicans.
The most recent evidence of this trend was a September poll of New Jersey voters that not only showed 33% of self-described conservatives accepting the notion that Obama was not born in the United States but 18% also agreeing with the statement that he is “the Anti-Christ.” The appearance of this view in a northern industrial state like New Jersey indicates that these kinds of beliefs can no longer be dismissed as geographic peculiarities of rural areas or the South rather than as a significant component of modern American conservatism.
Despite the concern, however, there has actually been little serious discussion of how opinion polls might be used to track the growth of genuinely delusional thinking in American politics. It is true that ever since many commentators began using the number of people who accept the “Birther” narrative – that Obama was not actually born in the U.S. – as a shorthand measure of conservative and Republican irrationality there have been similar attempts to demonstrate that an equal number of Democrats believe false “Truther” narratives about the 9/11 attacks. As we will see, however, these discussions have all been based on survey questions that do not accurately distinguish between genuinely delusional beliefs and non-delusional ones and, in the specific case of the “Truther” narratives, also ignore key polling data that does not support the “one extreme equals the other” point of view. As a result, these discussions are useful primarily as ammunition for partisan political debates and not as a basis for serious social analysis.
In contrast, in order to use public opinion polling to seriously attempt to track the growth of delusional thinking in American politics we need to first consider two questions.

1. Can peoples’ responses to survey questions be used to detect psychologically disordered thinking?
2. Can survey questions reliably distinguish between views that are so irrational as to be genuinely “delusional” in a clinical sense and those that are merely extreme or implausible?

The answer to the first question is actually not difficult to determine. In psychology there are a number of “self-report” questionnaires that use people’s response to written questions to gauge characteristics like paranoia, hypochondria and other psychological disorders. The Minnesota Multiphasic Personality Inventory (MMPI), for example, is widely used and – although far, far from perfect – has been found to be sufficiently predictive for use in a variety of screening and assessment settings.
The key to answering the second question, on the other hand, is to carefully focus attention on beliefs that are genuinely “delusional” — a term which is defined as “a rigid system of beliefs with which a person is preoccupied and to which the person firmly holds, despite the logical absurdity of the beliefs and a lack of supporting evidence”
The current version of the DSM-IV — the Diagnostic and Statistical Manual of Mental Disorders defines a Delusional Disorder as follows:

“A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.”

In diagnosing a delusional disorder there are three generally used criteria:

•certainty (held with absolute conviction)
•incorrigibility (not changeable by compelling counterargument or proof to the contrary)
•impossibility or falsity of content (implausible, bizarre or patently untrue)

Obviously there is often not 100% agreement among clinicians in diagnosing a particular delusional disorder, but there is generally a commanding consensus.
With this framework in mind, let’s examine both the “Birther” and the “Truther” narratives:

Read more…

So what’s going on with the House Republican leadership, the hard-core conservative base probably wants to know. Are they going soft and moderate?
First we learn that House Republican Whip Eric Cantor of VA participated in a very civil discussion of health care policy with Democratic Rep. Bobby Scott, sponsored by the Richmond Times-Dispatch. According to Dana Milbank’s account of the event in the Washington Post today, it was a very tepid affair:

No talk of death panels. No complaints about illegal immigrants. Nothing about killing Grandma, no mention of socialism, nobody calling anybody a Nazi. And at no point during the 90-minute forum on health care did Cantor, or anybody else, call President Obama a liar.
The Richmond area lawmaker wouldn’t have had any trouble riling up the people in the audience, many of whom wore “Tea Party” or “9-12 Project” T-shirts. But “what use is that?” he said after the session. In fact, he came away with some advice for his colleagues: “Stop the revival stuff and let’s talk.”

I was wondering what Glenn Beck would say about that when I got an email from Richard Viguerie, the legendary hard-right organizer and scourge of all things moderate, with the subject line: “Are you kidding? Boehner says Obama Not a Socialist!” Seems that on Meet the Press Sunday, David Gregory specifically asked if the House Republican Leader thought the President was a socialist, and he finally allowed as how he didn’t think so. Boehner has in the past called Obama’s agenda “a socialist experiment,” but never mind.
As you can imagine, Viguerie’s pretty upset at this backsliding, so he’s put out a poll of his internet readership to find out whether they think Obama is a socialist, or maybe a Marxist, a traditional liberal, or even a “centrist.” He promises to pass the results on to Boehner and others when they are in. I figure it will be “Marxist” in a landslide.
Ah, can’t trust these weasely Washington Republicans. It’s probably time for another Tea Party to stiffen their spines.

If you are really, really into health care reform, you should definitely check out the remarkably exhaustive summary done by Igor Volsky at ThinkProgress’ Wonk Room about the vast number of amendments to the Baucus bill being offered in the Senate Finance Committee. Volsky organizes them by subject-area, and as “helpful,” “dubious” or “political.”
Overall, Democratic amendments, as you might imagine, are aimed at pushing the Baucus proposal in the direction of what we’ve seen from the House and from the Senate HELP committee. Republican amendments generally represent efforts to unravel the Baucus proposal by eliminating essential elements such as the individual mandate and Medicaid expansion, or to promote longstanding conservative hobbyhorses like medical malpractice “reform” or preemption of state insurance regulations. There’s also a lot of extraneous crap about ACORN and “rationing” and so forth that is pure posturing.
Only a few of these amendments from either side are likely to have a big impact on what the Finance Committee actually produces. A couple of Democratic amendments aim at paring back the excise tax that Baucus uses as his main financing vehicle in order to reduce middle-class exposure, which is a big deal politically. And Sen. Snowe tossed in her “triggered public option,” which could wind up being the linchpin for ultimate congressional approval of health care reform, though perhaps at a later date.
But what you are mainly seeing here, particularly from Republicans, is a preview of what we will be hearing on the Senate floor. It’s a reminder of how long this process is likely to take, and why either cloture or reconciliation will be necessary to get to a final vote. Since Republicans are also prepared to offer long lists of points of order against proceeding on health reform via reconciliation before the debate time limits kick in, even that route won’t necessarily produce anything like a brisk floor debate. We’re going to be talking about health care reform well into this year’s pared-back Xmas shopping season.

TDS Co-Editor Ruy Teixeira’s latest ‘Public Opinion Snapshot’ at the Center for American Progress website provides a timely indication of just how marginal are the Obama-haters the conservatives are trying to claim are a majority. Teixeira cites a new Pew Research Center poll, conducted 9/10-15 and explains:

…The public’s view of Obama remains, in fact, very favorable across a wide range of characteristics. The conservatives’ extreme views on Obama are just that—extreme—and should in no way be confused with the American people’s views…In the Pew poll, 83 percent describe Obama as a good communicator, 78 percent describe him as warm and friendly, 70 percent describe him as well informed, 69 percent describe him as well organized, 68 percent describe him as “someone who cares about people like me,” 65 percent say he is a strong leader, 64 percent say he is trustworthy, and 58 percent say he is able to get things done.

Teixeira also notes that Obama has impressive credibility as an innovator, according to the Pew poll, which found that “the public says by 63-30 that Obama brings a “new approach to politics in Washington” rather than “business as usual.” Teixeira concludes that it’s no surprise that “conservatives are confusing their own benighted views with those of the general public.”

In The American Prospect TDS Co-Editor Stan Greenberg reviews an important new book by Lynn Vavreck, “The Message Matters.” Greenberg, whose strategic advice was instrumental in electing and re-electing Bill Clinton and helping Al Gore win the popular vote in 2000, says that Vavreck “breaks new ground in showing how presidential candidates effectively use the economy when it works in their favor and how some candidates win even when the economy is working against them.” In his review, Greenberg explains:

For decades political scientists have tried to predict the outcome of elections by constructing statistical models that use different measures of economic performance and ignore the character of the candidates and the choices of their campaigns. As a pollster who has helped direct campaigns, I have never found these academic models all that convincing. Missing the final vote by up to 8 points, as their forecasts often do, would have gotten me fired. And in most presidential elections, predicting the winner is not rocket science, and barbers and bartenders do as well as the modelers.
With considerable elegance, Vavreck departs from the dominant tradition in election forecasting by focusing on the strategies that candidates follow, including the narratives they build, and by showing respect for what voters learn from the campaigns. Voters do use the economy to judge the incumbent’s leadership and project future performance, but in some elections they also respond to other issues such as trust, domestic policy, and national security.

And further,

According to Vavreck’s analysis, if you want to know who wins the presidency and by how much, you start with the candidate who has been helped by the economy during the nine months before July 1 of the election year. If the economy has been growing, that’s the candidate of the incumbent party; if the economy has been stagnant or declining, it’s the challenger. Each of these is in a position to run what Vavreck calls a “clarifying campaign.” That is an appealing phrase for me, as it implies that what counts is not just the economy but how a campaign frames the economic argument to political effect.
…Strategy and message do indeed matter. You come away from this book with a new respect for the power of the economy. While other issues matter in elections, when a presidential candidate focuses on the economy, voters are more likely to listen and more likely to use the economy in assessing the candidates. But you also come away with a new respect for the campaign and candidate. The campaigns that understand the times and run the right clarifying or insurgent strategy add 6 points to their vote share.
Although Vavreck draws heavily on quantitative data and modeling, she conveys a sense of excitement about her breakthrough in understanding how presidential elections work. Human decisions matter: Campaigns can rise above the dull determinism of the economy. And voters are fairly discerning about what campaigns are saying on issues that matter to them.

Greenberg moves toward his conclusion with a comment that may be particularly important for team Obama to fully-appreciate:

As I write in my book, “Dispatches from the War Room“, national leaders often want to tout macroeconomic growth before it has produced gains that people see firsthand. The Democrats lost in 1994 as Clinton spoke prematurely of his economic successes, though by 1996 real gains in income helped produce a very different outcome.

Given current economic forecasts of “at best, halting growth” in the months ahead, Greenberg concludes “The message will matter in 2010 and 2012, more than ever.”