In a piece at Bloomberg Noah Smith complains that reducing costs is the sine qua non of health care reform:

Why is it so hard to agree on a health-care plan? One obvious possibility: Reform plans feel as intolerable as the status quo while lacking the promise of lowering costs. The U.S.’s uniquely dysfunctional hybrid public-private system has resulted in the country devoting a much higher share of its output to health care than its rich-world peers…

Advocates of single-payer plans tend to assume that switching to national health insurance will reduce costs. This assumption features in both Warren’s and Sanders’s proposals. There is some justification for this. Health care in Canada, which has a single-payer system, costs much less; if the U.S. spent the same percent of its gross domestic product on health care as its northern neighbor, it would save more than $1.34 trillion a year.

I’ve been arguing that the foremost objective of health care reform should be to reduce spending for the last ten years now. Welcome to the fight, Mr. Smith.

Note that nobody has proposed that we adopt Canada’s system or, indeed, anything resembling Canada’s system. What has been proposed are systems with greatly expanded coverage, less “skin in the game” for patients, and overblown estimates of the savings from lower administrative costs.

Canada spends about half what we do on the administration of their system but everything in Canada’s experience tells us that economies of scale are fully realized at fewer than 50 million people covered and our knowledge of bureaucracies is that their costs increase exponentially with size.

Dare I mention that Canada is tremendously demographically different from the United States? We haven’t been as homogeneous as Canada since the 19th century if ever.

Here in the United States we spend more on infrastructure, defense, and education than anybody else, too. That’s not because we have a fragmented hybrid system.

What we don’t have is the one thing most needed for health care reform to reduce spending: a commitment to cutting spending. Politicians don’t want it, patients don’t want it, and providers don’t want it.

In my second example of wishful thinking this morning I heard Matt Dowd on ABC News expressing skepticism that there was room in the Democratic presidential candidate roster for Michael Bloomberg, noting that 75% of Democrats have said they are satisfied with the present group of candidates.

The problem is that Democrats will need to settle on a single candidate. Democrats can’t vote for the roster and at this point each of the leading candidates has some serious issues. At best Joe Biden is a mediocre candidate. Bernie Sanders is an angry old man and I find the notion that a non-Democrat would be the party’s standard-bearer incredible. And Elizabeth Warren has just published what I have heard waggishly called “the longest suicide note in American political history”. Will enough Democrats vote for “anybody but Trump”? Will there be enough crossover votes to elect “anybody but Trump”?

Not to mention that there is always room for a Democrat with a track record and the ability to finance his own campaign.

The theme for today seems to be wishful thinking. My first exhibit is this editorial from the Dallas Morning News on what to do in reaction to the murders of the Americans living in Mexico:

So how can the U.S. help Mexican authorities stem the rising tide of violence and terror?

First, it’s clear that President López Obrador’s campaign promise of using “hugs not guns” to address the break down of Mexico’s social fabric and the rule of law was considered a sign of weakness by the cartels. Last month’s decision by the Mexican government to release Ovidio Guzmán López, the son of drug kingpin Joaquin “El Chapo” Guzman, to prevent further bloodshed after eight people were killed in a botched raid in Culiacán has also emboldened the cartels.

But do the high-profile arrests and extradition to the U.S. of kingpins like El Chapo actually weaken the cartels? Jake Dizard, a fellow with the Mexico Security Initiative at The University of Texas at Austin, is skeptical. “The U.S. should continue to provide intelligence on criminal groups to Mexico,” he us, but “U.S. law enforcement should recognize the counterproductive nature of playing whack-a-mole with cartel leaders and help Mexico develop a more comprehensive, civilian-led security strategy.”

What would such a strategy look like? All the experts we spoke with agree that a joint effort to crack down on illegal U.S. gun sales to Mexico should be a high priority. Patrick McNamara, a history professor at the University of Minnesota and an expert witness on more than 100 asylum cases, says the U.S. should also “stop obsessing about Central American refugees and allow Mexico’s new National Guard to be deployed to protect Mexican civilians in northern Mexico” instead of stopping peaceful migrants from heading north.

This is nonsense. If we can’t “crack down” on cross-border illegal drugs or human trafficking, how in the heck will we do so on the illegal gun trade. We can’t even crack down on illegal guns in Chicago. Nearly all Chicago’s homicides are perpetrated using illegal guns.

In his Wall Street Journal column Jason Riley attempts to explain something I have been trying to explicate for some time:

Your typical black Democratic primary voter is likely to be middle-aged and female, and right now Joe Biden is her guy. But who’s her second choice?

There is general agreement that black voters, while a small percentage of all voters, could again play an outsize role in determining the Democratic presidential nominee and the outcome of next year’s election. Blacks are concentrated in important primary states, such as South Carolina, as well as in the cities of key battleground states like Michigan and Wisconsin.

Perhaps taking them for granted, Hillary Clinton failed to mobilize enough black voters in 2016, when black voter turnout fell in a presidential election for the first time in 20 years. Mr. Biden believes he can succeed where she failed, and perhaps he can. His popularity among blacks obviously stems from his eight-year stint as Barack Obama’s vice president. He is quick to invoke Mr. Obama’s name in front of black audiences and to defend their administration’s policy victories, such as ObamaCare. Mr. Biden is also more politically moderate than most of his rivals, which sits well with older blacks who are more likely to vote.

Blacks are more conservative than Democrats, generally, they are more religious than Democrats, generally, their rate of military service is higher than Democrats, generally, and their median level of educational attainment is lower than Democrats, generally.

The editors of the Washington Post go off on “Medicare For All”:

SINGLE-PAYER HEALTH care can work. Government-run systems operate in other industrialized countries and often achieve comparable or better overall results, for less money, than the health-care patchwork in the United States. So why aren’t Sen. Bernie Sanders (I-Vt.) and Sen. Elizabeth Warren (D-Mass.) proposing something that resembles those systems?

The two presidential candidates promise far more generous benefits than other countries offer. They pretend that the United States wouldn’t have to make any of the trade-offs other nations have had to make. They promise fantastically generous benefits, no premiums, co-payments or other cost-sharing, and a miraculously low price tag. It’s fiction.

concluding:

All Americans should have decent health-care coverage. They should also have good schools, good roads and world-class universities. Nations with single-payer plans have had to make real-world compromises among these various needs. If the Warren and Sanders plans sound too good to be true, it’s for a reason.

Let me make some scattered observations. We can’t reduce the cost of our health care system without reducing somebody’s income. Some of those somebodies will be in the insurance sector but most of them will be in the health care sector.

What’s the fixation with centralization? Here are the populations of some of the countries with which people routinely compare the United States:

and here are the populations of some U. S. states:

The total U. S. population is something like 330 million. Get the point? Those countries are more like states than they are like the U. S. as a whole. We are also much larger physically and enormously more diverse than any European country. We are very nearly as large and diverse as all European countries put together.

If we’re seriously considering a single payer system, why not a system more like that of Canada, a country which we resemble culturally much more than we do France or Germany. Canada’s system is run by the provinces.

Administration of Canada’s system costs about half as much as ours. We simply are not going to realize savings in administrative costs beyond Canada’s. I would be astonished if the savings in administration from going to a single-payer system here would even match that and the financing assumptions of practically every body’s plan makes that assumption. Everything our government does costs more than anywhere else. Why should health care be an exception?

There are actually good reasons why a single payer system is not a good fit for the United States and I usually summarize them by saying that we don’t have enough social cohesion. That covers a lot of territory including a greater emphasis on individualism, diversity, and a long-standing culture of political incompetence. We don’t trust our government for good reason.

I’m actually more concerned that every American should have access to decent health care than I am that they should have access to decent health care coverage. Framing it that way conditions the discussion.

If you are unaware of the story of the day, here’s a synopsis from the editors of the Wall Street Journal:

The slaughter Monday of three Mormon women and six children, all American citizens who were longtime residents of Mexico, brings home a cruel reality of America’s neighbor to the south. Drug gangs control huge swathes of the country, and the government in Mexico City is too often overwhelmed by the criminal firepower and money.

The women and children were attacked by gunmen as they traveled in SUVs in the northern state of Sonora in broad daylight. Mexican officials said Tuesday that it could have been a case of mistaken identity. But according to survivors who hid in a nearby woods, one of the women was shot outside her vehicle with her hands up. It seems more likely that the murders were a warning from drug cartels to everyone in the region, and especially to Mexican officials, that the gangs are in charge.

and here’s their recommendation:

But if Mexico can’t control its territory, the U.S. will have to do more to protect Americans in both countries from the cartels. The Drug Enforcement Administration should be able to find out the identities and locations of those who ordered or carried out Monday’s murders, and ensuring their demise would be a signal that U.S. justice has a long reach. A U.S. military operation can’t be ruled out.

What do you think should be done in response to these murders?

1. Nothing
2. Warn Americans living or travelling in Mexico that it’s a dangerous place and they’re on their own. Otherwise nothing.
3. Keep doing what we’re doing now—provide the Mexican government with intelligence, cooperation, and support as requested. Otherwise nothing
4. Warn the Mexican government that, unless they apprehend those responsible, we will suspend intelligence, cooperation, etc. Otherwise nothing.
5. Arrest or eliminate those responsible via covert action
6. Deploy the U. S. military to create a cordon sanitaire from the U. S. border to 150 miles to its south.
7. Put the entirety of Mexico under U. S. military occupation
8. Other (specify)

I think there’s connecting thread among the recent remarks of Larry Summers (in the op-ed to which I linked), Joe Biden’s defending himself against charges of just not being Democratic enough darn it, Barack Obama’s critique of “cancel culture”, and Rahm Emanuel’s observations about candidate missteps. To coin a cliché, there’s a battle being waged for the soul of the Democratic Party between the Democratic establishment and the progressive wing of the party.

All of the individuals I mentioned above are party apparatchiks at one level or another. Not only that, they represent those who actually hold the reins of power in the party. Do Bernie Sanders and Elizabeth Warren actually represent the future of the party? Or do they represent a comparatively small number of progressives who want to be the future of the party?

All of the worthies in the list above have actually wielded power. Bernie Sanders and Elizabeth Warren have been elected to office in two of the oldest, best educated, least religious, and whitest states in the Union. Do they represent the future or a future that cannot be?

At Roll Call election analyst Nathan L. Gonzales points out the lessons of the 2019 elections may be different than most think. Here are his hypotheses:

• Kentucky was not an upset.
• Trump was an asset, not a liability.
• Impeachment isn’t the silver bullet for Republicans.
• Bevin clearly had a unique problem.
• Transformation of Virginia is complete.
• Suburbs continue to be a problem for Republicans.
• Mississippi is a red state.

Read the whole thing.

My own view is that people tend to over-interpret elections. Just because a candidate with a certain profile wins a particular election in a particular state, county, city, etc. doesn’t mean that another candidate with a similar profile is a shoe-in in another state, county, city, etc. Politics remains stubbornly local whatever analysts may think.

Update

Also, check out the author’s four potential scenarios for the way the 2020 elections might play out. I have lost any predictive ability I ever had in the Era of Trump. All I can say is that I wish that Democrats were taking a lower risk “eyes on the prize” strategy rather than a “high risk/high reward” strategy. And don’t underestimate Trump.

Dr. Lawrence Summers, the economic voice of the Democratic establishment, has an op-ed in the Washington Post sharply criticizing Elizabeth Warren’s “Medicare For All” plan. His criticisms are, first, that it’s the most ambitious plan in the world:

However, no other country offers as broad coverage as Medicare-for-all would or claims to provide universal health insurance without taxing its middle class. With respect to the admirably detailed plan the Massachusetts senator laid out, there will, I suspect, be serious questions about the accuracy of her arithmetic, the impact on labor markets, the feasibility of applying Warren’s full set of proposed taxes to the rich, and the financial and economic impacts of the plan.

It won’t generate as much revenue as she thinks it will:

Whatever the merits of these arguments, it is hard to see a defense for assuming — as the Warren proposal does — that wealth taxes can be doubled with no impact on avoidance, or that annual capital gains taxes can be levied without reducing the wealth tax base. The estimates are also infected by erroneous transcription of the CBO’s 10-year growth estimates and by a general failure to take account of interactions between the different tax measures proposed.

Its effects on the labor market will be extremely disruptive:

Second, there will be large labor market effects: Warren’s plan will discourage hiring, particularly of low-skilled workers, by firms that currently provide generous benefits. These firms will face the most burdensome taxes when they increase hiring and will gain the greatest cost savings by laying off workers. In addition, workers’ incentives to take jobs will be dulled because they will no longer be compensated with health benefits (which will become available regardless of what they do). There are further potential economic perversities as well: To cut costs, firms will be incentivized to get below the 50-employee threshold and scale back on current health benefits. And all the efforts that employers have engaged in to contain costs and to encourage prevention will become pointless.

To that I would add that companies that self-insure may well end up spending a lot more, something that will certainly be resisted. 40% of all employer-sponsored plans are self-insurance.

The plan will have an extreme effect on taxes:

The sum of all the new taxes on the wealthy proposed by Warren is of comparable magnitude: adding together around $310 billion a year in new wealth taxes; $330 billion a year in corporate taxes from her new proposals and her previous real corporate profits taxes; $240 billion a year from her new capital gains and finance tax proposals; at least $90 billion from her across-the-board 14.8 percent taxes of labor and investment income; and $190 billion in increased compliance. This totals nearly $1.2 trillion — more than millionaires’ total after-tax income.

There will be run-on economic and financial effects:

Recognizing that some of these taxes fall on salary income or non-corporate business, it is reasonable to estimate that investors will pay an extra $500 billion to $600 billion in taxes related to corporate profits. Then, Medicare-for-all proponents cite a severe hit to health industry profits, currently on track to be over $200 billion this year. Then, there will be the broader impacts of overhauling regulation, often to serve vital social interests, in initiatives such as banning fracking and reforming the energy industry, stepping up financial regulation, a major increase in antitrust enforcement and the regulation of technology companies, and filling corporate board seats with labor representatives. It is hard to see an argument that investors’ claim on profits would fall less than a third. The figure could be considerably greater.

Because of abnormally high valuations, along with increased uncertainty and volatility, loss of business confidence and selling pressure from those in distress, the market would likely fall more than proportionally to earnings. Accurate market predictions are impossible and will in any event depend not on what is proposed but on what the market expects will actually take place. There is, however, the real risk of economic contraction following a sharp market decline, especially given that the current very low level of interest rates puts the Fed in a weak position to pursue counter-cyclical policy.

A summary of his observations is that as campaign rhetoric Sen. Warren’s plan is fine. As serious policy it would be catastrophic.

Those are somewhat different from the criticisms I have lodged but they’re interesting.