Since the Supreme Court issued its decision last week, I’ve been following the commentary on the PPACA AKA “ObamaCare” in the new media and various and sundry blogs on all sides of the political spectrum pretty closely. All sorts of people from Joe Klein to the editors of Bloomberg have been offering their ideas on how to fix the law, something that would have been handy several years ago. A couple of things have struck me.
Have you noticed that nobody is really enthusiastic about the law? For some it’s an ugly but necessary first step, for many a false step, and for some, apparently, the last straw. But I have yet to find anyone who sees it as an optimal first step. I guess some would say that’s what happens with laws in the United States: necessarily, they are compromises. I don’t see the PPACA so much as a compromise as a Rube Goldberg. I considered using other, less polite characterizations but this is a family blog. Engineers in the audience will probably know what I mean.
The other thing that struck me and that I’ve mentioned from time to time is that the law is a technocrat’s fantasy of how government works in the United States: you revisit and tinker and adjust and fine tune and modify until you get something that works. We’ve never done that before but, apparently, they think we’re going to do that now. I honestly don’t understand how anyone could have applied for a drivers license, gotten a building permit, or done their own income tax and still believe that.
I honestly don’t understand how anyone could have applied for a drivers license, gotten a building permit, or done their own income tax and still believe that.
I can’t speak for Illinois (no one can) but here in California the drivers license experience has become quite efficient. In and out in less than an hour for the first round. For the address change when I moved the Marin County they simplified to the point of just giving you a sort of business card that makes you legal. No fuss, no muss, in and out in minutes. In fact, I could have done it online.
As for the IRS, I’ve found them damnably efficient. Stuff that used to have to go through an accountant can now be done automatically online. When they screwed up and seized some money from an account a single phone call brought a reversal, a return of the money and an apology. (!)
I think there’s a sort of learned helplessness in assuming things can’t be improved. In point of fact, since everyone agrees the system can’t be sustained, it obviously won’t be and will inevitably be altered.
We now get the policies approved by the 60th Senator.
“The other thing that struck me and that I’ve mentioned from time to time is that the law is a technocrat’s fantasy of how government works in the United States: you revisit and tinker and adjust and fine tune and modify until you get something that works. We’ve never done that before but, apparently, they think we’re going to do that now.”
This puzzles me. I am not sure I can think of a government program that we do not or have not tinkered with. The GI Bill, Medicare, Medicaid, Social Security, the Justice system, transportation, our military, education, our welfare system, agriculture. Sometimes we make them better, sometimes worse. I kind of think that is how democracies work.
On the private side, you must be a much better manager than I have ever been or anyone I have ever known if you do not need to tinker with things. Occasionally things go exactly as planned, but most of the time we modify because we find we missed something, or if we listen to our juniors, our nurses and our patients, we find that they have better ideas. What was that old military saying? No plan survives first contact with the enemy?
Am I misinterpreting what you are saying?
Steve
@Michael Reynolds
The DMV is light-years beyond what I went through getting my license the first time. Much more efficient than any Verizon store I’ve EVER been in, less confusing and takes less time. I would have said the same for the Post Office a couple of years ago, but cuts to services have made a mildly inconvenient stop downright unpleasant.
Go back and look at the legislative history of the GI Bill, Medicare, Medicaid, and Social Security again. Sure, they’ve been changed. But they haven’t been changed every year, every Congress, every administration, or even every decade. They haven’t been tinkered with continuously which certainly seems to be what’s envisioned for the PPACA.
When I moved back to Florida I went to the DMV to get a new ID with my new address. Usually I just did this online since I was out of state. After the usual wait (don’t visit the DMV around lunch), I was told that because of REALID requirements, I’d have to have a bunch of documents, including my social security card, which I didn’t have. So I went home, got online, changed my address and they sent me a new driver’s license in the mail to my new address with no documentation.
Michael,
The IRS seized funds in one of your accounts? Wow, that’s pretty drastic, but an apology? First sign of the apocalypse?
Ben:
Apropos of which, have you seen this? My new hero: http://www.youtube.com/watch?v=VbnEB9ntztY&feature=player_embedded
Andy:
It’s possible they were reacting to the fact that I just toss their letters on the counter and don’t actually read them. I’m pretty sure that’s not the grown-up way to handle IRS letters.
Go back and look at the legislative history of the GI Bill, Medicare, Medicaid, and Social Security again. Sure, they’ve been changed. But they haven’t been changed every year, every Congress, every administration, or even every decade.
Every year? No. But otherwise, Medicare has been tinkered with more or less constantly since its inception:
http://www.kff.org/medicare/timeline/pf_entire.htm
Let me make it easier: it’s been amended 6 times in 47 years:
1980 — Medicare Secondary Payer Act of 1980, prescription drugs coverage added
1988 — PL 100-360 Medicare Catastrophic Coverage Act of 1988
1989 — Medicare Catastrophic Coverage Repeal Act of 1989
1997 — PL 105-33 Balanced Budget Act of 1997
2003 — PL 108-173 Medicare Prescription Drug, Improvement, and Modernization Act
2010 — Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010
The ’88 reform was repealed in ’89. That leaves ’80, ’97, ’03, ’10. Or, said another way 15 years, 17 years, 6 years, and 7 years. I repeat: the degree of continuing revision that its proponents anticipated is unlikely in the extreme. Healthcare reform in the United States just doesn’t work the way they think it does.
Something else to chew on: what groundwork has been laid since 2010 to make it easier, more palatable for Congress to tackle healthcare reform more frequently? Does it look like it’s getting easier?
I think you’re being far too literal. Many of the most important changes to Medicare have occurred through omnibus budget reconciliation acts, which your shortened timeline leaves out. The Resource-Based Relative Value Scale, for instance, was instituted during the 1989 budget reconciliation. Per Kaiser’s timeline, there were at least seven other significant changes instituted through Congressional budgets.
Now the RBRVS may not have been the source of a heated debate over healthcare reform – but it was really important (if not in a good way). Which IMO would be a better argument from your end – that the frequent tinkering we might see is at least as likely to make the PPACA worse rather than better.
As a pessimistic idealist, I respect that position, even though I think the law was worth trying anyway.
To be honest I think that the revisions that occur in omnibus budget reconciliation acts, since they frequently are not subjected to the scrutiny that might otherwise take place, are almost invariably worse. Procedurally, I’m skeptical that the kinds of revisions that, for example, Joe Klein or the Bloomberg editors recently proposed would be tucked into the innards of an omnibus budget bill.
I also repeat the question I asked: does it look to anybody as though healthcare reform legislation is getting easier? It certainly doesn’t to me.
It all sort of reminds me of a medical test I once had prescribed that required me to undergo one blood draw per hour over a period of four hours. On the first blood draw the technician botched the draw six times. I asked one question: does it get easier or harder from here? When the answer was “harder” I thanked him for his time and left.
That’s the source of my present policy: after the fourth attempt I insist that the technician and I trade sticks.
No. But it doesn’t look like it’s getting harder to me, either. Should the Republicans gain all three branches this fall, I suspect we’ll get a PPACA reset and a watered-down version of the Ryan-Wyden plan right quick. And if somehow that doesn’t happen, and the Democrats bounce back in the next few cycles, we’ll get a “public option” plus some more modest payment reforms.
For better or for worse, we’re moving towards a more parliamentary style of government. I don’t really like that, but politicians follow the incentives, just like everyone else.
Man, if we were moving towards a more parliamentary style of government I’d be overjoyed by comparison with what I think we’ve evolved into: government by bumper sticker. All we seem to get now is slogans. No new taxes! Community rating! Guaranteed issue!
A parliamentary systems sounds very appealing, but I’m not sure how to make it work within a federation of nominally sovereign states.