The Details of Romney’s Plans

You probably know that Mitt Romney is trying to reinvigorate his campaign. The new strategy is supposedly to project what Romney would do if elected. Instead of talking down the Other Guy he is going to come clean on his Big Plans.

I will bravely predict here and now he will do no such thing. In our current political environment no presidential candidate can afford to talk about Big Plans in a candid or courageous way.

It’s a staple of presidential campaigns that pundits urge candidates to offer sweeping and detailed plans to clean up our problems. In recent days David Brooks and Tom Friedman, two commentators I greatly respect, have expressed great frustration that Obama has offered nothing so grandiose. Brooks wants him to explain how he will lower American debt and reform Medicare, while Friedman wants him to offer a plan to rejuvenate our economy, fight global warming, and rebuild our infrastructure along green lines.

I’m all in on wanting such plans, as these are genuine and deep problems. I know, however (as these pundits surely do too), that no sane American politician would offer such plans. It’s all pain and no gain in our political environment. The details would be seized on, distorted and treated as if they represented a deliberate assault on American virtue.

Don’t believe me? Think of the caliber of debate on Obamacare. Death panels, anyone? Government takeover?

Or consider Paul Ryan’s plan to reform Medicare. It’s been reduced to a single word: “vouchers.”

It might be worthwhile to offer grand plans if they would be met by counter-proposals leading to a legislative process and a bipartisan compromise. That’s simply not going to happen. The last thing Republicans want to do is offer an alternative to Obamacare, and the last thing Democrats want to do is spell out how to reform Medicare. No, wait, the truly last thing either party wants to do is to offer a concrete proposal for dealing with debt and deficits. (No, Ryan hasn’t. Not until he tells us where the cuts will go and which tax deductions will disappear.) Neither party wants to offer such specificity on plans that will surely include pain.

Now, it’s nice to blame the political process, the political parties, and the politicians for this state of affairs. Surely at some point, however, we have to blame ourselves. We the American people–and I think this applies to all of us–have developed an inordinate fondness for dessert without vegetables, and for bumper sticker attacks on the people we disagree with. We punish politicians who spell things out. We prefer to talk in slogans. So for the foreseeable future, we are stuck with muddling through.

Health Care Update

Item: I am now paying $27,000 per year for Blue Shield catastrophic care health insurance for myself and my wife. (The first $7,200 comes out of pocket. That’s our pocket.)

Item: Recently I went to my doctor to see about some hip pain. He examined me for about ten minutes. The bill was $199. When I called Sutter Health to ask how that could be, the woman in customer service seemed offended that I wanted an explanation. She said it could be more, and that the cost of a doctor’s visit varied, depending. When I asked depending on what, she said it was a government formula and she couldn’t tell me. When I asked whether there was any way to know in advance how much a doctor’s visit would cost, she said no. Question: is there any other service that cannot give you an estimate of cost in advance?

Item: according to my doctor, his office now has two employees working on insurance for every doctor or physician’s assistant. That’s not counting the insurance company employees.

The conclusion I draw is that our medical care system is broken. It’s broken even for people like me who can get insurance, let alone for the ever-increasing millions who can’t, at any price.

Obamacare is, generally, an attempt to save the system. It preserves the basic elements of individual or company health insurance, paying to independent providers. Within that framework it tries to make sure everybody can get insurance–especially those who have an ailment or a history that currently makes them uninsurable. It makes some preliminary attempts to rein in costs.

Whether it can work, I have my doubts. I’m inclined to hope it gets a chance, because right now it is the only game in town. Has anyone else offered even the shadow of a plan that would enable people who need it to get insurance? I don’t think so. If Obamacare is thrown out, or fails, we’re left with the current system, which gets more impossible every minute.

The only other option is single payer, like every other industrialized nation has. Politically, we’re not ready to go there. Yet.

Folks, we are in a mess.

Cutting the Deficit

I’m never going to be a policy wonk, but I find that if I squint and tilt my head a little to the side, I blur a lot of distracting appendages and can make out the main shape of the budget problem. The distractions are things like NPR and Planned Parenthood. The main shape is the bloated form of health care—Medicare and Medicaid—that promises to keep growing forever. If you can’t get health care costs under control, you have no hope of balancing the budget.

If you have ever had the slightest involvement with health care, you know there is money to be saved. For example, a resident working in a major county hospital tells me that because the authorization process for certain tests takes so long that the patient would be dead before they got the okay, residents sometimes admit patients to the hospital who don’t need to be there. It’s horribly expensive (and comes out of your pocket) but it’s the only way to get the tests. Anybody working in the guts of the health care system can tell similar stories. There’s tons of waste and abuse. But the system has a lot of built-in resistance to change. And it’s easy to demagogue proposals for change. (Death panels, anyone? Rationing health care?)

Obamacare took a shot at some cost control measures—not many, but some. In the Obamacare approach, the diet is in the details—a million and one policy-wonk changes to the system.

Paul Ryan’s approach is just the opposite. Don’t bother with the details. Just say: here is how much money we have—figure it out. People (and states) will be given vouchers to pay for health care. The rest is up to them and the health care system (including insurance companies).

It’s a Gordian-knot solution. You don’t untangle the knot. You cut it. There’s a lot of appeal in its simplicity. But the devil will still be in the details.

If the Obama approach puts a lot of faith in policy wonk prescriptions, Ryan places a lot of faith in the “free market” health care system.  If you give it a certain set amount of money, it will figure out how to spend it wisely.  I’m not optimistic. As far as I can see, the system isn’t a system, just a collection of interest groups whose workings are greased with a lot of money.

Suppose we adopt Ryan’s approach. What happens when a middle-class somebody with inadequate insurance gets very, very sick, requiring a million dollars worth of treatment that his insurance won’t pay for? Does that somebody just die? If ten thousand middle-class somebodies die, how long does Ryan’s approach last?

What do you think? Can the policy wonks figure out how to make the system work efficiently? Or will putting the system on a strict allowance make it stop overeating?  When I consider these two options, I’m pushed toward the much-reviled Canadian option, which combines elements of both: a strict allowance, with policy wonks in charge of figuring out how to spend it. And yes, we ration health care. Just like we do now.