Year: 2013

Yuval Levin reflects on last month’s two big political stories, the populist-fueled government shutdown and the technocrat-led Obamacare roll-out:

If abject populism or gross technocracy were our only options for governing ourselves, the experience of this past month would be enough to leave us in despair. And it does sometimes seem as though we imagine those are our options. But I think the past month should actually be cause for hope that we might see beyond these two dead ends. Not only are technocracy and populism not the only choices we have, they are not really quite alternatives at all: They are in a sense two sides of one bad coin.

In their extreme forms, the forms we have seen this month, both populism and technocracy assume that the answers to our most profound public problems are simple, and are readily available. One assumes that the people possess these answers, and that they are denied the power to put them into effect by some elite that wants to oppress them; the other assumes the experts possess these answers, and they are denied the power to put them into effect by a system that empowers heedless and prejudiced majorities or the venal economic interests of the wealthy over the attainment of the objectively obvious good of the people.

That’s an interesting take, and I largely agree with it. The conservative alternative to today’s Republicanism would be a) never to risk the US and global economy just to make a point – let alone be reckless enough to wait until the very final minutes before possible default to concede, and b) to craft policies that only reform what can practically be done, without any grand scheme of progressive general improvement.

Where I’d differ with Yuval is in his excessive critique of the ACA. Our current healthcare and health insurance market is dreadful. The private sector is grotesquely inefficient and often inhumane. Insurance that can be canceled when you really need it, that screens any sick people out, that costs a fortune compared with other countries, that burdens the economy in ways not seen in our competitors – is not something conservatives should want to conserve.

And any serious reform of it will have to be technocratic.

The ACA, moreover, was not a technocratic dream invented out of the blue. It’s actually a product of federalism in the best sense – it models a successful and existing system in one state, Massachusetts, and attempts to replicate it on a bigger scale. If I had my druthers, I’d favor the states taking the lead on this, rather than the feds. I’d end the employer subsidy and create HSAs and a marketplace not unlike Obamacare’s to empower individual insurance policies. But if I am asked to pick between Obama’s vision and nothing (which is effectively the GOP’s position), I’ll go with Obama’s and aim to amend it as time goes by.

My difference with the GOP is that I do not question the sincerity or legitimacy of this president or the importance of upholding the law. I also favor universal coverage. The president won two elections with this policy out in the open. We should give him the chance to make it work, instead of hurling spitballs, egging on sabotage, and mindlessly piling on. And we should acknowledge that being bankrupted because you are sick is not a good thing. It’s inhumane; it’s cruel; and it’s not like other products that people can do without. “Amend it, not end it” would be my preference. That’s neither technocratic in any overweening sense, nor populist pabulum.

I just want to second everything Kermit sings. I loved New York City with a passion until I tried to live here. It’s been over a year and I am horribly home-sick. So we’re going to move back to DC next month. I miss my DC apartment (1500 square feet of a school classroom I got for a steal in 1991); I miss my friends, many of whom I’ve known for decades, and some of whom I bonded deeply with during the plague years of my 20s and 30s; I miss the relative calm; I miss the green; I miss the increasing vibrancy of the city – which somehow doesn’t make it harder to live in. I miss the oases of quiet and the energy of a new emerging city that is both a second Brooklyn and a global hub of media and politics.

But I’ll be commuting to New York City for up to two weeks a month – as a visitor. So it’s more like finding a home I love while keeping New York close. I realize I’m married to Washington, and it’s best for me to think of New York as a mistress. Besides, I need to be here for the Dish (all my colleagues are New Yorkers), and for AC360 Later. I also have many friends here I think I’m more likely to spend time with if I’m not actually struggling every day to handle the, er, challenges of actually settling into the massive metropolis. And in this experience – to love and yet leave this amazing place – is not new, I’m relieved to say. Eryn Loeb just reviewed a new essay collection Goodbye to All That: Writers on Loving and Leaving New York, an anthology inspired by Joan Didion’s 1967 essay of the same name:

As laid out by Didion and the anthology’s contributors, it happens like this: First there’s anticipation, imagining how your life will finally make sense when you arrive. The actual experience of living here is one of finding your place, followed by an intense feeling of ownership. You can stay at that point for years. But eventually, sometimes without knowing it, you begin the slow slide toward a moment of decisiveness. Sometime after that, there’s the actual leaving. And then, the having left. Living in New York turns out to be a process of earning nostalgia — hoarding enough memories to give you the kind of claim on a place that makes it possible to leave it. When you reach your limit and set out elsewhere, memories are your consolation prize. (Bonus points for writing about them.)

If you’re tired of hearing about how New York is the center of the universe, you’re not alone.

Even those of us who live here and love it get annoyed at the relentless fascination with the city, the way people project so much onto it and then feel betrayed when it doesn’t live up to their expectations. (Emma Straub, who grew up here, captures this tension nicely in her essay, writing, “because my hometown is New York City, everyone else thinks it belongs to them, too.”)

But even in basic ways, the city is still special enough to justify the fixation. It’s concentrated. It’s diverse. It’s where a lot of important things have happened and influential people have lived, and so it is full of history and legend. It’s a place of ideals, “where anything is possible.” And yet it’s also a place of limits, one people leave when their desire for more space or stability — or very often, a family — begins to clash with reality.

Previous Dish on New York and its discontents here, here, here and here. Update from a reader:

I’ve lived in NYC for exactly 11 years as of today. But on Thanksgiving weekend, I’ll be packing up all of my stuff and moving into a home in Vermont that my father left to me after his death this year. My girlfriend and I just got engaged – and she’s converging on VT that weekend as well from Chicago to settle down with me.  I’ll still be working for the same NYC firm up there remotely.  So I’ll have a slim tether keeping NYC in my life – which feels just about right.  I didn’t want to totally break up with this place, despite the fact that it has ground me down into fine powder.  I look forward to missing the city again and coming back to visit it.

I’ll also be running the NYC Marathon on Sunday – which feels like a real nice way to say goodbye to the place that I once deeply loved, but now curse every day.

Readers push back against this post:

Some people are going to lose, but look at this chart from TPM. Considering all the changes, 3% “losers” is pretty darn good.  Like Gruber said, “… no law in the history of America makes everyone better off”. Indeed.

Josh Barro identified significant problems with that chart. A reader from the 3 percent writes:

I’m one of the people who got a “cancellation” letter. Blue Shield told me the individual policy I have for my healthy 17-year old will end Dec. 31. They said if I do nothing they will enroll my son in a new plan that will be $7 more per month. It is just about equal to the old plan, except the co-pays will double, and vision care has been added. It is November, and my son has had zero visits to the doctor this year, so no co-pays have been shelled out. He has terrible vision and needs an annual eye exam. I figure it will all even-out over the course of the year. Put me in the “no big deal” category of the 3 percent whose individual policies went away.

Another reader:

Mr. Laszewski doesn’t say what “Obamacare rule” purportedly makes his current coverage not “good enough.”  Maybe that’s so, and maybe it isn’t, but it’s hard to evaluate his complaint based on no information.

David Frum apparently found a policy substantially identical to the one he currently has on the D.C. Exchange for $200/month more, and acknowledges that that is the likely cost of community rating.  High income wealthy people who are currently in the individual market are going to pay a bit more under Obamacare – that’s the cost of not quizzing people about preexisting conditions.  In any event, he didn’t lose his coverage.

Another:

Sorry if I cannot muster much sympathy for someone who can afford a Cadillac Plan. After I finished grad school and before I had my first real job, I had to muddle through without health insurance for about 9 months. I got one lousy urinary tract infection (read: INCREDIBLY treatable) and it ended up costing me a little over $800 because the initial antibiotics didn’t work. Oh, and I had a catastrophic plan. Some help those are! So yeah, sorry if I’m not bringing out the violins about some rich dude having to pay more for his extravagant plan.

Another:

I know a lot of people are commenting on the rate shock some people are experiencing when looking on the exchanges for insurance, even those who have very expensive health insurance today. I think there’s a very big piece of the puzzle most people commenting on this rate shock are missing.

Insurance companies on the individual market are in a bit of a fog for next year with pricing their coverage options. Many of them have never had to cover as many benefits as they are now. Many of them have no idea how many claims new people purchasing their coverage will make. They all know for sure that the premium rate review rules will stop them from making up potential losses next year with bigger premium hikes in the future. The confluence of these events has potentially pushed companies to overprice their plans.

What people are forgetting is there is a stopgap that prevents these companies from gouging people if they did end up overpricing. Plans on the exchange must spend at least 80% of their premium on actual health care services; similarly, businesses offering insurance to their employees must spend at least 85% of their premium on actual healthcare services. If they fail to do so, they are legally obligated to send their beneficiaries a rebate check for the difference. That will stop insurance from getting too expensive.

Of course, if it turns out the companies are spending enough on healthcare to avoid sending rebate checks, then the insurance companies will have done their job and actually paid for their beneficiaries’ healthcare! People love getting refunds on their taxes. I presume people will love getting refunds on their health insurance as well.

Another:

It’s worth remembering that Cadillac plans create serious cost problems for our healthcare system.  If they are tax-deductive, then it’s a huge tax expenditure, but even when not, they encourage over-utilization.  There should be cost sharing mechanisms that put a slight disincentive on healthcare spending, especially utilization all over the place, where there are no shared medical records, tests are likely to be duplicated and there is more defensive medicine due to this.

As a physician, I see a lot of patients with disabling neuromuscular conditions.  Many are forced to stop working, and thereby lose their insurance.  I see this over and over again.  There is just no comparison the gain these patients are getting by being able to get insurance, compared to this guy who has to either pay more for a Cadillac plan, or get a more regular plan.

One more:

At the very end of Robert Laszweski’s post he states that he will actually be keeping his Cadillac plan until at least December of 2014. It seems like an important point to make that he left hanging until the 2nd to last paragraph. A lot can change in 14 months …