Month: November 2013

Jonathan Cohn argues that most Republican healthcare plans would be more far disruptive than the ACA:

With Obamacare, a small number of people lose their current insurance but they end up with alternative, typically stronger coverage. Under the plans Republicans have endorsed, a larger number of people would lose their current insurance, as people migrated to a more volatile and less secure marketplace. Under Obamacare, the number of Americans without health insurance at all will come down, eventually by 30 or 40 million. Under most of the Republican plans, the number of Americans without insurance would rise.

Honest Republicans would justify their policies by arguing that Medicaid is a wasteful, inefficient program not worth keeping—and their changes, overall, would reduce health care spending while maximizing liberty. In other words, forcing people to give up their coverage is worth it. I don’t agree with those arguments, but they are honest. But they should stop pretending that it’s possible to address the problems of American health care without disrupting at least some people’s insurance arrangements—because, after all, they want to do the very same thing.

Chait thinks this is why Republicans have failed to propose a real Obamacare alternative:

Every iteration of an alternative conservative health-care proposal would impose far more disruption on the status quo than would Obamacare. Most conservative plans involve drastically curtailing the tax deduction for employer-based insurance. That would create cancellation notices for many times the number of people currently seeing them. Even the more modest plans to scale back Obama’s regulation of the individual market would run the GOP into a political minefield. Which regulations do they want to strip away? Discrimination against people with preexisting conditions? Discrimination against potentially pregnant women? Mental-health parity? Every single one of those changes creates millions of angry potential victims.

This is exactly why the actual Republican Party health-care plan is not repeal and replace, but repeal and cackle. Republicans are on strong ground exploiting fear of change. They have understood perfectly well that they must avoid having to defend a different set of changes to the status quo. They have kept their various replace ideas safely to the side for exactly that reason.

Beutler piles on:

[S]mart conservatives — which is to say, policy wonks without much cachet on Capitol Hill — would replace all insurance with subsidized catastrophic coverage and tax-preferred health savings accounts. Nobody with private insurance or Medicaid would get to keep what they have, no matter how much they like it.

Reihan objects:

To be sure, there are some people who think that government policy should lean against comprehensive insurance. David Goldhill, author of Catastrophic Care, favors something like single-payer catastrophic coverage. Brad DeLong has floated the idea as well. The conservatives I think Beutler has in mind certainly like the idea of catastrophic insurance. It’s just that they have no problem with allowing people to buy comprehensive insurance if that’s what they’d like to do with their money, and they recognize that low-income and disabled individuals will need larger subsidies than other people. …

One can definitely imagine alternatives to Obamacare that would be more disruptive than Obamacare. If consumers were banned from purchasing comprehensive health insurance, for example, there would definitely be a lot of disruption. But by and large, “reform conservatives” favor more modest measures that are designed to ease the transition to a more sustainable system.

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.