In comments to the post on pragmatic evolution of US health policy on Monday, The Question raised a point that I want to respond to:
on health care why do we always have to pre-negotiate with ourselves and have ourselves primed to accept half a loaf? I am so tired of being sensible when there is no gorram reward. If loudly shouting the most extreme thing we want gets us even half what the republicans have gotten out of it why the hell not??
I want to raise an empirical point and then a broader political/policy point that explains my thought process.
First, empirically, what has “shouting the most extreme thing” gotten Republicans?
It has gotten them power.
What have they done with it so far? In 2009, Democrats at this point had a smaller functional majority in the Senate and a slightly larger majority in the House than the Republicans have today. Democrats had passed and signed into law the stimulus, CHIP re-authorization, Lily Ledbetter, and the
Dodd-Frank CARD ACT by now. They were grinding their way through what would become the ACA.
What have the Republicans accomplished as of today?
They got a Supreme Court justice at the cost of allowing liberals to nominate liberals in the future. And they named a bunch of post offices. What else have they gotten at the legislative level? And they also got a President who is at 34% who is leading to massive swings against the GOP. Those swings are large enough to endanger the gerrymandered House GOP majority even if they do nothing.
That is my pragmatic point. Being howler monkeys may be a successful strategy to gain power but it has not been a successful strategy to exercise power.
Now onto the broader point of pragmatism or pre-compromising depending on your point of view, I want to bring back a post from December 2015 regarding a statement made by the current FDA Commissioner Scott Gottlieb on the ACA Exchanges. First I will highlight a post from earlier that week explaining the bullshit:
leading lights of the conservative “health wonk” community is peddling bullshit that is technically true if you parse it correctly but designed to mislead anyone but a hyper technical reader.
Last year open enrollment started on November 15th. The 6th week of open enrollment would have been the first week of January.
This year, open enrollment started on November 1st. The 6th week of open enrollment just wrapped up.
Yes, at the six week mark of open enrollment, 2014 enrollment is running higher than 2015 enrollment. However there is one massive fact that will show 2015 open enrollment 7th week selections running ahead of 2014 7th week selections. Sometime at the end of this week, Healthcare.gov and most of the state based exchanges will conduct a massive automatic renewal of plans.
Trump is a partial consequence of over-promising
And next year, when Obamacare does not collapse in on itself like a neutron star of fail, the same opinion leaders and expert validaters will trot out the same story.
The Republican base has been promised a lot and their party can’t deliver on those goals. The elites don’t have legitimacy because their bullshit has been marked to market so new entries with new, creatively destructive forms of bullshit have a niches that they can fill and a willing mass audience that wants to believe that this time the new guy can deliver on their promises while ignoring the elites who have no credibility.
I want to avoid that cycle. I would rather under-promise and over deliver than over promise and under deliver.
I also believe that the details matter and an accurate assessment of the current state and a reasonable approximation of future states is critical in doing anything well. I can be accused of having that bias for professional and financial reasons as I am a health policy wonk and figuring out complex systems pays the mortgage. I don’t think that is what drives me, but I will acknowledge that possibility.
I want a political and policy program that has two realistic chances. The first is that it needs a realistic chance of passing Congress and being signed into law. The second is that once it is law, it needs to have a realistic chance of actually working and doing what it intends to do without surprising consequences in type or scale.
From these preferences, that means identifying things that imperil those two chances. Great politics don’t always means great policy as we see with the risk pool damage that the Under-26 provision of the ACA creates by pulling out healthy young people from the market. Needed policy is not always great politics as we see with the individual mandate. Sometimes a bad is needed to be accepted on one side of the equation to allow the other side to work but those bads should be minimized to the essentials for passage or functionality. And that means being disciplined in our thinking.
The valuation of “bad” will vary. It is a combination of projection and a value judgement as to what trade-offs are acceptable. Having that discussion now and hopefully coming to some type of consensus or at least a clear understanding of different valuations is a good thing as there is time to tweak and rejigger plans.