Monday, June 04, 2007

"The Timidity of Hope"
A few weeks ago I asked one of my friends, who also works in policy, what she thought about the Democratic presidential race in general, and Barack Obama in particular. She kind of made a face and said, "I'm a wonk. You're a wonk. We need specifics, details, programs."

It was a fair criticism, though I'm not totally sure I share it. Democracy is a mass exercise, even (or especially) in as flawed and imperfect a version as we have in the United States, and almost by definition the mass public isn't going to wonk out with me and my friend and our colleagues. This might the corollary to the best line John Edwards got off in last night's debate, which I wrote about earlier today: "Being president isn't about legislating--it's about leadership." (The irony, of course, is that Edwards has issued the most detailed plans of any major candidate on either side, and is pretty clearly trying to position himself as "the candidate of ideas" in response to the greater star power of Obama and Hillary Clinton.)

This brings me to Paul Krugman's column today about Obama's health care plan. He issued it somewhat in response both to the detailed proposal Edwards made earlier this year, and Obama's own widely perceived flop at a candidates' forum on health care a couple months ago.

I'll admit up front, and not even with a great deal of shame, that I haven't read either plan. I've read a fair amount about both, for whatever that's worth, and I grasp how they're different in concept and ambition. But aside from impressing super-wonks like Krugman, or lesser wonks like me--a feat that has some value, but not a ton, as I'll explain below--I'm not sure I totally get the point. Here's Krugman:

The Obama plan is smart and serious, put together by people who know what they’re doing.

It also passes one basic test of courage. You can’t be serious about health care without proposing an injection of federal funds to help lower-income families pay for insurance, and that means advocating some kind of tax increase. Well, Mr. Obama is now on record calling for a partial rollback of the Bush tax cuts.

Also, in the Obama plan, insurance companies won’t be allowed to deny people coverage or charge them higher premiums based on their medical history. Again, points for toughness.

Best of all, the Obama plan contains the same feature that makes the Edwards plan superior to, say, the Schwarzenegger proposal in California: it lets people choose between private plans and buying into a Medicare-type plan offered by the government.

Since Medicare has much lower overhead costs than private insurers, this competition would force the insurance industry to cut costs — making our health-care system more efficient. And if private insurers couldn’t or wouldn’t cut costs enough, the system would evolve into Medicare for all, which is actually the best solution.

So there’s a lot to commend the Obama plan. In fact, it would have been considered daring if it had been announced last year.

Now for the bad news. Although Mr. Obama says he has a plan for universal health care, he actually doesn’t — a point Mr. Edwards made in last night’s debate. The Obama plan doesn’t mandate insurance for adults. So some people would take their chances — and then end up receiving treatment at other people’s expense when they ended up in emergency rooms. In that regard it’s actually weaker than the Schwarzenegger plan.

I asked David Cutler, a Harvard economist who helped put together the Obama plan, about this omission. His answer was that Mr. Obama is reluctant to impose a mandate that might not be enforceable, and that he hopes — based, to be fair, on some estimates by Mr. Cutler and others — that a combination of subsidies and outreach can get all but a tiny fraction of the population insured without a mandate. Call it the timidity of hope.
[Obama's plan] doesn’t quell my worries that Mr. Obama’s dislike of “bitter and partisan” politics makes him too cautious.

Two points here. First of all--and this is something so obvious and uncontestable that I think it's kind of negligent for Krugman not to mention it--there's next to no chance that anything proposed by any candidate on something as big and important and contentious as health care gets enacted as drawn up by the David Cutlers of the world. (He's a brilliant guy, by the way--this isn't a slap at Cutler. It's just that academics aren't generally successful, ever, in writing legislation.) The details--the substance that Krugman and my friend were both waiting for--are, in that sense, totally irrelevant. Whatever legislation the 111th Congress passes, assuming a Democratic president and Democratic majorities and other favorable circumstances for major health care legislation, will be written by anonymous staff (perhaps, hopefully, with input from people like Cutler), chewed over in countless private meetings with colleagues, officials, lobbyists and advocates, torn up and rewritten, marked up in committees, argued in public, salted with goodies, revised and amended a hundred times, and perhaps finally enacted. Or not. It's a slight exaggeration to claim that any resemblance would be coincidental, but that's almost the case.

Two, since this is the case, one can look at Obama's approach, which I think can be characterized as "do what can be done," in one of two ways. The partisan will suggest that the inevitability of compromise means that an advocate should set his or her position at the far end of what they want, giving as little ground as possible before settling on an agreement or walking away if the proposal is too diluted. The consensus-seeker will counter that it's better to minimize the level of conflict up front, improving the chances for some kind of accord, and going back later if need be to fix what's wrong.

I've written here before that I believe the essence of executive leadership is threefold: to know where you want to take the public on an issue, to know where they are, and to have an idea of how to get them from Point B to Point A. It's an exercise in finding consensus, then shifting the consensus, accomplished through exhortation and patience. My sense is that Obama grasps this, which is why I'm planning to support him next year. Just because my version, or Krugman's, of where Point A should be, is different from his, doesn't in my opinion trump the sense that he knows how to carry out the journey.

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