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The Right Prescription

America's Policy Graveyard

By on 6.23.09 @ 6:09AM

Afghanistan is the graveyard of empires; healthcare is the graveyard of policymakers. Yet Washington reformers are massing again at the healthcare frontier. Like their predecessors, they will march in with flags unfurled, bands blaring, and intentions good. And like their predecessors, they believe they have it right this time – the country's receptivity, the politics, and the policy. Without predicting today's outcome, it is worth pausing to survey the past and terrain. 

Today's healthcare reformers face a tall order, not only in shaping policy but facing history. Both Afghanistan and America's healthcare system have been most unforgiving to those seeking to affect change on their respective landscapes.

Afghanistan is called the graveyard of empires for good reason. Since Alexander, the invader can only hope to reach accommodation with the indigenous. Rulers who have left their names indelibly in the history books, have left barely a trace in that country. 

It could well be argued that Afghanistan was the final undoing of the USSR. A failure in crafting domestic policies for its citizens, the USSR held one claim of insuperability: its military might. It had defeated the Nazis and still could protect Mother Russia. When after ten years futility in Afghanistan, its military might had been transformed into military myth, no justification remained for the Soviet state itself. 

The U.S. healthcare system has been no more welcoming to those policymakers seeking to remake it. The case could well be made that the failure of healthcare reform in its first year essentially undermined the Clinton administration for the remainder of its time in office. Truman and Nixon also tried to create a national healthcare system without success. In contrast, the list is also notable for its absences. FDR and LBJ, authors of the expansive New Deal and Great Society programs, both knew to leave well-enough alone, despite having ambitious agendas and overwhelming political majorities. 

Like Afghanistan's rugged and inaccessible frontier, the U.S. healthcare system has evolved into a similarly perplexing inaccessibility. Its most prominent feature, the ability of employees to receive health insurance tax-free from their employers, is the product of attempts to circumvent WWII's price controls. As a result, the private healthcare system is largely comprised of beneficiaries and providers with third party payers between the two. This creates a bizarre dynamic separating customers from cost, helping fuel America's health cost spiral.

American healthcare is also pockmarked with government-run healthcare systems. Medicare and Medicaid at the federal level pay hundreds of billions of dollars annually to provide healthcare to tens of millions of individuals. Independent state systems also abound. And finally, relatively straightforward customer-provider relationships exist in areas such as eye and dental care, where cost increases have been restrained and quality is highly.

As odd as this mix-and-match payment-provider system is, Americans are attached to it in large part and easily can become opposed to change of it. 

Because of the healthcare system's complexity and immensity -- it comprises almost 18 percent of the nation's GDP -- it is dauntingly hard to placate all the sectors and stakeholders in it when it comes to reform. And it is correspondingly easy to assemble a coalition resistant to change. 

Reformers too are bedeviled by their own plans to bring order to disorder. A pride of lions pales in comparison to a pride of authorship. Reformers find it hard to alter their approach to rationalize the healthcare system to accommodate parts of the system's prevailing irrationality. 

For these reasons, no other area of U.S. public policy has proven so difficult to reform. Tax, energy, agriculture, trade, finance, and a host of other policy areas have all been overhauled -- usually multiple times -- in the time since reform of the healthcare system was attempted back in the Truman Administration. Instead, the healthcare system at most has had additional layers added to itself without appreciably reordering the underlying layers. The onion has gotten larger, but it is still an onion. 

None of this is to say that America's healthcare system should not be reformed. It should. Or even to say that it cannot be. It can. It is just a reminder that it has not been…at least up to this point. Despite the best of intentions and some thoughtful policy proposals, reformers have repeatedly marched out of America's healthcare system much the worse for wear from when they marched into it. It will be interesting to see if in today's attempt, the reformers make a bigger impression on the healthcare system, or if the system makes a bigger impression on the reformers. And if either impression is positive.

Letter to the Editor

topics:
Health Care, Afghanistan

J.T. Young served in the Department of Treasury and the Office of Management and Budget from 2001 to 2004 and as a Congressional staff member from 1987 to 2000.

Comments

Robert Rosencrans| 6.23.09 @ 6:55AM

A good analogy of what will happen to health care can be found in the Metro accident yesterday. For whatever reason, it happened. A mistake was made. Nine citizens died.

The Metro is a system controlled mainly by four governments, D.C., Maryland, Virginia and the federal government. It is a well used system which is designed with all the best intents.

Some of the impetus which propelled these systems were environmental concerns. Right or wrong, the system was created and put in place.

After 33 years the system is plagued with problems and accidents. An industry has sprung up around the country defending the alleged victims of Metro accidents.

There are many government themes to be found in these Metro management styles. Affirmative action and community involvement being two of the themes which guide these agencies. What you don't see is the legal team behind the scene, constantly on defense against the many slip ups. The legal teams are the ones really involved with the community.

Here's a link which shows the cottage industry which has sprung up in response to this government plan which packs them in like sardines and tells you it's Nirvana.

Can a health care system designed by the government or any combination of government forces be so different? It's not likely. Be prepared for a wild ride.

http://search.yahoo.com/search?fr=ffds1&p=metro+accidents+in+us

Ryan| 6.23.09 @ 7:31AM

One of the many problems is there really is a need for reform in the health care system.

The problem in the debate is the fallacy that we have a free-market system. We don't. As JT stated, we have a "bizarre dynamic separating customers from cost, helping fuel America's health cost spiral."

The system is run by insurance, government, and doctors without the real consumer in the loop who is the real determiner of cost-effectiveness. Whether malicious intent or not, that's the way it wound up.

Liberals are painting what we have as being free-market, when it is anything but. With that perception, of course they're going to run to a public option with their viewpoint.

I honestly think that all the poll questions, all the reasoning behind a public option is skewed in that manner - it doesn't take into account that the market for health care is NOT a free market. It just assumes it is because it's not a true "public" option.

I also think that the American people know this at heart, and are mostly opposed to government-run health care, but they don't really know how to make what we have work better.

I DO think we need a medicare/medicaid-style safety net, but only extended to the poorest and inable. If we can free up certain insurance restrictions (simply getting rid of the state line issue may be half the solution) BEFORE we reach for a public option, we may be able to prevail.

That being said, I'm not so sure anything can or will pass, at least nothing that can be rolled back later.

Alan Brooks| 6.23.09 @ 8:18AM

not Afghanistan; the Roman Empire, you blockhead!
this is why I will never subscribe to AS-- too much rightwing gobbledygook and not enough conservatism.

Mike| 6.23.09 @ 8:21AM

This is an excellent article that clearly outlines the shape of "the best health care system" in the world, according to some on the right. One point I would make about insurance: at its inception what was fundamental to insurance was assessing risk and pooling funds for the benefit of the unfortunate policy holder who paid premiums for the coverage. It wasn't about doing business to make a profit for shareholders (i.e. how many claims can be denied), or building gigantic buildings, or paying CEOs exorbitant salaries or hiring lobbyists to protect its interests in the nation's capitol (including AIG like bailouts when the non-insurance business of the insurance company goes awry) At one time it was about, well, insurance.

Alan Brooks| 6.23.09 @ 9:56AM

but why the silly analogy to Afghanistan? is it babytalk for gumplicans? America is like the Roman Empire, not the Soviet Union.

But don't worry, an imaginary universal health care system with nonexistent funds is nothing to worry about.

BTW no wonder Obama is president-- you all deserve him.

Alan Brooks| 6.23.09 @ 10:12AM

well it makes sense not to use the analogy of the R. Empire; such would be too on-target.

Raoul Ortega| 6.23.09 @ 10:38AM

I will never subscribe to AS-- too much rightwing gobbledygook and not enough conservatism.

And yet, at this point, half the comments have been by you, all repeating the same (wrong) point.

The US is the Roman Republic shortly after the destruction of Carthage. We've got a long way to go before we get to Caesar, despite our current president's similarity to Elagabalus.

Pingback| 6.23.09 @ 11:54AM

The Obama Moment: What Iran, Golf, Ice Cream and Hungarians have in common « Jim Blaz links to this page. Here’s an excerpt:

…will be remembered forever. More Articles Obama-come-lately on Iran By Michelle Malkin Review: The Stoning of Soraya M. by John Nolte The 2nd Amendment and Iran by Ed Morrissey America’s Policy Graveyard By J.T. Young Obamacare ground troops at the airport By Michelle Malkin Obama Should Denounce the Iranian Regime as a “Rogue State” by David P. Goldman Crossroads in Middle East as Obama Stays…

John II| 6.23.09 @ 12:22PM

Raoul's analogy is much closer than Alan's: America is indeed much more like the late Roman Republic (a few years before the clumsy reform efforts of the Gracchi touched off a century of civil war) than like the Roman Empire. But both analogies are wide of the mark in more ways than I have fingers and toes to count.

The fact is, historically, the American experiment is sui generis. Nothing quite like it has ever been attempted before, under conditions that have no precedent in recorded history. Starting with only the broadest guides in the form of classical and Christian precedent, we've been winging it decade by decade for more than two and a quarter centuries, and we have no precise antecedents by which to judge where we're going with this experiment in ordered liberty; we have only the expectation, if not the certainty, that it's going to continue being a "wild ride."

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Old Texican| 6.23.09 @ 12:48PM

When we "producers" in this country have ENOUGH...of this statist fantasy world...we will make our presence known...big time.

The charts show the fantasy evaporating right now...in spite of the "State Controlled Media" hiding it the best they can.

But ladies and gentlemen, its haaaaaaard, to give up a belief in Santa Claus, or idols of gold. Our liberal friends are already getting antsie...and the "middle of the roaders" are beginning to see the wreck and moving to the shoulder. (grin)

We the People...still retain sovereignty in this country!

L. Ross| 6.23.09 @ 1:03PM

Alan Brooks:

Sir, do yourself a favor and edjumacte yourself on what you propose to expound upon.

J.T. Young was comparing efforts to subdue Afghanistan with efforts to provide universal healthcare in the United States. He was in no way implying that the United States is like Afghanistan. He was saying that many, many failed attempts have been made to conquer Afghanistan, and to provide universal health care in the U.S.

Lame, Alan. Very lame.

Tim| 6.23.09 @ 1:21PM

Clean, efficient public transportation. Hey is he supposed to be texting? ...

Old Soldier| 6.23.09 @ 2:18PM

I think the Administration is turning Afghanistan into America's Afghanistan.

http://news.yahoo.com/s/ap/20090622/ap_on_re_as/as_afghanistan

Old Texican| 6.23.09 @ 5:25PM

I WOULD LOVE "INSURANCE REFORM" (mis-named health-care reform.)

Folks, the health-care providers in our country are the best in the world. Yes, they are fallible human beings where judgment calls happen every day, and are demanded every day.

The bad ones do not last long. The good ones make a nice living.

So in a few short steps we can END the problems:

1. One State out of all 50 could get it right...and everybody could buy insurance under the rules of THAT State....where ever they live.

2. Throw all the HMOs' brass in jail! (foxes guarding the hen-house)

3. Allow employers to pay a given percent of the premiums...tax deductible...to say thank you to good employees.

4. Allow independent contractors and sole proprietors...(like real estate agents for instance), to gather together for a bundled policy to take advantage of economics of scale, and lower underwriting costs.

5. Make State governments level the playing field, by demanding that insurors have similar benefits protection from EVERY policy sold...or BOLD PRINT..."WE DON'T COVER THAT...SO INITIAL HERE!"

6. Insurance policies ALL pay 100% of medicare reimbursement codes...plus 20%....... (The ONLY variable as to premium costs...is the "deductible" amount for which each family or individual chooses the risk to bear independently.

It truly is that simple, ladies and gentlemen, and all the bull you are hearing is just that...BULL #&*%%#

Old Texican| 6.23.09 @ 5:28PM

Darn!
Even I, the most brilliant...forgot one essential thing.
"SHOOT ALL THE AMBULANCE CHASING LAWYERS!"
(tort reform big time)

Global Aussie| 6.23.09 @ 6:22PM

As an Australian working in the US for a period of 2 years I received a generous health plan paid for by my employer. During my stay I had to have an operation for a bowel problem and this was fully covered at one of the finest hospitals in LA. What surprised me was that the fees for the surgeon and hospital charges ended up 3 times higher than the quote we received, even though I went home on the same day and did not occupy a hospital bed for more than a couple of hours. I was told this gross overcharging was normal and accepted by the insurance industry. I was also surprised when I left this job to take up another job in the UK that in the period after leaving the employer health scheme I could not get an appointment at my regular doctor even though I offered cash instead of an insurance number. This is a health system that makes very little sense. In Australia we have a Medicare levy of 1.5 % of income that pays for "universal" cover for basic doctor and hospital treatment - with up to 12 months waiting list for operations. We also have a voluntary medical/hospital insurance scheme that most people pay privately. This ensures doctor of choice and does away with the waiting time for operations. Not a perfect system, but one that on some level looks after those who cannot afford to pay, while providing a better class of service to those with insurance.

Jeff | 6.23.09 @ 6:26PM

What every single Republican seems to missing when they use the phrase "government run healthcare" is the current Democrat plan resembles nothing of the sort. If you are opposed to a government run insurance option; say that, but stop using cheap, misleading rhetoric like "socialized medicine" and engage in real debate.

Alan Brooks| 6.23.09 @ 8:44PM

"J.T. Young was comparing efforts to subdue Afghanistan with efforts to provide universal healthcare in the United States. He was in no way implying that the United States is like Afghanistan. He was saying that many, many failed attempts have been made to conquer Afghanistan, and to provide universal health care in the U.S.
Lame, Alan"...

Yes, the photo of Soviet tanks for a piece on health care, alone, is very lame.
And fer chrissakes I didn't literally mean the Roman Empire or Republic-- anymore than the author meant for the photo of Red Army tanks to literally symbolize HillaryCare and ObamaCare, etc.

So if I'm lame then that makes more than one.

Alan Brooks| 6.23.09 @ 9:04PM

How 'bout a D-Day photo of an amphibious vehicle for an article on Ted at Chappaquiddick? hmm, Come to think of it, not a bad idea.

John II| 6.23.09 @ 9:49PM

Alan: Point taken. Sorry, but I make my living teaching stuff like Roman history. The devil is always in the details, so I inevitably got sidetracked. Interesting Chappaquiddick analogy.

Jeff: If you don't think that Obama and handlers are ultimately interested in socializing EVERYTHING (because all they're really interested in is POWER and CONTROL), then make your point: show why it ain't so. But I'm warning you: I've been working in academia for more than 40 years, and I already know what the ambitions of that (useless, unproductive) social caste are about. So you'll have to make a very strong case for "good intentions" on the part of the Obama crowd, even before you can possibly make any case at all for their policy proposals and the mendacious manner in which they are advancing them.

Marcell| 6.24.09 @ 1:03AM

“It will be interesting to see if in today's attempt, the reformers make a bigger impression on the healthcare system, or if the system makes a bigger impression on the reformers. And if either impression is positive.”

If the reformers just got the price of today’s health care cost down, “!t would be a victory for the reformers.”

=)

Robert Rosencrans| 6.24.09 @ 6:25AM

Here's a good article that shows the Democrats are raking in millions behind the scenes for them and their friends, shamelessly exploiting the health care issue.

It also explains the on again off again scenario. The Democrats are obviously playing both sides off of each other, cashing in on every option.

While silly citizens believe they are going to get free health care, it's most likely whatever comes out of this will screw them in two ways. Sloppy incompetent health care and higher taxes.

http://www.washingtonexaminer.com/opinion/blogs/beltway-confidential/GE-hires-Linda-Daschles--lobbying-firm-48798437.html

GE hires Linda Daschle as a lobbyist
By: Timothy P. Carney
Examiner Columnist
06/22/09 4:29 PM EDT

General Electric, a top-20 source of funds for Obama in 2008, and owner of the Obama-friendly MSNBC, already has strong ties to Democrats, but the company has bolstered that relationship, according to recently filed federal lobbying registrations.

GE's transportation business has hired as a lobbyist Linda Hall Daschle, wife of Tom Daschle, the former Senate Democratic Leader and Obama's first pick to head the Department of Health and Human Services. Mrs. Daschle will lobby on issues including Amtrak, high-speed rail, and freight rail, the lobbying form says. Obama has declared support for added federal funding for high-speed rail.

GE is also a member of the U.S. Climate Action Partnership, which lobbies for restrictions on greenhouse gas emissions.

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