So: at about one o’clock this morning, the United States Senate, or at least the 60 members of its Democratic Caucus, passed the long-awaited cloture vote to proceed to a final consideration of a health care reform bill.
As one who has had an irrational faith that the Senate would get to this point somehow or other, I have to say it was still an improbable accomplishment.
As recently as a few days ago, Joe Lieberman looked all but unreachable for this vote. Then Ben Nelson looked unreachable, even as Republicans Olympia Snowe and Susan Collins made it clear they had decided that nearly a year of begging from the White House and Senate Democrats wasn’t enough to overcome the right-wing heat they were experiencing. Then Democrats like Sherrod Brown and Bernie Sanders came under intense pressure to hold up the bill from progressives determined to derail the latest deal and force a recourse to a 2010 reconciliation strategy.
More fundamentally, a 60-vote Democratic Caucus was an exceptionally improbable achievement. It took (a) a near-sweep by Democrats of winnable seats in 2008; (b) a complex deal to keep arch-apostate Lieberman in the Caucus; (c) a favorable resolution of the near-tie vote in Minnesota after months of GOP legal obstruction; and (d) swift action by the Massachusetts legislature to provide for an interim Senator to replace the late Ted Kennedy.
It all came down to a one a.m. vote after a rare Washington snow storm, with Republicans openly praying that someone (i.e., the infirm Robert Byrd of West Virginia) wouldn’t be physically present.
The current conservative caterwauling about a “rushed” vote is pretty hilarious, given the endless delays undertaken by Senate Democrats all summer and early fall in an effort to engage Republicans, the open and notorious GOP strategy of running out the clock (reminiscent of the Bush strategy for securing the presidency nine years ago), and the front-page status of every detail of the legislation since last spring. Does anyone doubt for a moment that if Democrats had gone along and delayed final Senate action until after the holidays, the same people whining about their spoiled Christmas would be demanding the legislation be put off until after the 2010 elections? Indeed, that’s what we will in fact be hearing in January when a House-Senate conference committee completes its work.
That conference committee, and the House and Senate votes necessary to ratify its report, is far from a slam dunk, given House Democratic resentment of Senate deal-making, and substantive disputes on issues ranging from the public option to abortion. But the struggle to get to 60 votes in the Senate makes the endgame of health care reform look manageable by contrast.
It seems almost elementary that the governments of Pakistan and the U.S. both have a vested interest in extending Islamabad’s authority over the whole of its country, a point David Ignatius makes today:
Here’s the cold, hard truth: U.S. success in Afghanistan depends on Pakistan gaining sovereignty over the tribal belt. If the insurgents can continue to maintain their havens in North Waziristan and other tribal areas, then President Obama’s surge of troops in Afghanistan will fail. It’s that simple.
Extending the Pakistani government’s writ is certainly a core element to any hope of securing Afghanistan. A safe base of operation across the border in Pakistan would allow al Qaeda’s senior leadership room to incubate in hopes of re-spreading its wings in a larger Taliban-protected region. Points for identifying the problem, but it’s not that simple.
But just a handful of pages away from Ignatius is a reminder of just how difficult that challenge will be:
Pakistan’s Supreme Court nullified on Wednesday a controversial deal that had given President Asif Ali Zardari and thousands of other government officials amnesty from prosecution on corruption charges, a decision likely to further weaken Zardari’s shaky hold on power.
The ruling could open the door to additional legal challenges against Zardari. Although he still has immunity from prosecution under the constitution, opponents plan to contest that by arguing that Zardari is technically ineligible for the presidency. …
But Zardari’s ability to make decisions about the level of Pakistani cooperation with the United States has been compromised by his struggle to simply hold on to his job — a task likely to be made more difficult by the court ruling.
There are essentially three legs of power in the Pakistani government — the military and intelligence services are the largest center of gravity, followed by the courts and then the civilian leadership. Rivalries between all three are intense to say the least, a dissection of which could take up an entire encyclopedic volume. And even though the military isn’t mentioned in the WaPo’s article, it almost goes without saying that the generals would be fine if Zardari fell from power.
The point is that as long as these communities’ main focus is a struggle for power, the White House will never get them to pay primary attention to internal security. And even if you could, each power base has reasons (some better than others) to turn a blind eye to the Taliban lodged in Pakistan’s hinterland.
The situation isn’t hopeless…yet. Despite long-standing suspicions of civilian President Zardari’s corruption (hey, the guy wasn’t called “Mr. 10 Percent” for nothing), he is the legitimately elected leader and was allowed to return to Pakistan — with his late-wife Benazir Bhutto — in an amnesty deal reached with ex-President Pervez Musharraf. Therefore, the U.S. should stand by Pakistan’s nascent democracy and support Zardari, without making him look like an American puppet.
Then the U.S. government should work on aligning the military under Pakistan’s civilian leadership. Congress tried this by conditioning aid on just such a goal in October. Guess what? It didn’t go over so well with Pakistan’s generals. Back to the drawing board.
Word going around Washington this week is that Sens. John McCain (R-AZ) and Maria Cantwell (D-WA) are pushing to reinstate Glass-Steagall:
McCain and Cantwell, a Washington Democrat, join other lawmakers in Congress proposing to reinstate the 1933 law, repealed a decade ago by the Gramm-Leach-Bliley Act that led to a rise in conglomerates including Citigroup Inc., JPMorgan Chase & Co. and Bank of America Corp. active in retail banking, insurance and proprietary trading. Legislation to reinstate the ban was introduced today in the House.
While this move is a well-meaning attempt to rein in the financial sector, it doesn’t address the issues that caused last fall’s crisis.
Glass-Steagall was aimed at separating “boring” retail banking (the Bailey Building and Loan Association, for example) from “risky” investment bankers (Gordon Gekko). It was eventually repealed, as U.S. banks felt it put them at a disadvantage in the global marketplace against European “universal” banks, such as Deutsche Bank, Credit Suisse, and HSBC.
At the time there was concern that repealing Glass-Steagall would create banks that were systematically dangerous. In hindsight, that concern would seem to be born out — but it isn’t. After all, the three major bank collapses that precipitated the crisis were Bear Stearns, Merrill Lynch, and Lehman Brothers. All three were obviously Too Big Too Fail, but all three would have been unaffected by a reinstatement of Glass-Steagall — none of them is a retail bank (this is why you never saw Merrill or Lehman ATMs).
Rather than focusing on micromanaging bank structure, and stifling entrepreneurship in the financial sector, the Senators would be better served by evaluating different options to limit the size of Too Big Too Fail banks. A smarter idea would be to extend the retail bank deposits cap idea to total bank assets. Currently, no bank can have more than 10 percent of total national retail deposits (Bank of America got a waiver for the 2007 purchase of Chicagoland’s LaSalle bank and now has 12.2 percent of national deposits). Peter Boone and Simon Johnson suggest applying this simple principle to total bank liabilities. They recommend a limit of 2 percent of GDP, which is in line with the $300 billion that Felix Salmon has been recommending since March. Importantly, it’s also in line with the de facto $100 billion threshold that bank regulators are using now.
This way the government isn’t running banks and bankers can pursue the capitalist impulse that drives our economy. But with a cap on liabilities, the decisions of bankers cannot threaten our economy like they have in the past.
Let’s examine Hacker and Pierson’s definition of “the center.” When they compare activists to independents, changes in the distance from independents may be due to growing extremism among activists. However, the distance may grow without activists changing their views at all if independents change their views. So saying Republican activists drifted further away from the center than Democratic activists may misstate what occurred; independents may simply have drifted toward Democratic activists over time without activists drifting anywhere. It’s also possible that Republican activists have grown more extreme, which has pushed independents closer to Democratic activists’ (unchanged) views.
Furthermore, secular changes in ideology over time can move people from the independent category into Democratic and Republican camps and vice versa, making it difficult to say whether the changes identified indicate that activists (or independents) are changing their views, or that it’s just flows into or out of the parties that is changing. If one of the parties looks more or less extreme, it could simply be that people who would have called themselves independent in the past are now identifying with one of the parties, making the leftover independents look somewhat more extreme in the opposite direction.
Rather than compare activists to independents, why not simply measure how far they are from the midpoint of the ideology scale? When one does so, one obtains the graph below.
By this measure, which avoids all of the problems with using independents as a reference point, the change in extremism among Democratic activists looks exactly the same as the trend for Republican activists. Once again, Republican activists look more extreme in any year, and this time (not shown) this remains the case when one looks at the unsmoothed data points.
A Better Way to Measure Ideology
There is also a problem with Hacker and Pierson’s measure of ideology. If we want to know whether party activists have become ideologically more extreme over time, we should use as pure a measure of ideology as possible. The measure Hacker and Pierson use, however, conflates ideology with tolerance and empathy because it is based on questions asking how warm or cold one feels toward liberals and conservatives. It could be that Democratic activists are simply more tolerant of their opponents than Republican activists rather than being more centrist. One can feel warmly toward a group without identifying oneself with it.
A better measure of changing ideology among party activists would be to look directly at changes in self-identified ideology. The NES asks respondents to place themselves on a 7-point scale ranging from extremely liberal to extremely conservative. Here, then, is a final chart showing trends for activists in each party, with ideology measured as the distance of activists from “4” – the midpoint of the seven-point scale. The actual data points are connected and the smoothed trends are shown as black dashed lines. It should be noted that this chart is based on even smaller sample sizes than Hacker and Pierson’s, so I show the margin of error for the data points as dashed vertical lines. I also omit off-year elections to make the chart less noisy.
This chart confirms that Republican activists more often than not have been more extreme than Democratic activists, though the two groups were statistically tied in 1972, 1976, 1992, and 2004. There is a clear trend toward greater extremism among Republican activists. Among Democratic activists, there was little consistency between 1972 and 1998, but they appear to have moved to the center in 2000 and 2002 before jumping up to the level of Republican extremism in 2004.
Finally, there is the claim by Hacker and Pierson that Democratic activists are more centrist than other Democrats. In my results, this was not true in 2004 whether one used the thermometer index or the self-identified seven-point ideology measure and was not true in 2002 unless one used the seven-point measure (which Hacker and Pierson did not). Regardless, none of the differences between the two groups – in my results or theirs – are statistically significant due to the small sample sizes.
In sum, Republican activists have generally been at least as extreme as Democratic activists and often more so, though not in 2004, which makes the Republican pattern seem less worrisome. Furthermore, while in 2002 it looked like Republican extremism had increased and Democrats had become more moderate, by 2004 Democrats had completely caught up to Republicans. Republican and Democratic activists were equally far from the center in 1972 and in 2004, so the shift was of the same magnitude for both. And there’s no reliable evidence that Democratic activists are more moderate than other Democrats.
The Bush administration and the Republican Congress may have used various tactics in order to pass an agenda that lacked strong support. But they were not “off center” if that phrase is taken to mean that their agenda was outside the bounds of what the public supported. Or more specifically, where Republicans succeeded, their agenda was not out of bounds. Hacker and Pierson downplayed the extent to which Republicans had to reach out to the center in what they did or did not favor. Education spending, for instance, increased more under Bush than under Clinton, in a nod to “compassionate conservatism.” Furthermore, where Republicans truly moved off center, they failed, as with Social Security privatization. And of course, 2006 and 2008 happened.
The views expressed in this piece do not necessarily reflect those of the Progressive Policy Institute.
The never-ending story of health care reform took another turn for the weird this week.
It began with liberals working themselves into a lather over Sen. Joe Lieberman’s threat to scuttle reform unless the Medicare buy-in was dropped. Now Howard Dean, liberal paladin and former Chairman of the Democratic National Committee, is campaigning openly to kill a Democratic president’s top domestic priority. Vermont’s Sen. Bernie Sanders, the Senate’s sole self-avowed social democrat, warns the White House that he is not a certain vote for health reform, though it’s unlikely that he would cast a vote with the Republicans to filibuster it either.
Liberals believe, perhaps with some justification, that Sen. Lieberman has forced changes in the bill simply to spite them. But it has to be said that Lieberman, at least, makes no pretense of being a party loyalist. He crossed the political Rubicon by appearing at the Republican National Convention in 2008 to endorse his friend John McCain. His decision to caucus with the Democrats is a marriage of convenience, so charges of infidelity seem beside the point.
No good purpose is served by the left’s fixation on Lieberman as a kind of progressive Judas. It’s creepily reminiscent of the orchestrated venom directed against the fictional turncoat “Goldstein” in George Orwell’s 1984.
What prompted Dean’s scream on health reform was the decision by Senate leaders, backed by the White House, to drop both the public option and the Medicare buy-in in pursuit of the 60 votes needed for passage. In a characteristically self-righteous outburst in today’s Washington Post, Dean helpfully accused his fellow Democrats of selling out to the health insurance industry.
The rifts among Democrats, coupled with monolithic Republican opposition to the Senate bill, have fed growing public doubts about health reform. According to a new NBC-Wall Street Journal poll, more Americans oppose the legislation than favor it (44-41 percent). Other surveys show that voters are worried that they’ll actually wind up paying more for health care after reform.
The President’s Principles
Now, liberals are understandably angry that Senate filibuster rules effectively give a handful of moderates inordinate power to block progressive measures backed by a majority of Senate Democrats. That’s triggered an important debate – featuredhere on P-Fix over whether it’s time for progressives to change those rules to either circumscribe or abolish the filibuster.
But it’s also true that liberals should not have expected that the Senate bill include a public option or the provision allowing people as young as 55 to buy health coverage from Medicare. The Senate Finance Committee bill did not include them and Obama promised neither during the campaign. In fact, the president has explicitly ruled out a single-payer approach, instead echoing PPI’s call for a distinctly American approach to universal health care, a public-private hybrid based on the principle of “shared responsibility.”
Many single-payer advocates, however, apparently view the president’s stance as purely tactical; surely, deep down, he’s with them. They see the public option and the buy-in as incremental steps toward a “Medicare for all” approach that ultimately will displace private health insurance.
Obama, however, has been admirably consistent about his top-line goals: expand coverage through public subsidies and mandates; prevent insurance companies from denying coverage or dropping people who get sick; drive medicine toward higher quality and lower costs; and do it all in a way that adds nothing to the deficit. The Senate bill, though riddled with imperfections and compromises, does an acceptable job of advancing those goals and moving the process forward to the final stage: a conference to reconcile House and Senate versions of reform.
So liberals have a choice. They can torpedo a bill backed by a Democratic president and nearly all Senate Democrats, a bill that would cover 30 million uninsured Americans, discipline health insurance companies, and begin the challenging task of containing health care cost growth, in favor of alternatives that stand no chance at all of passage. Or they can pocket the undoubted progressive gains embedded in the House and Senate bills, help their party pass landmark legislation, and keep working to build support in the country for their vision of health reform. Congress meets every year and there will be ample opportunities to refine whatever emerges from today’s legislative scrum.
Despite the public infighting and fratricidal rending of garments, congressional Democrats are only one vote away from an historic victory on health care reform. So progressives should stop obsessing over Joe Lieberman, turn off Howard Dean, and help Barack Obama bring home the prize.
OK, to review the debate so far: I wrote a post suggesting progressives might want to think twice before jettisoning the filibuster. Ed thought twice and said, yup, still want to get rid of it. Ezra did the same. I wrote another post saying, oh well whatever nevermind and tried to shift the subject to polarization being the real problem. I said I’d follow up about whether increasing polarization has been a one-sided affair. Crickets chirped. All hell broke loose on the health care reform front.And here we are.
So….one-sided polarization….Ever since Jacob Hacker and Paul Pierson’s Off Center, all good progressives know that the growing political polarization has been one-sided, with Republicans pulling public policy “off center” through various nefarious means. Right?
Well….yes and no. Hacker and Pierson argued that, as of 2005, Republican activists and legislators had grown more conservative, but Democratic activists and legislators had not grown more liberal (and had even moved to the right themselves in some regards). Along with this shift, Republicans had developed effective strategies to move public policy further rightward than the typical voter preferred.
Since the rightward shift of Republicans occurred during a period in which Hacker and Pierson showed the distribution of self-identified ideology had not changed, the implication was that the electorate was being deprived of the more progressive policies that it desired. But a closer look at their data and analyses shows that while the increase in polarization among legislators has occurred disproportionately among Republicans, the evidence hints that this is because it proceeded from a Nixon-era Democratic Congress that was well to the left of the electorate.
Rather than refuting the idea that policy reflects the preferences of voters in the middle (the “median voter theorem”), as Hacker and Pierson claimed, the evidence actually bolsters this view. Correcting their claims is important if progressives are to govern effectively. Republicans did not simply pull public policy to the right of where Americans preferred, and now that Democrats are back in control of Congress, progressives should not assume that the median voter is leftier than she really is.
Why Off Center Is Off
To argue their case, Hacker and Pierson turned to scores created by Keith Poole and Howard Rosenthal that put members of Congress past and present on a common scale measuring ideological position. Hacker and Pierson report that the polarization of Congress between the early 1970s and the early 2000s was almost entirely due to growing extremism among Republicans. Democratic legislators had not moved nearly as far from the center. Because of the increasing conservatism of Republicans, Congress was, in the early 2000s, far to the right of the median voter, who had not grown more conservative over time. But Hacker and Pierson’s account is flawed.
Consider the Senate.* Poole and Rosenthal’s scores, using every vote by every member of every Congress through the 108th Congress (which ran from 2003 to 2004), indicate that the “center” as of 2003-04 was typified by northeastern Republicans such as Lincoln Chafee, then-Independent Jim Jeffords, and William Cohen; Arlen Specter (now, of course, a Democrat); and by red-state Democrats such as Ben Nelson and John Breaux. In 1971-72, the median senator had a score of -0.056, equivalent to Ben Nelson’s score in 2003-04. By 2003-04, the median senator had a score of 0.061, equivalent to Arlen Specter in 2003-04.
This small change in the median of the Senate as a whole only hints at the fact that, as Hacker and Pierson claim, Republican senators did move farther ideologically than Democratic senators. The evidence that Hacker and Pierson presented describes how the median in one year compared with then-recent senators’ scores. In the early 1970s, according to Hacker and Pierson, the median Republican senator lay “significantly to the left of current GOP maverick John McCain of Arizona—around where conservative Democrat Zell Miller of Georgia stood” [where the references to McCain and Miller are to their 2003-04 scores, italics in the original]. The median Republican senator’s score then “doubled” by the early 2000s so that it sat “just shy of the ultraconservative position of Senator Rick Santorum.”
These descriptions do not quite reflect what the Poole-Rosenthal scores show. The median Republican senator’s score in 1971-72 was equidistant between McCain in 2003-04 and Miller in 2003-04, not closer to Miller, and it was just as close to McCain as the median Republican senator’s score in 2003-04 was to Santorum.
This claim also raises a technical issue. The Poole-Rosenthal scores are not ratio scales with a meaningful zero point. The distance between 0.2 and 0.4 is supposed to be the same as that between 1.2 and 1.4, but 1.2 is not “six times as conservative” as 0.2, because a score of 0 does not indicate the complete absence of conservatism. The zero point is completely arbitrary. The doubling from 0.2 to 0.4 would become an increase of just 50 percent if we added 0.2 to all of the scores (from 0.4 to 0.6). We cannot know whether Republican senators grew twice as conservative between the early 1970s and the early 2000s. Indeed, the phrase “twice as conservative” has no obvious meaning.
More to the point, Hacker and Pierson’s interpretation of these results is an even bigger problem. Rather than the Republican Party drifting ever rightward (the whole time increasingly “off center”), if the Democratic Party was “off center” in the early 1970s, then the movement among Republicans could be interpreted as a restoration of an equilibrium reflecting voter preferences. This is exactly what appears to have happened.
First of all, the medians for the 2003-04 Senate were 0.379 and -0.381 for Republicans and Democrats – essentially identical. That means that after this great rightward shift by Republicans, the parties were equally “extreme” by historical standards. Furthermore, the median Democratic senator in 1971-72 wasn’t much less extreme than the median senator from either party in 2003-04.
Second, at least in terms of self-identification, the ideological distribution of Americans was unchanged over this period, with roughly twice as many people calling themselves conservative as calling themselves liberal.**
Taking these facts together – a rightward shift by Republican legislators, an end state where Democrats and Republicans are equally “extreme”, and an ideological distribution among voters that was static over the period (and right-leaning) – the conclusion that best fits is that the Democratic Congress of 1971-72 was off center rather than the Republican Congress of 2003-04. The median Republican became more extreme over time, but that was because Congress became more representative of the electorate, not less. The story on the House side is much the same, except that the median Republican was a bit more “extreme” than the median Democrat by 2003-04 (although no more extreme than the median Democrat was in 1971-72).
Comparing the Activists
Hacker and Pierson also argue that Republican activists grew more extreme while Democratic activists became less so (becoming even less extreme than Democrats in general), but these claims are also problematic. Hacker and Pierson began by defining an activist as someone who self-identifies as a Democrat or a Republican and who participated in three out of five election-related activities asked about in the American National Election Studies. They measured ideology using a combination of two “thermometer” items – one of which asks respondents how warm or cold they feel toward liberals and one inquiring about conservatives. These scales range from 0 (cold) to 97 (hot). (The scale ends at 97 rather than 100 because in some years, the NES used codes 98 and 99 as missing value codes.) The liberal score is subtracted from 97 (so that high numbers then signify cold feelings) and then added to the conservative score. This number is divided by two, 0.5 is added to it, and the decimal is dropped. The resulting measure ranges from 0 (extremely warm toward liberals and extremely cold toward conservatives) to 97 (extremely cold toward liberals and extremely warm toward conservatives).
To determine how far activists drift from the center, they compared the activist scores on this index to the scores for independent voters. The distance from independents is expressed in percentage terms (e.g., 10 percent more conservative or liberal). Hacker and Pierson plotted the average distance from independents for Republican and Democratic activists and then “smoothed” the trends by imposing curves to describe them. The result is a graph that I replicated, more or less:
The graph shows that Republican activists were more extreme than Democratic activists to begin with, that they became more conservative over time, and that after becoming more liberal, Democratic activists tacked back toward the center. The first important thing to note about this graph is how much the nice, smooth lines depend on fitting the data points to a quadratic equation. The original data – without the smoothing – looks much messier:
The upward trend among Republican activists is still readily apparent, but the trend for Democratic activists no longer points toward moderation. The bouncing around is partly due to different turnout patterns in off-year elections, but also a result of statistical noise, as the sample sizes for each group are less than 70 – and as low as 18 – in each year. Furthermore, Republican and Democratic activists are statistically the same distance from the center for much of the period between 1968 and 1992. To illustrate further how deceptive the smoothed trend lines can be, look what happens to them when 2004 data – which was not available when Hacker and Pierson created the graph – is added:
The Republican line hardly changes, but now Democratic activists appear to grow steadily more liberal. It still appears as though Republican activists drifted from the center more than Democratic activists did, and Republican activists look more extreme in all years.
OK, take a breather. Tomorrow I’ll wrap up with some revealing evidence about how Hacker and Pierson’s definition of “the center” affects these analyses of political activists.
* Following their recent book, Polarized America (McCarty, Poole, and Rosenthal, 2006), I use scores on Poole and Rosenthal’s first DW-NOMINATE dimension (for details, see https://polarizedamerica.com/ and https://www.voteview.com). Hacker and Pierson report using “d nominate” scores, but these are only constructed through the 99th Congress, so I am inclined to believe that they too used the first DW-NOMINATE dimension scores.
** Hacker and Pierson (2004), page 38. Hacker and Pierson cite ANES data. According to Gallup data showing self-identified ideology, the breakdown among Americans as a whole in 2004 was roughly 20 percent liberal, 40 percent moderate, and 40 percent conservative (Wave 2 of the June Poll, Question D10). In 1972, it was 25 percent, 34 percent, and 37 percent (Poll 851, Question 14).
The views expressed in this piece do not necessarily reflect those of the Progressive Policy Institute.
As the Democrats try to pick up the pieces of the blown-up public option compromise and move forward on health reform, some on the left have thrown up their hands and claim that the bill as it stands isn’t even worth passing any more. Cue Howard Dean:
“The Senate version is not worth passing,” former Democratic National Committee Chairman Howard Dean told POLITICO, referring to plans to strip the latest compromise from the bill, a Medicare buy-in. “I think in this particular iteration, this is the end of the road for reform.”
Dean said there are some good elements in the bill, but lawmakers should pull the plug and revisit the issue in Obama’s second term, unless Democrats are willing to shortcut a GOP filibuster. “No one will think this is health care reform. This is not even insurance reform,” he said. [emphasis mine]
Does Howard Dean really think that Obama is a shoo-in for a second term — and, on top of that, will face a more favorable Congress then — if the health reform effort collapses? That the bill’s failure now would lead to better chances for passage later? As Kevin Drum wrote, “If healthcare reform dies this year, it dies for a good long time.”
The estimable Nate Silver offers some forceful policy commentary to shake some sense into his fellow progressives, comparing the different scenarios for a family of four earning $54,000 under the Senate bill, under the status quo plus inflation, and under the status quo plus inflation plus S-CHIP. The result, you won’t be surprised, is that the family by far fares best under the Senate bill. Some might rightly argue that the cost is still not so affordable if a member of the family gets sick. But the costs would be debilitating without health reform at all.
Ezra Klein, who’s been banging the drum for passage, gets it right:
“This is a good bill,” Sen. Sherrod Brown said on Countdown last night. “Not a great bill, but a good bill.” That’s about right. But the other piece to remember is that more than it’s a good bill, it’s a good start. With $900 billion in subsidies already in place, it’s easier to add another hundred billion later, if we need it, than it would be to pass $1 trillion in subsidies in 2011. With the exchanges built and private insurers unable to hold down costs, it’s easier to argue for adding a strong public option to the market than it was before we’d tried regulation and a new competitive structure. With 95 percent of the country covered, it’s easier to go the final 5 percent. And with a health-care reform bill actually passed, it’s easier to convince legislators that passing such bills is possible.
Let’s hope progressive activists maintain their perspective on the bill and listen to the wonks (a divide that Steve Benen wrote about yesterday). Medicaid, Medicare, and Social Security all had their inadequacies when originally passed. But those shortcomings were addressed over time. The same would go for health care reform. But first you have to pass a bill.
The efforts by a handful of conservative commentators to steer the Republican Party from its Beck-Palin trajectory continue. Here’s Michael Petrilli writing in yesterday’s Wall Street Journal:
What’s needed is a full-fledged effort to cultivate “Whole Foods Republicans”—independent-minded voters who embrace a progressive lifestyle but not progressive politics. These highly-educated individuals appreciate diversity and would never tell racist or homophobic jokes; they like living in walkable urban environments; they believe in environmental stewardship, community service and a spirit of inclusion. And yes, many shop at Whole Foods, which has become a symbol of progressive affluence but is also a good example of the free enterprise system at work. (Not to mention that its founder is a well-known libertarian who took to these pages to excoriate ObamaCare as inimical to market principles.)
What makes these voters potential Republicans is that, lifestyle choices aside, they view big government with great suspicion. There’s no law that someone who enjoys organic food, rides his bike to work, or wants a diverse school for his kids must also believe that the federal government should take over the health-care system or waste money on thousands of social programs with no evidence of effectiveness. Nor do highly educated people have to agree that a strong national defense is harmful to the cause of peace and international cooperation.
He warns that the demographics don’t look good for the GOP – that, in addition to the party’s deficit among the young, blacks, and Hispanics, college-educated Americans are now trending Democratic as well. Unless the GOP changes, the country will leave it behind.
Petrilli’s column is worth noting not because it’s bad — it actually contains sound advice for his party — but because of how comically futile it is. Asking the Republican Party to renounce anti-intellectualism is like asking a fish to renounce water. The modern GOP eats, drinks, breathes, and lives know-nothingism. You might as well ask the Republican Party to disband.
I have no doubt that there are some moderate Republicans out there who cringe at the thought of Glenn Beck and Sarah Palin. I also have no doubt that there are plenty of independents who could be persuaded by a more moderate conservatism (or, failing that, fall for something that looks like it). And I should note that I’m pretty skeptical of the Democrats’ chances in November 2010 – the anti-incumbent mood combined with the narrower electorate in midterms seems to spell doom for Dems.
That said, the party that Petrilli dreams of doesn’t look remotely like the party that he actually belongs to. Here’s what the educated, independent voter thinking of becoming a Whole Foods Republican has awaiting them: a party now comprised of an all-time-high proportion identifying themselves as “very conservative”; whose majority thinks ACORN stole the election for Barack Obama; and whose rank-and-file honestly believe that Obama has a “secret agenda” to bankrupt the country and expand the government.
Having pegged so much of their party’s identity to a culture-war mentality pitting oppressive cosmopolitans versus red-blooded heartlanders, the GOP now finds itself stuck with the ones who brung ‘em. And the ones that brung ‘em don’t want to let anyone else in, unless they look and think exactly like ’em.
The big news out of Italy last weekend was the vicious assault on Prime Minister Silvio Berlusconi in Milan. The attack overshadowed the birth of a new center-left alliance determined to give Italians an alternative both to Berlusconi and a left mired in stale, social democratic dogma.
The launch of the Alleanza L’Italia (Alliance for Italy) in Parma over the weekend effectively dissolved the brief union of the two major opposition parties: the Democrats of the Left (the main social-democratic party) and the smaller, centrist Margherita (which in Italian means a daisy, not a drink). The two merged into the Democratic Party in 2007 in a bid to unify Italy’s fractious center-left.
But it was an unhappy marriage. The Democrats suffered a string of electoral defeats and leadership changes. Moderates chafed at the doctrinal rigidity of the dominant social democratic faction, which they believe has helped to polarize society while convincing many middle-class voters that progressives aren’t capable of governing. “We want to redress the balance toward the center,” explained Francesco Rutelli, the former Margherita chief and mayor of Rome who is the moving spirit behind the Alleanza. What Italy needs, he said, is a new center-left governing platform grounded in the values of “freedom, economic innovation and social cohesion.” (Full disclosure: I attended the Parma meeting as a guest of the Alleanza).
What apparently triggered the divorce was the Democrats’ decision to join the Socialist caucus in the European parliament. “Socialist parties in Europe are being defeated everywhere,” noted another key Alleanza leader, Gianni Vernetti. He’s right. In the 2009 European elections, center right parties led in 21 out of 27 European Union countries. In what many observers are calling the “European paradox,” the global financial crisis has given no boost to social democratic parties, despite their traditional skepticism toward free market economics.
One reason is that Europe’s center-right parties long ago made peace with the “social market,” which they promise to manage more efficiently. European social democrats, meanwhile, often seem more interested in defending the welfare state status quo than in modernizing their economies and politics.
Alleanza’s organizers repeatedly stressed the link between Italy’s political polarization and its economic stagnation. They promised pragmatic reforms intended to spur economic innovation and growth. And they framed their appeals to groups that have been cool to the center-left – small business operators, entrepreneurs and especially young voters, whose economic prospects are especially bleak.
The Alleanza also seems determined to break with the quasi-pacifist stance of many on the European left. Vernetti, deputy foreign minister in the last center-left government, emphasized Italy’s responsibility to contribute to security in an interdependent world. He urged progressives to rise above partisanship and approve the government’s request for funds to send 1,000 more troops to Afghanistan.
Seen from one perspective, the Alleanza’s birth marks yet another rupture in Italy’s fissiparous center-left. But from another vantage point – the need for Italian progressives to fashion a credible governing agenda for reform and renewal, to forge a new political center — it is a promising development indeed.
PPI Senior Fellow Ed Kilgore reviews two new books on Ayn Rand in the newest issue of Democracy. Here’s an excerpt:
When the novelist, philosopher, and social critic Ayn Rand died in New York in 1982, her world had been reduced to a small group of sycophantic disciples, ironically dubbed “The Collective.” Twenty-plus years later, though, the circle of Rand’s influence is arguably wider than ever. While Rand has never lacked for book sales–the nature of her fiction virtually guarantees a self-renewing audience of underappreciated adolescents and self-righteous business executives–at present, her work is exerting far more political influence than it has enjoyed since the earliest days of American libertarianism. As Jonathan Chait of The New Republic and others have explained, Rand’s denunciations of government taxation and regulation as “looting” and her moral defense of capitalism are crucial to conservative rhetoric these days, especially within the militant “Tea Party” movement.
What a coincidence, then, that two well-researched, serious books on Rand should appear this year. Jennifer Burns, a University of Virginia historian, has penned a fine account of Rand’s life that particularly focuses on her place in the pantheon of the American Right, while veteran magazine editor Anne C. Heller (her resume ranges from The Antioch Review to Lear’s) has written a more conventional biography that thoroughly explores the heretofore darker corners of Rand’s life, including her childhood and adolescence in revolutionary Russia. While neither are Rand disciples (although Burns, unlike Heller, was given access to Rand’s private papers, zealously guarded by her institutional monument, the Ayn Rand Institute), both defend her philosophical originality and her literary talent, and both view her as a tragic figure whose greatness was spoiled by her intolerance for dissent and her abusive private behavior toward her closest associates and potential allies. They also think she has been vindicated by her posthumous impact on the libertarian movement and a variety of writers and entrepreneurs, including the founders of Wikipedia and Craigslist.
But much as Rand craved appreciation for her work (as sadly reflected in the worshipful eyes of The Collective and her bitterness about every negative book review she ever received), it’s hard to imagine that she would have been terribly happy about its current appropriation by a motley assortment of conservative populists, who mix quotes from The Fountainhead and Atlas Shrugged with Christian Scripture and the less-than-cerebral perspectives of Sarah Palin and Glenn Beck. In her own view, Rand was nothing if not a systematic philosopher whose ideas demanded an unconditional acceptance of her approach to metaphysics, epistemology, ethics, psychology, literature, and politics.
Rand’s famous intolerance should not be dismissed as simply the psychological aberration of a flawed genius. She feared, for good reason, what lesser minds might do with the intellectual dynamite of her work when divorced from its philosophical context. The prophetess of “the virtue of selfishness” made rigorous demands of herself and all her followers to live self-consciously “heroic” lives under a virtual tyranny of reason and self-mastery, and to reject every imaginable natural and supernatural limitation on personal responsibility for every action and its consequences. Take all that away–take everything away that Rand actually cared about–and her fictional work represents little more than soft porn for middle-brow reactionaries who seek to rationalize their resentment of the great unwashed. This is why Rand was so precise about the moral obligations and absolute consistency demanded both of her fictional “heroes” and her acolytes. She hated “second-handers,” people who borrowed others’ philosophies without understanding or following them.
Stephen Hadley, George W. Bush’s national security advisor, has set forth some rather appalling revisionist history in this morning’s Washington Post. Though he supports President Obama’s surge, he effectively tries to wash his hands of any culpability for the entire Afghanistan mess.
Sorry Mr. Hadley, but that just won’t fly.
Hadley believes that everything was going just swimmingly until mid-2006, when those darned Pakistanis went and screwed the whole thing up:
As to security, the U.N. Security Council authorized an international military force in December 2001, put it under NATO command in August 2003 and expanded its writ to all of Afghanistan in October 2003. Afghan army and police forces were being recruited, trained and equipped. Most of the country was free of violence.
But in 2006, the situation deteriorated. Suicide bombings and attacks using improvised explosive devices spiked. Corruption and poppy production grew dramatically, and the central government failed to establish an effective presence in the provinces. The planned Afghan security force was simply too small to handle the escalating violence.
In September 2006, Afghanistan’s neighbor Pakistan embarked on a series of well-intentioned but ill-fated deals intended to entice local tribes to support the government in Kabul. The tribes were supposed to expel al-Qaeda and end Taliban attacks in exchange for economic assistance and the withdrawal of Pakistani troops. Instead, these badly executed agreements strengthened the terrorist havens.
Then, Hadley explains, Bush’s buddy Pervez Musharraf went and had himself a little constitutional crisis, which really put the well-meaning and allegedly competent Bush administration behind the eight ball:
Then Pakistan plunged into an 18-month political crisis, beginning in March 2007 when President Pervez Musharraf fired the country’s chief justice and ending with Musharraf’s resignation in August 2008. Consumed by political chaos, Pakistan could only watch as al-Qaeda terrorists and their Taliban allies launched attacks not only in Afghanistan but also in Pakistan — including the assassination of Benazir Bhutto.
Some argue that America could not respond to the deteriorating situation because its attention and its troops were all focused on Iraq. Yet despite troop demands for Iraq, President George W. Bush and our coalition allies launched a “quiet surge” in Afghanistan to meet the new challenge.
See? Isn’t it amazing how well the Bush administration handled everything and we just never knew about it?
Spare me. What Hadley chooses to selectively ignore is his administration’s failure to capitalize on Afghanistan’s relative calm in the 2001-2006 time frame. True, the initial Afghanistan war plan was successfully executed, and violence was significantly down (compared to, say, 2009 levels) across the country.
But instead of building on that initial military success by focusing on enduring security, infrastructure, and civil service capacities, Hadley shares responsibility for diverting America’s attention to a war of choice in Iraq launched under thin pretexts. In the process, billions of dollars and countless man-hours at the Pentagon, State Department, and White House (including Mr. Hadley’s NSC) that should have been spent stabilizing Afghanistan in 2003 were shifted westward.
The 10,000 additional troops that Hadley crows about later in the article are an embarrassingly weak and tardy prescription for an aggressive viral problem that was getting out of hand.
Too little, too late, Mr. Hadley. You should be ashamed.
Republicans’ favorite polling outfit, Rasmussen, sure gave the GOP a toxic little gift this week, in the form of a “generic ballot” for Congress listing the Tea Party Movement (hypothetically organized as a political party) as an option. The Tea Party brand outperformed the GOP 23 percent to 18 percent (Democrats lead the pack with 36 percent).
The Tea Party movement has been around for roughly 10 months, compared to 156 years for the Republican Party.
Unsurprisingly, another political parvenu is being closely linked to this third-party talk. On Friday, Sarah Palin was pressed by a conservative talk radio host to rule a third-party presidential run in 2012 out or in. She responded: “If the Republican party gets back to that [conservative] base, I think our party is going to be stronger and there’s not going to be a need for a third party, but I’ll play that by ear in these coming months, coming years.”
Palin nicely sums up the real meaning of the Tea Party threat. It is exceptionally unusual, not to mention counter-intuitive, for a major party to move away from what is generally perceived to be the political “center” and become self-obsessed with ideological purity immediately after two crushing general election defeats. But the Republican Party has been doing just that; it is a far more conservative party, in terms of its overall message, than it was going into the 2008 election cycle. But it’s not conservative enough just yet for a lot of activists, and for those Tea Party participants who really do think “looters” and “loafers” elected Barack Obama and are busily constructing a totalitarian society. Palin’s telling the world the rightward trend needs to continue, or she’ll be pleased to act out the GOP’s worst nightmare in 2012.
This item is cross-posted at The Democratic Strategist.
Nate Silver has a post up at 538.com that is sure to get a lot of attention. Looking closely at an IPSOS/McClatchey poll that asks supporters and opponents of health care reform their underlying concerns, Nate notices that about one-fourth of those opposing current proposals think they “don’t go far enough to reform health care,” and suggests there’s a little-discussed segment of the electorate that might either grow if reform is further compromised, and/or might eventually come around if and when legislation is on the president’s desk.
This is an argument that Jonathan Chait made a couple of weeks ago at TNR, based on earlier polling.
Both articles are important refutations of the common assumption of conservatives that there is monolithic majority opposition to health care reform, and also a monolithic majority of Americans happy with the status quo in health care.
Beyond that, of course, this argument will be catnip to those progressives who are searching for ways to convince the White House and the congressional Democratic leadership to abandon or greatly toughen its endless negotiations with Senate “centrists” and the odd Republican, particularly over the public option. A majority of Americans, they will argue, either likes the current bill or wants something with more and more generous coverage, and a stronger public option. This is, of course, a subset of the ancient debate among Democrats between the strategy of seeking a majority coalition by peeling off “centrist” independents, or by solidifying and energizing the presumably liberal party “base” (along with “populist” independents).
There are, however, two problems with excessive reliance on the “progressive majority” analysis on health care reform. The first is that the polling numbers are based on some pretty vague ideas about what would constitute “doing more” on the health care front; it’s not entirely clear “more” means “more” of what progressive opinion-leaders want. And the second problem, more to the immediate point, is that in a Senate with a sixty-vote threshold for enactment of major legislation, a handful of Democratic and Republican senators, who represent not the nation as a whole but their own states, have the whip hand on the details of health care reform. I don’t think many progressives would want to abandon health care reform if a durable majority did, in fact, favor the status quo; this is a complex issue that’s not exactly good material for a plebiscite.
The more useful observation about the existence of a “dissent from the left” on health reform involves the wrath that Republicans (and obstructionist Democrats) may well inherit if nothing happens this year, and health care premiums, along with insurance industry abuses, continue to get steadily worse. We will then be talking not about a constantly shifting and poorly understood thing called “Obamacare,” but about one party that sees a major national challenge and wants to do something about it, and another that’s fine with an increasingly untenable status quo.
The diversity of opinion among those unhappy with the present legislation is, to be clear, an excellent argument for increasing the frequency and volume of claims that said legislation really will accomplish a great deal, if not everything it should or could achieve. All the news that’s been made about compromises on health reform over the last few months, along with reform advocates’ efforts to reassure seniors and others that they won’t lose anything worth caring about, have undoubtedly “undersold” the extent of change that even a “weakened” bill would make happen. A reform effort that’s marketed as a tepid bowl of porridge won’t satisfy much of anybody.
Among some members of the chattering class, it’s become something of a meme to assert that the Obama administration is too deferential to its opponents — whether Tea Partiers arguing about health care or Senate Republicans attacking on Afghanistan. The charge has especially been taken up by his critics, who seem to delight in attacking the president they’re beating up as a president whom, well, they can beat up. In September, for instance, Fred Barnes wrote in the Weekly Standard, “There’s the Obama who defers, the one who dithers, and the one who’s out of touch. The Obama presidencies have one thing in common. They’re all weak.”
These critics should be silenced, at least for a while, by the Environmental Protection Agency’s (EPA) announcement today formally declaring that carbon dioxide is a dangerous pollutant, paving the way for its regulation under the Clean Air Act.
On the cusp of meetings in Copenhagen to discuss an international climate treaty, the announcement has huge significance. It essentially enables the administration to circumvent climate obstructionists in Congress. Under the rules announced today, the administration can not only directly regulate carbon — it can exceed the limits contemplated by current Senate and House bills that would cap carbon dioxide emissions by 17 to 20 percent by 2020, compared with 2005 levels.
It seems unlikely that the EPA will actually act unilaterally to regulate carbon; the most administrable policy will probably remain market-based solutions such as cap-and-trade and similar proposals, rather than a command-and-control approach. However, the announcement today has political and strategic significance beyond its legal effect — and shows that the administration has just opened a brand new offensive playbook on carbon.
Two things are clear from the announcement today. First, the EPA decision puts the president on an unequivocal and strong footing for his visit to Copenhagen in a little over a week. The president will now be able to assert leadership on the issue on the basis of a clear authority to act.
Second, with today’s announcement, Barack Obama has placed a big stick on his desk in the Oval Office. His opponents in Congress and in industry will be pounding their own desks in outrage. Rep. James Sensenbrenner (R-OH) immediately released a statement today, for instance, saying, “The EPA claims its process is dictated by science, however, it’s conveniently timed to push its politics.” Yes, that is a plaintive note you detected in Sensenbrenner’s statement. That’s because the president’s opponents will now have no option but to play on the president’s turf on carbon.
Cap-and-trade passed the U.S. House earlier this year. As it stands, cap and trade — originally a market-based, Republican-friendly program — faces a very uncertain fate next spring in the U.S. Senate. But with his move today, the president has told Senate opposition that he has the upper hand, and that if they do not act to cut carbon, he will. On climate change, where the president will certainly be faced with Tea Party-ish opposition every day of his administration, the Incredible Hulk-like transformation (green meeting muscle) comes just in time.
In the wake of President Obama’s West Point speech announcing the administration’s new strategy for Afghanistan, the White House must have been concerned that lingering charges of warmongering (on the left) or dithering (on the right) were going to dominate the public debate. Why would there be major weekend stories in the New York Times, Washington Post, and Los Angeles Times to set the record straight?
Coming from sources as wide-ranging as National Security Advisor Jim Jones to “more than a dozen senior administration and military officials who took part in the strategy review,” these newspapers’ accounts of the strategy sessions show a president asking careful questions to redefine the mission in a way that protects the country while limiting open-ended commitment.
Last week, I was in the offices of a certain 24-hour cable news channel that’s nice enough to put my ugly mug on the air. I overheard one of its regular pundits exclaim breathlessly, “I just don’t understand why Obama just doesn’t do what his commanders on the ground tell him.” This weekend’s trio of articles paints the best picture I’ve seen of why not.
Here’s the short version of that answer from the NYT:
The decision represents a complicated evolution in Mr. Obama’s thinking. He began the process clearly skeptical of Gen. Stanley A. McChrystal’s request for 40,000 more troops, but the more he learned about the consequences of failure, and the more he narrowed the mission, the more he gravitated toward a robust if temporary buildup, guided in particular by Defense Secretary Robert M. Gates. …
The group went over the McChrystal assessment and drilled in on what the core goal should be. Some thought that General McChrystal interpreted the March strategy more ambitiously than it was intended to be.
In June, McChrystal noted, he had arrived in Afghanistan and set about fulfilling his assignment. His lean face, hovering on the screen at the end of the table, was replaced by a mission statement on a slide: “Defeat the Taliban. Secure the Population.”
“Is that really what you think your mission is?” one of those in the Situation Room asked. …
“I wouldn’t say there was quite a ‘whoa’ moment,” a senior defense official said of the reaction around the table. “It was just sort of a recognition that, ‘Duh, that’s what, in effect, the commander understands he’s been told to do.’ Everybody said, ‘He’s right.’ ”
“It was clear that Stan took a very literal interpretation of the intent” of the NSC document, said Jones, who had signed the orders himself. “I’m not sure that in his position I wouldn’t have done the same thing, as a military commander.” But what McChrystal created in his assessment “was obviously something much bigger and more longer-lasting…than we had intended.”
Whatever the administration might have said in March, officials explained to McChrystal, it now wanted something less absolute: to reverse the Taliban’s momentum, deter it and try to persuade a significant number of its members to switch sides. “We certainly want them not to be able to overthrow the government,” Jones said.
On Oct. 9, after awaking to the news that he had been awarded the Nobel Peace Prize, Obama listened to McChrystal’s presentation. The “mission” slide included the same words: “Defeat the Taliban.” But a red box had been added beside it saying that the mission was being redefined, Jones said. Another participant recalled that the word “degrade” had been proposed to replace “defeat.”
Already briefed on the previous day’s discussion, the president “looked at it and said: ‘To be fair, this is what we told the commander to do. Now, the question is, have we directed him to do more than what is realistic? Should there be a sharpening . . . a refinement?'” one participant recalled.
Said a senior White House adviser who took extensive notes of the meeting: “The big moment when the mission became a narrower one was when we realized we’re not going to kill every last member of the Taliban.” [emphases mine]
Separately, a few other nuggets, like on troop numbers (NYT):
On Oct. 9, Mr. Obama and his team reviewed General McChrystal’s troop proposals for the first time. Some in the White House were surprised by the numbers, assuming there would be a middle ground between 10,000 and 40,000.
“Why wasn’t there a 25 number?” one senior administration official asked in an interview. He then answered his own question: “It would have been too tempting.”
And from the LA Times‘ piece on the date of withdrawal:
Gates was also persuaded by Petraeus and others that announcing the date would help create an incentive for the Afghans to act, he said this week.
The proposed date also would make it such that the withdrawal of troops would begin just as the campaign for the 2012 presidential election was heating up.
Still, it was crucial to Gates and other military officials that Obama not announce a specific drawdown plan. Doing so could embolden militants, Defense officials said. Gates and others wanted to make sure that the pace of the drawdown would be based on the security situation — not a set timetable.
“Ultimately,” said a senior Defense official, Gates “wanted conditionality, and got it.”
All three articles are must-reads to anyone who wants to understand the complexity of the White House’s decision. In sum, it seems that the review sessions narrowed the goal, and resourced it as robustly and quickly as possible.
I understand that the administration needed to fix a date for beginning withdrawal as a political concession to the progressive base, and I still remain uncomfortable with that notion, even as these articles do a good job clarifying that the withdrawal’s pace is subject to the security situation.
If you’ll forgive me for egregiously mixed metaphors, I want to draw attention to an implicit assumption among many health care reform advocates related to controlling healthcare spending: that if not for the politics involved, it would be fairly easy to rein in costs.
That’s because, the argument goes, there is easily identifiable inefficiency in the way we currently spend health care dollars. There are enormous regional disparities in, for instance, per capita Medicare spending. What is more, these differences are apparently unrelated to differences in the health of the underlying populations, and they don’t produce better outcomes. Rather, the differences reflect the ways that health care providers diagnose and treat patients in different parts of the country. So say the much-revered Dartmouth College health researchers, whose findings have been fairly uncritically embraced by many on the left.
Politics aside (the difficulty is that one person’s wasteful diagnostic test is another’s life-saving intervention), I always was suspicious of this argument. If there are excess profits to be made, then why is it that providers in only some parts of the country go after them or successfully extract them? Then a fascinating study came out that was mostly ignored but that should have raised questions about the Dartmouth research.
A potential problem with the Dartmouth research is that if there are unmeasured differences in health between patients who go to different providers, then the finding that greater spending is unrelated to outcomes could simply derive from people in worse health being very expensive to treat. The Dartmouth researchers use relatively crude measures to statistically control for these differences (because they are the only ones available).
MIT economist Joseph Doyle got around this problem by looking at patients who needed emergency care while they were visiting Florida. Because there is no reason to expect that unhealthy tourists are more likely to end up in higher-spending ERs, any differences in outcomes between those who went to high-spending hospitals and those who went to low-spending ones should reflect only the spending difference. Doyle found that higher spending did produce better outcomes.
Disparities in Data
Now MedPAC, the panel that monitors how Medicare reimburses providers and makes recommendations to Congress, has released a study that shows that disparities in Medicare spending are quite a bit smaller when other important factors — such as regional differences in wages and extra reimbursement related to medical education — are taken into account (hat tip to Mickey Kaus). If one looks only at per capita Medicare spending, high-spending areas of the country have costs that are 55 percent higher than low-spending areas of the country (I’m talking about the 90th and 10th percentiles, for those of you statistically inclined). After making MedPAC’s adjustments, however, that difference shrinks to 30 percent.
Thirty percent might still be considered a big number — in a perfect world adjusted spending shouldn’t differ at all — but other evidence in the MedPAC data gives reason to question the precision of any of these kinds of comparisons. I put the figures for all 404 geographic areas into a spreadsheet (which you can get from me if you’re interested — data wants to be free!) and looked at the top and bottom quarter of adjusted spending.
High-spending areas are dominated by the South, particularly the states stretching from Florida across to Texas and Oklahoma. They also include 15 of the 30 biggest metropolitan areas, including all of the biggest southern and midwestern metros, save Atlanta and Minneapolis, and none of the biggest northeastern or western metros, save Los Angeles, Las Vegas, Phoenix, Denver, and Pittsburgh.
On the other hand, low-spending areas are dominated by the West, particularly Alaska, Hawaii, Washington, Oregon, Idaho, and most of California (with the exception of Los Angeles and San Diego). Also overrepresented are small metropolitan areas in the upper Midwest and Dakotas, in New York, Maine, Virginia, and Georgia. None of the biggest ten metropolitan areas are represented in the bottom quarter, and only four of the biggest thirty are (San Francisco, Seattle, Portland, and Sacramento).
Compare these findings to those of the Dartmouth folks (Map 1). While many of the same conclusions show up in their map, there are some notable differences. Most importantly, California and the Boston-Washington corridor look like they spend a lot more in the Dartmouth map than they do in the MedPAC data (and the Mountain West states look like they spend a lot less).
Fixing Inefficiencies Not a Silver Bullet
If different sets of rankings differ as notably as these two do, then that says to me that there is a lot of noise in these rankings and that perfectly adjusted spending figures would potentially produce a distribution of areas that would look different from either set. In particular, I suspect that it would show that the vast majority of spending variation could be explained by factors that had nothing to do with inefficiencies.
The point is that even discounting the political difficulties of enacting policies that rely on comparative effectiveness research to weed out inefficiencies in healthcare spending, it’s not at all clear that regional variation in healthcare spending is proof that such inefficiencies exist. That’s not to say that there are no inefficiencies, but weeding them out won’t be as simple as making Florida providers act like Minnesota ones.
The views expressed in this piece do not necessarily reflect those of the Progressive Policy Institute.
Word going around Washington this week is that Sens. John McCain (R-AZ) and Maria Cantwell (D-WA) are pushing to 
Stephen Hadley, George W. Bush’s national security advisor, has set forth some rather