Have You No Honesty, Sir?

Over at TNR, in an article titled ‘Have You No Decency?‘ Harold Pollack engages in some gratuitous Palin-basing in his commentary on healthcare policy:

Palin and Bachmann remind no one of Hillary Clinton in their success in grasping complex policy issues, or in their desire to do so. It may be too much to expect them to trace the origin and veracity of these talking points.

…but politics ain’t beanbag, as they say, and I’m not in the Palin-defending business (or in the business of defending any other public figure).

I am in the trying to get people to be honest and consistent in their arguments business, and so – given that the thrust of his argument is that Palin and Bachmann are being dishonest when they say that one of the consequences of healthcare reform is that:

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

– he needs to show just a little honesty himself.

Instead he responds by making five points:

1) “I can’t find the words “death panel” in any administration position paper, the stimulus package, or the House and Senate draft health reform bills.”

2) “First, these issues are quite separate from the main issues being debated in health reform.”

3) “Second, health reform would address an equally fundamental dilemma of human dignity and human rights: millions of people’s lack of access to basic care.”

4) “Third, people genuinely worry that comparative effectiveness research (CER) is a stalking horse for rationing or for curtailing care for the sick, elderly, or disabled. This is a misplaced concern.”

5) “Fourth and finally, publicity-seeking politicians subtract a lot from these conversations. Palin, Bachmann, and others score cheap points by scaring people and by spreading falsehoods.”

To which I respond:

1) When the bill calls for Medicare to make ‘end of life counseling’ part of the healthcare process, we’re talking about some kind of change. And when administrative decisions are made about what will and won’t be covered – when government and law reaches deeper into personal medical decisions as it will have to in order to rationalize them – the point he’s making is somewhere between niggling and deceptive.

2) Yes and no; as I noted in my personal story about this, these are brutally difficult decisions that are wrenching at a personal level and massively expensive to us socially. As my cohort ages, they will get far more wrenching and far more expensive. By shifting the locus of decision from social norms and personal choice (and yes, personal means) toward an administrative handbook, we are changing the game. There’s no way around that.

3) Straw man. Careful you don’t catch fire carrying that around. It’s perfectly possible to propose a health care plan that doesn’t touch end of life care; it just won’t be as ‘curve bending’ as it would be otherwise.

4) Liar, liar, pants on fire. Here’s Pollack later in the same paragraph:

None of the identified high-priority items involved anything approximating the rationing of life-saving or life-extending care. End of life care ranked 28th in their chart of priority areas for CER research. This may be a mistake. Better approaches to palliative care often look very good when evaluated against the standard benchmarks of medical cost-effectiveness.

(emphasis added)

5) The answer to bad arguments is better debate. If Pollack weren’t so concerned with shutting his ideological opponents out of the argument (“I wish the Post would exercise greater quality control over what appears in its pages.”), he might plausibly be making a case for a higher level of debate. But to him – no debate is necessary.

Which makes him the most dishonest person in this argument.

Because on an issue this big, complex, and important, we need lots and lots of debate.

I honestly don’t know where I stand on Obama’s bills. I believe we need to make changes in our healthcare system. I even – shudder – think it’s legitimate to talk about how much of other people’s money we’ll use on treatments that are certain to be fruitless (I’ll go stand over in the corner with the UK National Health bureaucrats now).

But the idea that we’ll do something like this in 90 days to get it done before midterms is a f**king joke. And makes me as inherently suspicious as the used-car salesman who says that I can have this deal on the car, but only if I sign right now.

Let’s work on health care without buying any clunkers, if we possibly can.

UPDATE: Here’s the Charles Lane of the teabagging Washington Post on the issue:

On the far right, this is being portrayed as a plan to force everyone over 65 to sign his or her own death warrant. That’s rubbish. Federal law already bars Medicare from paying for services “the purpose of which is to cause, or assist in causing,” suicide, euthanasia or mercy killing. Nothing in Section 1233 would change that.

Still, I was not reassured to read in an Aug. 1 Post article that “Democratic strategists” are “hesitant to give extra attention to the issue by refuting the inaccuracies, but they worry that it will further agitate already-skeptical seniors.”

If Section 1233 is innocuous, why would “strategists” want to tip-toe around the subject?

Perhaps because, at least as I read it, Section 1233 is not totally innocuous.

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that’s an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic.

What’s more, Section 1233 dictates, at some length, the content of the consultation. The doctor “shall” discuss “advanced care planning, including key questions and considerations, important steps, and suggested people to talk to”; “an explanation of . . . living wills and durable powers of attorney, and their uses” (even though these are legal, not medical, instruments); and “a list of national and State-specific resources to assist consumers and their families.” The doctor “shall” explain that Medicare pays for hospice care (hint, hint).

Go read Section 1233 yourself…

19 thoughts on “Have You No Honesty, Sir?”

  1. I understand that you mean “the teabagging Washington Post” in the same ironic sense that some other boor might say “the dago-loving Sonia Sotomayor”, but it’s still boorish.

    What possible reason can there be to have a 1000 page bill? Why not break it up into several components and debate and vote on each one?

  2. bq. I honestly don’t know where I stand on Obama’s bills

    How could you? They haven’t been written yet!

    It’s not a used car saleman saying “I’ll get you great deal if you sign right now!” but he’s also saying “I’ll just fill in a few of the terms later on”.

    We should also note how suspicious it is that the Democratic Party seems to eager for GOP votes. Why, unless they know that in reality it is going to be an epic fail and they need to spread the blame? What politician ever schemed to spread the acclaim?

  3. We have government-run health care here. I think we have one of the better systems, certainly superior to that of the UK and possibly Canada based on what I’ve heard about those systems. We also have private hospitals and private health insurance.

    Let me tell you, the public health system isn’t great. It’s under-funded, poorly run, wasteful and there are increasingly horror stories about botched or refused emergency treatment. Voluntary surgery waiting times are long (sometimes measured in years). There’s a shortage of doctors and nurses and it’s getting worse – many of them are treated so poorly by the bloated and inept bureaucracy that they are quitting or moving to another country. I know several doctors, from intern up to department heads, and they are constantly telling me about waste, mistakes made and how they don’t feel like sticking around much longer.

    What’s worse, not only do I not get to choose to avoid paying for this system – we are explicitly taxed 1.5% of income to pay for it plus plenty more through other avenues – but we are penalised if we don’t have private health insurance (another 1% of income if you earn enough) despite the fact that we can’t choose not to pay for the public system!

    What’s worse it seems private health insurance is virtually useless. They refuse to pay for many treatments. I don’t pay for it since if I’m going to be forced to use the public system anyway, why should I pay for private insurance too?

    I don’t know how long our system will survive. If things continue the way they are – where the system is a money black hole, perpetually underfunded and understaffed – collapse is inevitable. Fixing it will require even more money.

    I think you need to get rid of the ridiculous system where employers pay for health care. Make the cost of insurance a deduction for individual and then undertake some tort reform and you will gain a lot more than you will by moving to a hellish system like ours.

    By the way, stories of waiting for 12+ hours for treatment in an emergency room in a socialised system are not hyperbole. It’s a well known fact that unless you’re bleeding out in the waiting room you’re going to be in for quite some wait (and even then sometimes they leave people to die waiting for care due to sheer incompetence).

  4. I think Palin grasps a larger truth here than the narrow rebuttals by Tapper and Pollack. She is pointing to the lawn, they are counting blades of grass.

    Government health care eventually fails to deliver health care (see Nicolas above) or it becomes utilitarian, with the value of people’s lives tabulated and properly depreciated. The latter is the rational approach and the bio-ethicists, whose job it is to provide a moral basis for killing, can no doubt give you chapter and verse on why it is a good thing. From a rational point of view, of course.

    From a purely medical point of view, I think the most important thing is science and technology. Without vaccines, aseptic technique, anesthesia, and antibiotics medicine would still be back in the early 19’th century. I might be more inclined to government run health care if the countries with that system advanced medical science faster than we do. But they don’t. There is nothing so conservative and unimaginative as a bureaucracy dedicated to filling out forms.

    But what bothers me most are the assurances that I can keep my current insurance if I wish to. Frankly, the government has no damn business telling me what insurance I may or may not keep. The fact that Obama seems to feel that this sort of authority is constitutional and within the government purview is a bad sign. That the nomenklatura is exempt from some of the provisions is really all you need to know about this monstrosity.

  5. By the way I should point out that despite all the above we still get very good quality care from the doctors – most of the time – when we get to see them.

    I have a lot of respect for the doctors who, despite the poor conditions, have invested a lot of time and effort into treating people in the public system. If I get hit by a bus tomorrow, assuming I don’t end up waiting twelve hours to be seen, chances are I will a good level of treatment. On the other hand, people with chronic conditions are not going to have a very good time dealing with the public system. That seems to be the way these things work, if you’re in a bad way you get decent care but if you’re in chronic pain take a number…

  6. Do we have a problem with health care that requires some legislative intervention, or not?

    Expensive and getting less and less affordable? Seems like it. Problematic if you lose your job and you can’t get insurance because you have a pre-existing condition? Seems so.

    Tens of millions of uninsureds? Also a problem. This is at the very least hugely problematic for uninsured individuals when they get sick or injured, and hugely inefficient for the system as a whole. How does this work? You show up at an ER, you get treatment (the most expensive and least efficient or effective kind, after waiting for hours in the lobby) and there is no clear or satisfactory way for the hospital to follow up or get reimbursed?

    If we have a problem, what’s the solution? It seems that one issue is that fee for service has built in lots of inefficiency and waste into medical care. Serious people working on the legislation currently being considered are earnestly trying to come up with some solutions that make sense.

    Obama is letting Congress draft this legislation, so Palin is off base by pejoratively suggesting that this is a plan the Administration is trying to rush through. It also strikes me that Palin’s talk of bureaucratic death panels, and lots of other talk like it, is doing nothing constructive to address the problem.

    We should keep our eyes on the ball . . . do we have a problem, and if so, what are possible solutions? Naysaying with extreme rhetoric–becausee it is politically opportune–is not helpful. Indeed entering into the discussion at that level is not helpful.

    I haven’t heard Ms. Palin’s proposed solutions. The observation that Kennedy, the Clinton’s, and now Obama have been trying do do something constructive in this area for a long time strikes me as accurate. Similarly, the observation that the Republicans in general have done their best to obstruct any change strikes me also as correct. It would be nice to hear less inflammatory talk of commie bureaucratic death panels, and more constructive ideas presented in a positive way.

  7. I haven’t heard Ms. Palin’s proposed solutions.

    The physician must be able to tell the antecedents, know the present, and foretell the future – must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.

    Do no harm strikes me as a good starting point. Rushing through complicated legislation without debate or consideration of consequences strikes me as having great potential for doing harm. Witness Massachusetts. Nor do I trust Kennedy or Obama with these things. Obama in particular is spectacularly ignorant and uninterested in details. And in this sort of thing details matter a lot, perhaps even more than making large scale irreversible changes without a good deal of public debate and analysis.

    I agree that pre-existing conditions and non-portability of insurance is a problem, I also think part of that problem is that insurance is usually obtained through employment rather than obtained independently. Note also that the Republicans have offered proposals for these problems.

    An incremental approach is generally the best bet for complicated problems. I don’t see that here, 1000+ pages of legislation is not incremental. And I haven’t any trust in Pelosi and Reid, neither possesses integrity, IMHO, and both are willing to say anything to gain power. They are politicians first, problem solvers a distant secont.

    Furthemore, if you consider that a good 50% of the population doesn’t trust this legislation, pushing it through begins to look like tyranny and government overreach. Just because some folks think they know better, folks who on the whole *don’t* have problems with healthcare because of their privileged position, is not an argument for action. For an act this far reaching there needs to be a good deal of consensus, without consensus there is bound to be conflict. And rightly so.

  8. BGates: Let’s reduce the 1000 page bill to a two sentence bill, for the purposes of illustration, even though it’s admitted a reduction to the absurd. Let’s say the bill is as simple as: “The NIH is directed to establish and implement a program of national health care and insurance. The revenue for this shall be generated by a flat income tax of 5% across the board.”

    Now let’s imagine this is separated into two bills, each of its respective sentence. The former passes. The latter, obviously, fails.

    Now what?

    Sometimes, massive bills are massive to hide things. Other times, they are massive because they are dealing with complex subjects, and piecemeal implementation is foolish to attempt and obviously worse than no implementation at all.

    I don’t doubt that this is a bit of both, just for the sheer scale of the program and the sheer temptation of that many dollars and that much power being influenced by that many legislators.

  9. I’ve said before, I really don’t think there is any good result for Democrats, in the long run, from getting a major Health Care bill passed.

    The results are almost certainly going to be bad– likely not in a death-of-the-republic, film-at-eleven sense, but on personal levels. I flatly do not believe that politicians are clever enough to work out schemes for positive rights to extremely scarce goods. And when, as I am sure it will, this system produces suffering, the Democrats, with unstoppable majorities in both legislative houses and control of the White House, there will be no one for the public to blame except the Democrats.

    I have phrased this carefully, because I would be willing to at least entertain a program providing some certain level of free food to every man woman and child, for instance– I think we have made basic grain and vegetable produce sufficiently plentiful that this could probably work.

    That, in turn, suggests what I’d really like to see. I would really like to see health care made so plentiful by technology that we could conceive of a program that would work, and would be only a small portion of the economy instead of a gigantic one.

    One of the more practical things we might do to get there is easing up a bit on the drug companies and the punitive lawsuits waged against them when, despite going through all the excruciating FDA trial and approval processes, side effects become known years later and the legal fights ensue.

    Likewise, backing the FDA itself down a paranoia level might have some good effects, too. No one wants a re-run of the thalidomide debacle, of course, but sometimes the FDA is as big a hurdle in drug development as the actual medical chemistry itself.

    Sadly, these are strategies that will yield results a decade from now, rather than today, but it would help.

    At least we’ve getting over the stem cell ban. Legally, if not societally. That, also, will yield results, and I give Obama all due kudos on that decision.

  10. Now what?

    The program is unfunded and unimplemented, a correct result if folks aren’t willing to pay for it. I don’t see the problem here. And at least the costs weren’t hidden away in obscure places, which is what is happening now. Can *you* tell me where the money is going to come from for the current proposal? Do you think it can be paid for by folks making more than $250K a year? And do you believe the cost estimates? When was the last time a cost estimate for something this complex was even in the ball park?

    Because cost estimates are almost always low, just as the time estimates for software development are almost always low, the CBO cost estimate should probably be multiplied by two, if not more. The adjustment factor for software development is about four, so I may be a bit optimistic using a factor of two for the CBO figures. Against all experience, I am extending them the benefit of the doubt.

  11. No, it seems to me that in that case, the program is unfunded, but still legally mandated and therefore some attempt at implementation would be made.

    Hence the problem.

  12. therefore some attempt at implementation would be made.

    Sure. Put a title on the door and hire a senator’s niece to sit behind the desk and play solitaire. See, it’s easy.

  13. Marc — I was expecting a stronger fisking from you, I’m honestly surprised.

    _2) “First, these issues are quite separate from the main issues being debated in health reform.”_

    Palin’s _entire argument_ is based on cost, leading to government intervention and all the other nastiness that brings with it.

    This article is full of enough dodge and weave to make one’s stomach turn. Urp. He wants it so badly, he’ll twist arguments, facts, logic, you name it, any which way to fit the narrative.

    We can discuss this issue until the sun goes cold, but no matter how much we _want_ it, how badly we _feel_ that everyone is entitled, when the bill goes live, day 1, we as a society actually have to have solutions, not just conjecture (or even worse, merely goals).

    *Reality*. What happens when you wake up, the sun rises and, today, human beings in government are responsible for assuring you healthcare?

    It’s the difference between the theoretical, and the practical, the point when ideas meet reality and human beings have to actually work to make things happen. It gives us the cliche “when the rubber hits the road.” Most of us have been burned going into something we thought we understood and had a plan for, but quickly discovered we didn’t know how to make things work.

    Reality is responsibility (accepted or not). You have to provide a means as well as an end.

    This man isn’t, and his arguments don’t. He wants an outcome, but he doesn’t have good answers on the “how,” just rhetoric explaining why he’s right in wanting it.

    This article is written by someone who _wants_ it, he wants it so badly, (_”don’t you understand!”_), he’ll argue for it no matter what he has to say, no matter what problems you present, because it’s an end that _needs_ to be.

    When you’re ready to go to pass a law, when you’re going to bat with an idea on the “how”, you’d better be ready to engage. This article was terribly disappointing.

  14. Conservatives are in a no-win situation on this. Basically the president is saying, “OK- show me your plan for vastly expanding government intervention into health care? Don’t have one? Hah- then shut up.”

    Its essentially the old when did you stop beating your wife fallacy. The Dems and their media allies have successfully made this about _how much_ government intervention we will have. They’ve ignored things like tort reform, health savings accounts, and interstate insurance completely. Those are important, if piecemeal suggestions.

    The first question I have is _why does something as large and complex as healthcare reform have to be comprehensive?_ That doesn’t seem like a feature to me at all. I mean- if Obama says he can wring tens of billions out of medicare, I say let him show us. I think that is a legitimate argument, and not a cop-out at all.

    For that matter the Dems haven’t even defined their primary goal. Is it to reduce healthcare costs for the middle class? Or to expand insurance universally. These are mutally exclusive activities until proven otherwise.

  15. Actually, Marc, when I said “I understand that you mean [it] in the same ironic sense,” that was meant to be a signal that I understood that you were being ironic.

    Your “correction” is nothing of the sort. Since Sonia Sotomayor’s most notorious interaction with Italian-Americans was the Ricci case, to call her “Italian-loving” would be ironic. To call her “dago-loving” would be both ironic and offensive, because “dago” is a slur. To call her “wetback loving” is just offensive.

    The Washington Post is opposed to the tea parties. To call it “tea party loving” would be ironic. To call it “teabagger loving” was both ironic and offensive, because “teabagger” is a slur.

    Sorry if this is too far off-topic, but this is supposed to be a place that prides itself on staying out of the gutter. You’d ban people who started referring to their opponents as “cocksuckers”; “teabagger” is a little bit lower, if you’ll pardon the pun.

    As far as the health care debate, +1 chuck.

  16. The problem I have with the current plans, is I believe that our government is currently unable to generate a plan that:

    a) includes a fair debate on the issues & effects
    b) creates a bill that will be voted on the issues, and not party loyalty
    c)create a bill that does not include gratuities for lobbyists..

    With all of these things the devil is in the details, and there are 1000 pages of details I have not seen yet. The mere mention of 1000 pages leads me to believe they are starting on the wrong track.

    In theory, I like the idea of haelthcare reform. Frankly, I’d prefer a hybrid system, where government is in charge of basic health (checkups, dental cleanings etc) that are massively important to overall health, but largely missed by those without insurance. Meanwhile private insurance would be in charge of dramatic things like surgeries, expensive tests, etc.

    I think it would be a way for a government to start simple and not get involved of the death of my baby/grandmother accusations that have been made.

  17. It looks like the Senate is stripping that particular provision out of its version of the bill. Despite some protests to the contrary this seems to me to be a tacit vindication of Palin and Bachman’s opposition to it. If the provision was as benign or even as beneficial as supporters of ObamaCare had maintained, then fight to keep it in and explain why it’s important. By removing it, they’ve essentially acceded to the argument that this could and likely would lead to at least some of the abuses Palin and Bachman pointed out.

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