Healthcare wonkery

TPMCafe summarizes yesterday in the discussosphere, focusing on a point Mark Schmitt made, that proposing detailed healthcare plans is pointless. Kevin Drum, Steve Benen, Matt Yglesias and Ezra Klein all weighed in for or against laying out detailed policy plans in the campaign, and I think Ezra's point is dead-on.

What's important is not that you present a legislative proposal, or some irreducibly complex policy that would have to be implemented exactly as you propose it. A dozen people in the wonkosphere will care, and everyone else will have changed the channel before you tell the punchline. The thing to do is to deliver the punchline, or what Klein calls bottom-lines.

John Kerry's health plan was very smart. It was incremental, effective (at least in principle) and painless for everyone. But it wasn't clear what problem he thought he was solving. The plan would have let the government re-insure health insurers for catastrophic care, the most expensive, but rarest, part of the insurers' risk. In theory, taking that part of the risk pool away from insurers would let them lower costs and therefore prices, making insurance accessible to more and more people.

There were a couple of reasons this never caught on. Partly we can blame the inherent complexity of the plan, but there is a more fundamental issue. The problem that the plan was supposed to solve was very distant from the proposal. He wanted to be talking about universal healthcare, but his plan was about reinsuring a small fraction of sick people. It didn't sound like universal healthcare, it sounded like an insurance company bail-out.

The link between the principle – everyone should have health insurance – and the practice was too loose.

But, as Ezra Klein points out, just saying nice things about universal healthcare doesn't get us anywhere, any more than saying that we should cut the deficit, protect American workers or promote sustainable development and liberal democracy abroad. These principles are all important, and I expect any serious candidate to be talking about how to do that. But I, like any thoughtful voter, know that the President can only do so much. What I want to know is not exactly what the President wants to do, but what he or she would refuse to accept, or refuse to do without.

Those are details of a sort, but not the nerdish level of detail that sometimes get offered. A serious proposal on the environment ought to talk about a broad program for promoting energy efficiency, encouraging use of renewable energy source, etc. But there's no need to pick one horse. Nuclear, solar, and wind are all good options, as are ethanol, biodiesel, hydrogen and synfuels. A carbon tax, increased regulation of emissions, or cap-and-trade all will encourage changes toward renewable energy, as well as promoting energy security. This table (reproduced from a paper we discussed before) shows a range of options for flattening carbon emissions by 2054. All are practical now, and choosing any 7 of them would work. There's no need for a candidate to choose only seven, just explain how he/she would choose among the available options, and critically, what options would not be acceptable.

On healthcare, there are clear building-blocks for universal coverage, which Ezra discusses quite nicely. Community rating would make premiums more uniform and eliminate the absurd discrimination against people with pre-existing conditions (people who most need health insurance!). A clear path to universality has to be visible, or else the entire exercise feels worthless. People understand that traversing that path will require negotiation with Congress, doctors and insurers, but it has to be clear that the path, however wide it might be, does have clear boundaries that cannot be escaped.

There's nothing wrong with offering model legislation to enact a plan, and presenting whitepapers offering precise details, provided that the whitepaper explains unambiguously what is or isn't negotiable. What will the candidate fight for, what will the candidate fight against? That's what we need to hear about.