Hospitals and physicians like the bill because the mandatory insurance provisions will make it possible for them to get paid for a lot of the services they now do pro bono. The bill is good for insurers (although they are still bargaining for more) because it will give them 30 million or so new taxpayer-subsidized policy holders, and no effective limits on their pricing policies or profit margins. There is even a provision that may perversely drive up insurance costs. The other big political players, drug companies and device and equipment makers, may anticipate some sales growth but are otherwise unaffected. The so-called cost containment provisions are limited to studies, pilot programs, increased anti-fraud measures, and other eyewash measures that don't require any belt-tightening by anybody.

Those in favor of the bill say we should get this big "reform" in place and "fix it later." They don't explain—and I think there is no way to explain—how subsequent legislation to drive down costs will overcome the opposition of a healthcare industry that will stand united against measures that only threaten to reduce their incomes. Proponents say that if we don't pass healthcare now, we can't hope to address it for another generation, but they are implicitly abandoning—for another generation or longer—the opportunity to address the society-destroying affordability problem, which is a much more serious problem than incomplete coverage. I say forcing more Americans into a system on the verge of economic collapse will only hasten and exacerbate the collapse, whereas fixing the cost issues would by itself lead to expanded coverage. Presidential candidate Obama was right when he said this:

A mandate means that in some fashion, everybody will be forced to buy health insurance. ... But I believe the problem is not that folks are trying to avoid getting health care. The problem is they can't afford it. And that's why my plan emphasizes lowering costs.

Our fundamental economic problem is that real incomes have not increased since 1973 for the five-sixths of working Americans who are not bosses, while healthcare costs have continued to increase at an average annual rate of 3.6%—which means they double in real terms every 20 years. Link. If the real incomes of ordinary people had continued to rise at or near the rate that real healthcares costs have risen, we would not have a big healthcare crisis now. But they didn't, and we do. I have argued that the best solution to this and many other problems is doing whatever it takes to get real wages for ordinary people steadily rising again, but there's no political will to do that. The pending healthcare bill is yet another trickle-up program to support rising incomes of healthcare firms and professionals, all of whom are protected by law and practice from any real competition. They and others at the top of the income pyramid need to recognize that their revenues cannot keep rising when their customers' incomes are stagnant.

Some say President Obama and his advisors have mismanaged healthcare reform and that's why we have a "dogs breakfast" of a bill and a reversal of his campaign promise to address costs instead of mandatory coverage. Perhaps it was mismanaged, but it seems more likely to me that there was never any prospect of enacting cost containment over the objections of the politically powerful healthcare industry.  We should not increase that political power more by passing the pending "reform" package. 

[F]or all their differences of style and speech, Obama and Daley shared a basic approach to politics as a constant negotiation of interests and ideals—Chicago's brand of Realpolitik. Both had advanced by capitalizing on the prevailing power structure, not by dismantling it, and they were united, above all, not by ideology but by pragmatism.

That fits exactly with the impression I have formed by watching and listening to Obama for two years. At the top of Obama's agenda for change has been improving the tone of discourse and encouraging bi-partisan cooperation. That is not at all a desire to dismantle the prevailing power structure, but would merely make it easier for him to be a pragmatic leader. He has never had a liberal policy agenda or any other substantive agenda, in my view. He has readily accepted that his initial proposals about healthcare, Guantanamo, gay rights, government secrecy, executive powers, global warming, economic stimulus, financial regulation, etc. would have to be scaled back, but he has never wavered from his commitment to bipartisan reasoned discourse and cooperation. That's what he seems to really care about. He's a process guy and would probably be pleased with the notion that his tombstone might say something like, "He played a major role eliminating gridlock in the Congress and making government function effectively." Yes, he's said he admires FDR and Reagan because they led transformations, but I interpret that as his loving the idea that he might have a central role in some historical transformation rather than that he has a vision about a particular transformation he is committed to leading. Not that any of that is bad or disappointing or that it makes him at all unique among successful politicians. I offer it only as a model for interpreting what Obama does, predicting what he will do, understanding what he really cares about, and figuring out how he can and cannot be influenced.

He's learning the hard way that he'll have to govern from the center. He turned the key pieces of his legislative agenda—health care and climate—over to liberal congressional leaders and committee chairs, and now we have a dog's breakfast on two critical issues which he'll have a very tough time turning into saleable meals.

It is a dog's breakfast, but I attribute the cause more to supermajority rules than to negotiations within the majority caucus. It seems to me that more often than not a bill that has majority support gets worse when additional votes have to be rounded up and "paid for" with watering-down amendments, earmarks, and other legislative currency. As the managers have to move further and further ideologically to pick up more votes, the price they pay is frequently to make amendments that change a reasonably coherent bill that has a good chance of doing what it proposes to do into a bill beset with crippling and even contradictory provisions that is in fact a dog's breakfast.

A recent example of that is the odyssey of the public option in the pending Senate healthcare legislation: It went from being a robust Medicare-like proposal that would truly have threatened for-profit insurers and driven down premiums to something that is in the bill only because it will be a very unattractive option available to hardly anybody—a public option in name only and probably a waste of money. Now suppose the Senate didn't need just 60 votes but 100—what would that bill have looked like? I submit that any healthcare bill that got 100 votes would be trivial or a travesty or both. Similarly, every year in the California state budget process, which requires a 2/3 majority in both houses, the concessions that have to be made to get the last vote or two are just nauseating. Building supermajorities makes legislation worse, not better. That is particularly true when there is no ideological middle in a legislative body, as I have shown here there clearly is not in the US Senate.

Let's get back to majority rule in all matters. Those who won the last election should grow a spine, take responsibility, write bills they're proud of, pass them with just enough votes, and be accountable in the next election. If they lose, let the other bunch of rascals, repeal it. That would give us clearer policy options, less internally contradictory and wasteful legislation, more personal accountability, a more engaged and informed electorate, and overall better government. Also, it would seem more propitious to run for reelection on a record that people can understand, even if they disagree with it, than to run an entire campaign wearing a dog's breakfast.

America is, quite simply, a center-right country. Many have cited polling data showing that self-described conservatives outnumber liberals 2 to 1. But that's not nearly so telling as the fact that self-identified conservatives have outnumbered liberals in every year since 1968; when combined with self-proclaimed moderates, the country is enduringly 65% to 75% moderates and conservatives.

I set out to find out if that's true and, if it is, whether one can make any useful inferences about what policies are supported and opposed by majorities of the electorate. I found it is true that self-described conservatives have outnumbered self-described liberals in every election year since at least 1970. But I found that when polled on specific policy questions likely voters were apt to skew liberal instead of conservative. In other words, respondents' self-described ideology is useless in predicting public attitudes toward specific policy issues.

The American National Election Studies, a collaboration of Stanford University and University of Michigan, has a wide array of interesting polling data from 1972 to 2004, including this on how respondents self-identify on the political spectrum. (There was no survey in 2006 and I don't have 2008 data.)

See the long term trend? Me neither. Excluding the 23-36% of respondents who said they did not know or had not thought about an answer to the question, self-described Liberals have been 18-28% of the population, self-described Conservatives 36-47%, and self-described Moderates 28-38%. There are fluctuations from year to year, but no long-term trend that I can see. Regrettably, there are no comparable data for the 1960s, when Congress gave us civil rights legislation, Medicare, the War on Poverty, and other landmark liberal programs. However, virtually the entire body of federal environmental legislation, another liberal cause, was enacted in the 1970s. So, clearly an electorate that is 37-38% Conservative and only 24-28% Liberal does not preclude very liberal activity in Congress.

And this seeming paradox was still true in 2008 and 2009, as described here on Sabato's Crystal Ball.

In the 2008 ANES, for example, 42 percent of Americans placed themselves on the conservative side of the 7-point ideology scale while only 28 percent placed themselves on the liberal side. But in the same survey, 51 percent of Americans placed themselves on the liberal side of a similar 7-point scale measuring support for government-sponsored health insurance while only 37 percent placed themselves on the conservative side. More recently, a CBS/New York Times Poll in September 2009 found that almost two-thirds of Americans supported a government-run insurance option as part of a plan to reform health care in the U.S. It is findings like this that have led some liberal political commentators to argue that the United States is now a center-left nation.

Moreover, the article reports, it wasn't just healthcare on which likely voters skewed liberal.

When asked in an October 2008 Time Magazine poll about their views on specific policy issues, however, these likely voters took the liberal side more often than they took the conservative side. On six of ten issues–abortion, health insurance, the war in Iraq, regulation of financial institutions, government assistance to homeowners threatened by foreclosure and global warming–a majority or plurality of respondents came down on the liberal side. On three issues–gay marriage, offshore drilling, and business tax cuts–a majority or plurality of respondents came down on the conservative side. On one issue, federal bailouts for financial institutions, it was not possible to identify liberal and conservative positions.

Opinions on seven of the ten policy issues were correlated strongly enough that it was possible to combine them into a liberal-conservative issues scale. The issues included in the scale were abortion, gay marriage, health insurance, offshore drilling, global warming, the war in Iraq, and regulation of financial institutions. Scores on this scale ranged from 0 for those who took the most conservative position on all seven issues to 70 for those who took the most liberal position on all seven issues. . . .

So on these issues, likely voters skewed distinctly liberal. Notice also, that the distribution of opinions seems to be roughly normal, i.e., concentrated in the middle and not polarized. To pass legislation on these issues then, it seems, Congress should craft center-left solutions—not center-right ones. Regrettably, attitudes and preferences among Members of Congress are not normally distributed but are highly polarized. Here is the bimodal distribution of Senators' 2009 votes, from this earlier post.

That's how close we are to having zero ideological overlap between Senate Republicans and Senate Democrats/Independents. Note also how far the parties' centers of gravity are from the average of all Senators (-2.63). The average Republican (-49.55) is about 47 points from the center, and the average Democrat/Independent (28.65) is about 31 points from the center. Because the center is so unpopulated it is necessary for either party to skew legislation substantial ideological distances to pick up votes from the other side--especially to overcome a filibuster.  

If Democrats wanted to pass a measure supported by all of its most progressive members, it could get the 51st vote at a +12 ranking.  On the other hand, if it needed 60 votes to end a filibuster without Republican votes, it would have to skew to minus 7 to pick up the last Democrat. Republicans wanting to add 11 Democratic/Independent votes to their united caucus would have to skew the measure to plus 12 to find a 51st vote and to plus 20 (which is coincidentally majority leader Reid's ranking) to break a filibuster.

I'm quite sure the bimodal distribution of the Senate does not reflect the distribution of voters, which I expect is a normal bell-shaped distribution--high in the middle with two tails to the extremes. If I find the ambition and the data, I'll add a chart illustrating that. Further work could also include charting the House of Representatives, using issues selected by a conservative organization, and tracking back a few decades to see if there has been increasing polarization of Congress, as some pundits say. But what I'd rather do is access this work already done by others. Please leave a comment if you can steer me toward such work.

If we can have a recovery and resume economic growth and generalized prosperity in the near future, then it behooves us to use government fiscal policy aggressively and continue to keep money cheap to stimulate a recovery as rapidly as possible. The deficit accumulated to do that will be a much better thing to leave to the next generations than several unnecessary years—or a decade, or a generation—of stagnation, high unemployment, missed opportunities for education and career-building, declining international influence, etc., etc.

On the other hand, if this is the new normal, and we can't jump start the economy to perform like it did in the late 1990s, say, and we can't avoid a long period of high unemployment, stagnant family incomes, and declining prices—in other words, a lost decade or generation—then it would be better to start making now the painful adjustments that would be required to survive long-term in that environment. In this scenario, any stimulus money would add to the deficit but would have no expansionary effect. There would be not only smaller federal, state, and local government budgets, but smaller household budgets too. Infrastructure could not be expanded, properly maintained or replaced. Investment abroad might be more profitable than here. Funding for education would continue to decline, increasing the opportunity gap between rich and poor. The safety net for society's least vulnerable would be underfunded. Social Security benefits might have to be reduced, but there would be no employer-sponsored or private replacement—people would just have less to live on when they retire, if they can afford to retire at all. Net job creation would slow and could become negative. The average age of the population would increase as immigration of younger workers slowed and perhaps reversed, exacerbating the Social Security funding problem. The professional, managerial, and small business owner class could not avoid being sucked into this downward spiral, because the vast majority of their revenues come exclusively from what the others in their class and the 5/6 of American workers who are not bosses have available to spend. Real estate and other asset values would decline, and imported goods would become more expensive.

On this cusp of history, what we assume about the future may change what actually happens, which makes a wrong choice all the more perilous. If it is possible to pull out of the Great Recession only with aggressive stimulation, then doing too little or adopting policies appropriate for long-term stagnation might well foreclose the sunny path and assure the dark one. The Obama Administration seems to have chosen not to chose—it will not propose aggressive stimulation to help end the Great Recession, and it will not propose the painful policies that would be appropriate for long-term stagnation. We wait.