So earlier this year I received a flu shot. Today I have the flu. What gives? I demand answers! More accurately, my wife, who finds herself today responsible for the care of a third larger, crankier, 30 year-old child with less hair, demands answers. Because I am a fun guy to talk to at parties, my failed flu shot naturally got me thinking about the topic of policy failure.
After all, a flu shot is something like a policy response. Public policies generally are created to address problems, and flu shots are merely a pre-emptive action against an annual public health problem. Perhaps flu shots even represent the way many talking heads wish public policy were made. The annual flu vaccine is not a created through a political process, but rather, according to the National Institute for Health (NIH), by a panel of experts which selects the three strands of flu to be included in the next year’s vaccine.
In other words smart technocrats gather and decide what is best for the public. Sound familiar? It’s not all that different than current calls for a non-partisan redistricting panel, or for the selection of merit-judges. As the progressive argument goes, if we could take the politics out of public policy, we would have better public policy. We need technocrats with expertise, not politicians with agendas.
I am reminded of a ridiculous book I read a few years back titled the “The New Lion of Damascus” which hailed Syrian President Bashar al-Asad as a benign technocrat merely seeking to guide Syria into the international community at a pace acceptable to its citizens. Whoops. I suppose the benign label was dropped as soon as the technocrat’s power was threatened.
The al-Asad example is extreme, but my flu-clouded point here is that solving complex policy problems is a lot harder than gathering smart caring people into a room to address a problem. I often write about urban education, a field flooded with smart caring people who cannot seem to fix urban education. Maybe politics, for all its ugliness and incivility, serves the vital function of slowing down the policy process so that one group of experts’ one-best way is not unilaterally imposed on those who happen to disagree.
Which brings me back to my ineffectual flu shot. Seems the experts got it wrong. Should we overhaul the process, hold hearings, and demand accountability? Perhaps I should run for Congress on a platform of better flu vaccines. Or, perhaps, I should thank the technocrats at the NIH for annually crafting flu vaccines that have helped me avoid the flu for 29 of the 30 years of my existence. Or, perhaps, I should just go back to bed.
Since the US Supreme Court afforded states the right to forgo Medicaid expansion under the Affordable Care Act, without losing all of its federal funding, many Republican governors have exercised their right—at least rhetorically—to opt out of such expansion. While the Supreme Court’s decision on the Affordable Care Act (hereinafter the ACA) allowed the federal government to place strings on money it gives to states as part of Congress’ spending power, affirming precedent from South Dakota v. Dole, inter alia, the Court ruled that the federal government cannot tie existing funds to Medicaid expansion. Only additional Medicaid fundingincurred by expansion under the ACA can be subject to revocation, since past attachments were “relatively mild encouragements” consonant with the judicial test of coercion. In other words, the Federal government maintained its carrot to coerce, but lost its stick. “So although the Obama Administration lost on this issue, it’s probably a loss that it is willing to live with for now, as few states (if any) are ultimately expected to turn down the new Medicaid money, even with the strings,” writes Amy Howe of SCOTUSblog.com. The prevailing thought was that only insensate ideological zeal would move a governor to turn down such an offer. However, as we move past the Court’s decision and thus gain critical distance from it, is this really the case?
Providing Medicaid coverage for virtually all poor and middle-income Americans—up to 133% of the federal poverty line—under the age of sixty-five is a significant expansion from what the federal government requires currently. Under Medicaid, states design their own programs within bounds established by federal regulations, with the federal government paying for a large share of the expenses. Although the formula is complicated, the more a state spends, generally, the more the federal government contributes—with diminishing returns to prevent abuse. Thus, with the goal of providing near-universal healthcare coverage under the Medicaid formula utilized currently, politically conservative states stand squarely in the center of Congress’ approach, since they can expand for cheaper at the margins than a generous, liberal state (which covers more of its citizens). Congress’ approach “was essentially to make Red America an offer it couldn’t refuse.” That offer was an agreement by the federal government to front 90% of the expenses under the new scheme.
But in recent days, Democratic governors have joined the Republican chorus by expressing misgivings about Medicaid expansion vis-à-vis their state budget projections (though of course the former have done so less vociferously). Governor Dave Heineman of Nebraska said pointedly that his cash-strapped state had no room for such expansion—it was a stark choice between funding the state’s flagship higher education institution, the University of Nebraska, or Medicaid expansion, and he preferred unequivocally the former. Many governors think it prudent to wait until after the election in November 2012 to render a decision on Medicaid expansion, given Mitt Romney’s commitment to repealing and replacing the ACA. Yet, how do we explain the concurrence of recent Democratic suspicion regarding Medicaid expansion? It is difficult to tell whether this is simply another consequence of election year politics and the unwillingness to be linked with an unpopular sitting President. The fact that Democratic governors have bemoaned Medicaid expansion quietly, however, appears to indicate something else is at work.
The answer, I believe, is no secret: governors understand the unknowable factor in this situation is the rising rate in healthcare costs, expected to continue to rise through the decade (with the ACA doing little to curb cost and possibly contributing to rising costs). Thus, the federal government’s promise to pay 90% of the bill may seem tepid and unpersuasive in the face of rising costs. What is more, it may seem ineffectual to use Medicaid as a means of achieving universal coverage, given its reputation for stingy reimbursements to providers may result in a lack of coverage or poor coverage for those utilizing it. There are also further logistical questions impeding a governor’s decision on Medicaid expansion: does a state that opts in have the option to opt out later, should its budget swell? Do states that chose to opt-in late still receive the 90% guarantee from the federal government? May a state chose to participate partially, for instance, by cutting the qualifications for subsidization somewhere lower than 133% of the federal poverty line? These questions will dominate the meeting of the National Governors Association, commencing this weekend in Williamsburg, VA. For now, the great irony is that the reason Democrats in the House and Senate chose Medicaid as the vehicle of healthcare expansion—the issue of cost, specifically, to earn a lower cost analysis for the ACA from the Congressional Budget Office—may drive governors of both political parties to forgo Medicaid expansion and instead invent new ways of expanding coverage through existing state programs.
The polite warning quoted in the title to this entry is in reference to healthcare obligations threatening the budgets of local governments. The quote comes from Wisconsin Taxpayer’s Alliance President Todd Berry at the end of a Journal Sentinel story touting the strength of Wisconsin’s state pension system.
First, the main subject of the story is worth celebrating. By all accounts, the WRS has been well managed by government. The health of the Wisconsin Retirement System (WRS) gives our state a competitive advantage over states with significant unfunded pension obligations.
But, as Berry alludes, unfunded healthcare obligations still need to be addressed to ensure the future quality of local government. The reason is straightforward, as I detailed earlier this week (and as WPRI has detailed repeatedly) growing health care costs reduce the amount of revenue available for basic services.
In school districts this means fewer resources are available for things like teacher salaries. In cities and counties this means fewer resources for garbage pick-up, parks, transportation, libraries, public art, public health and any number of services that contribute to the quality of life of a place.
Call me a big-government advocate, but local government in particular has a role far greater than simply creating a social safety net; people want to live in place where government is responsive to the basic needs of residents. The ability of government to fulfill that role is being diminished annually by cost pressures (most notably retiree health insurance) that are totally unrelated to service delivery.
There is no one perfect answer and the public certainly has an obligation to fulfill promises made to public employees. However, there needs to be a long-term solution or the quality of local government services will erode. The necessary first step is talking about the problem openly and honestly.
George Wagner brings out the old “What’s the matter with Kansas” argument in today’s Milwaukee Journal Sentinel. For those unfamiliar, “What’s the matter with Kansas” was a book written in 2004 by Thomas Frank that argued Kansas residents supported Republicans despite it being against their economic interest. The implication is that Kansas conservatives are ignorant and/or being distracted by social issues.
Wagner applies the sprit of the argument to income inequality, citing a finding that Americans, “even traditional Republican constituencies,” support a more equal income distribution. Yet, Americans somehow do not support raising taxes on CEOs. Why? Wagner says the reason is ignorance, writing: “most Americans believe that wealth distribution is a lot more equal than it actually is.”
I agree with Wagner that growing income inequality is a potential problem. Data from the Department of Revenue indicates that between 1996 and 2009 the percentage of all Wisconsin tax filers with annual incomes between $20,000 and $70,000 has decreased from 43% to 40% while the percentage of all filers with incomes above $200,000 increased from 0.78% to 1.71%. To the extent that is attributable to an inequality of opportunity, it is troubling.
However, it is not clear why a higher percentage of Wisconsinites are earning more than $200,000 today than in 1996. More wealthy Wisconsin residents can be viewed as a positive, especially given that the percentage of total state tax revenue being collected from filers earning over $200,000 annually has increased from 14.9% to 25.3% between 1996 and 2009. More importantly, the increase in wealthy Wisconsin residents is certainly not the reason that 46% of Milwaukee children are impoverished, as Wagner alludes. Increasing taxes on the rich, a solution that Wagner argues Americans are too ignorant to support, will not in and of itself decrease poverty.
I’ll call this the housing project principal, based on that well-meaning urban policy failure. People needed better housing, so cities built public housing projects. It solved the immediate problem facing the homeless and those with inadequate housing, but did nothing to address the myriad of social issues of which a lack of adequate housing was the most obvious symptom. Yes, poverty is a lack of income, but it is so much more. Simply taking money from the wealthy and giving it to the poor does not address urban education failures, infant mortality, inadequate health-care, crime, or any other of the social problems that are also symptoms and causes of poverty.
Growing income inequality is a problem if it means that the United States is no longer an egalitarian society where everyone has a chance at success. One of the reasons I blog so often on urban education is that addressing policy failures in that arena is necessary for our society to get closer to true equality of opportunity. The discomfort I and others have with proposals to simply soak the rich comes not from ignorance, but a desire to enable success rather than punish it.
While there are a few websites out there dedicated to fact-checking Wisconsin political ads (including Charlie Sykes’ “Politicrap,” to which I have contributed), it’s hard to catch all the ads that are circling the airwaves. In fact, a good campaign will keep the accusations flying, so that by the time someone can actually test their veracity, it seems like old news.
But there’s one accusation that caught my eye in the past few days that needs some attention. An ad run by the Greater Wisconsin Committee (funded with $1 million of Governor Jim Doyle’s campaign money) claims that Scott Walker once voted to “deny women mammograms,” and to “cancel” their policies.
The source cited by the ad is Assembly Amendment 15 to Assembly Amendment 2 to Assembly Substitute Amendment 1 to Assembly Bill 133, which is the state budget bill from 1999. (Technically, Walker voted to “table,” the Amendment, not against it – but that’s neither here nor there.)
This vote was part of the kabuki dance that goes on with every state budget. A caucus (in this case, Assembly Republicans) gets together and agrees to their version of the budget. When their negotiated agreement comes to the floor, the minority party (in this case, Assembly Democrats) offers dozens, if not hundreds, of amendments to the budget package – knowing full well that none of them will pass. The purpose of offering them is solely for campaign season, so they can use them against members of the majority party. (Who knew they’d keep this one in their back pocket for 11 years to use against Walker?) Oddly, nobody in the state media considers the hours they spend taking these votes to be “campaign activity,” when, in fact, these votes exist only to hammer lawmakers in political ads.
To show this is a bipartisan phenomenon, take the 2009-11 budget bill deliberations. When 2009 AB 75 (the budget bill) came to the floor, Republicans offered over 120 amendments. One by one, the Democratic majority tabled them. So each Democrat voted “against” those amendments in the same way Scott Walker voted “against” mammograms.
As someone who’s run campaigns in the past, I know there’s a hierarchy of attacks you can make against an opponent – if you have something really good, you use it the best way you can. If you have something that’s semi-good, you twist it to make it as good as you can. And if you have nothing on your opponent, you use one of these obscure, castoff budget votes.
But let’s look at what Scott Walker voted “against.”
In the 1999 budget, Assembly Republicans sought to include a provision that would have helped small businesses purchase affordable health care for their employees (see page 128 of the amendment here.) The “Private Employer Health Care Purchasing Alliance,” as it was called, would have had the Wisconsin Insurance Commissioner solicit bids from plans that wanted to take part in the program. If an employer took part in the program, the employer was required to offer health insurance to any employee that worked more than 30 hours per week – and pay for between 50% to 100% of those employees’ health care premiums.
However, in order to provide more flexible plans to keep costs down, some of the plans were allowed exemptions from state-imposed mandates. For instance, every health plan in Wisconsin must carry coverage for chiropractic service – which adds cost to health plans. Mammograms are another state mandate, and health plans were allowed to take part that did not cover them.
However – and this is important – plans offered by employers had to include at least one plan with the full complement of state mandates. From page 132 of the bill, line 22:
The department shall ensure that at least one health care coverage plan includes all of the coverages specified in subd. 2. (the list of mandates.)
What the bill attempted to do was to keep costs down by offering flexibility within plans. If you are a young, healthy, male, you wouldn’t be forced to buy a plan that makes you pay for mammograms. If you’re a female who’s never taken a drink of alcohol, you wouldn’t be forced to pay extra for a plan that covers services for alcoholism. And if you didn’t want to pay for a chiropractor, you wouldn’t have to. Although legislative Democrats purport to want to keep health costs down, every mandate they add raises the cost of health insurance.
However, the bill ensured that if you did want coverage for all these things, there would be a plan available to you through your employer. (If your employer didn’t take part in the program, you’d have to purchase health care just like you do now – but with the full complement of expensive mandates.) The amendment Walker voted to table would have moved many of these procedures back into the “mandated” category – but his vote didn’t deny mammogram coverage to a single woman in Wisconsin. In fact, if the program were to be administered correctly, it would ensure that many more women received better health care through their employer for a lower price.
I’m sure you all remember the Simpson’s episode “Sweets and Sour Marge.” For those that need reminding, though, this is the episode where the Town of Springfield attempts to set a world record for tallest human pyramid, but ends up setting a record for the fattest town in the U.S.
After they make it into the world records, Marge Simpson, concerned about the health of her community, goes on a crusade against the sugar company and ultimately succeeds in getting sugar products banned from Springfield. It seems that the government remembers this episode quite well, for upon the release of the “Healthiest Wisconsin 2020” report by the state health department, the department suggests that local governments begin to regulate the sales of fast food by creating zoning laws that limit the density of fast food restaurants.
Seems like the perfect solution, right? Remove the temptation, and cure the habit. But what about just pushing the temptation another ten miles down the road? And what if there are substitutes for the habit, namely the calorie-packed junk food that can be found in the traditional grocery store? Well in that case, kicking the habit must rely on a conscious decision rather than the inability to attain the desired substance.
There is a deeper issue with the proposal at hand as well. That is the question of who is to make the decision about what we do and do not allow in our neighborhoods and on our dinner tables. Historically, this was never even a question. Now, however, enough people have found themselves seeking help with this decision and even burdening the rest of society with the consequences of their choices that we contemplate turning to government action to regulate everyone’s options.
For some, though, eating fast food is not a health decision, but an economic one. Wisconsin Public Radio recently hosted a discussion on childhood hunger in the United States that mentioned how fast food can be the only option for some families, as National Public Radio’s Pam Fessler explains:
“And a lot of people who are poor and who do struggle with food issues do tend to be overweight. And one reason is that some of the food that’s available to them is and costs less – happens to be higher calorie, more processed. They might have less access to fresh fruits and vegetables. And as a result, some of them do tend to be overweight or that they just aren’t educated to know what food is better for them…if somebody is hungry, you might be trying as a parent to fill up that child with extra calories so that they won’t complain about being hungry.”
Getting rid of the McDonald’s still does not remove the true problem. When a family cannot afford alternatives, they must just travel further to find what is affordable. The report’s recommendation of making food stamps more widely accepted at farmers’ markets also falls short of solving this problem. Many of the products at farmers’ markets, especially organic meats and dairy products, are more expensive than the ones you would find at the grocery store.
The best solutions to obesity as a result of poverty are food pantries, and to a greater extent, soup kitchens that do not have to rely as heavily on non-perishable goods.
Indeed, the community is in the best position to watch out for the health of its members. Initiative by individuals to start soup kitchens, organize recreational activities, and exercise concern for the family meals has the greatest potential to be the preventative measures that are needed in health care. Local governments can enhance these by organizing active parks and recreations divisions or encouraging strong health and physical education curriculum, but they need not set society’s choices for them.
After Springfield’s ban on sugar, a smuggling operation springs up to bring sugar into the city. Once exposed, rather than punishing the smugglers, the citizens of Springfield realize that they truly want the freedom to consume unhealthy foods, so they reverse their decision and legalize sugar. Ultimately, Marge Simpson learns that providing the resources for people to make good decisions can be far more effective than eliminating the bad decision. Though the Healthiest Wisconsin 2020 report merely poses suggestions for local governments, many of which could be beneficial, it must be careful not to cross the line between allowing citizens to function at their best and babysitting them.
My new commentary is up over at the mothership; it attempts to draw a parallel between Congressman Paul Ryan’s attempts to repeal the new health care law with former Wisconsin Senator John J. Blaine’s successful attempts to repeal prohibition in 1932. (Although, as the last paragraph points out, prohibition prevented individuals from doing something they wanted to do - drink – while the current health care bill forces many people to do something they don’t want to do – purchase health insurance.)
In my research for the piece, I ran across an awesome old Milwaukee Sentinel column from 1932 by a man named Gunnar Mickelsen, who vigorously defended the benefits of drinking. And it may not even fit in well with my column, but it was too awesome to leave out. I couldn’t help myself. Here’s his logic for why drinking is necessary to society:
“Now, it is our theory that Milwaukee was happy because it talked. The urge to hold conversation, to communicate ideas and experiences is one of man’s major motivations. It is behind most of his endeavors and his works. Deprive him of the privilege to talk and you rob him in no small measure of his ambition to do.
What use are actions if he can’t talk about them later? The man’s ego who is satisfied at the mere doing, without telling others or hearing their praise or criticism, is a rare fellow. The happiest persons are those who have something to say, know how to say it, and are given the opportunity to do so.
Beer and wine make for conversation. There is in liquors of mild alcoholic persuasion that which quickens the flow of the thoughts in a man’s cranium, loosens a notch the belt about his reticence, and releases upon his tongue the fruits of his meditations. It is for precisely this reason that men have resorted to alcoholic drinks as a means to make their companionship more vivid and happy.”
There you have it – people only do important things so they can brag to friends about them. And liquor makes people talk more. Ergo, without alcohol, nobody would really do anything, since they wouldn’t be able to boast about what they did. Simple as that.
I, personally, think it’s air-tight. In fact, I had a couple beers just now, so I could brag to you about my column. Only reason I wrote it, really.
Filed under: Health Care — Christian Schneider @ 7:38 am
It was at 10:37 on Sunday night that Speaker of the House Nancy Pelosi announced the big health care bill had passed. (Boy, is she going to be surprised when she finds out what’s in it.) As the Speaker banged the gavel to close the proceedings, a cheer went up, and Democrats could be seen on C-Span awkwardly hi-fiving each other.
Yet the Democrats within the walls of the House chambers on March 21st may be the only ones celebrating. In living rooms all over America, state and local Democratic lawmakers likely swallowed hard when the final vote finished. That sound you heard at 10:37 wasn’t Pelosi banging the gavel – it was the sound of Tom Barrett, Jim Sullivan, Pat Kreitlow, and Kathleen Vinehout dropping a couple of Filet-o-Fish in their shorts.
Americans are busy people. They’re busy raising their families. They’re busy working. They hunt, they fish, and they read books. (Apparently the only thing none of them do is watch The Marriage Ref.) In the time they allot for paying attention to politics, they really can only pay attention to the large national debates of the time. Few of them can name their governor. Fewer still can name their state representatives and senators. As a result, state Democrats may pay dearly at the polls for what their federal masters hath wrought.
We’ve seen it before, and only a couple years ago. In 2006, Wisconsinites were fed up with the war in Iraq – and Republicans at the state level paid a heavy price (despite 80% of Wisconsin lawmakers being unable to find “the Iraq” on a map.) The lengthy and unpopular war sent people flooding to the polls to vote against Republicans, costing the GOP four state senate seats and dropping them into an 18-15 minority. The Assembly, which once had an almost insurmountable GOP majority, lost in the neighborhood of 10 seats in 2006 – holding on to a slim majority that they eventually relinquished two years later.
Our polling at WPRI shows that there’s still plenty of time for the GOP to screw their Wisconsin legislative races up – but it appears that despite not taking a single vote on ObamaCare, Democrats in swing districts may get swept up in the anti-health care tidal wave. In this respect, ObamaCare will be like the Democrats’ Iraq – a historic overreach that angers the electorate to the point where they defenestrate the majority party.
Some of these Democrats in swing districts have already smartly tried to distance themselves from the federal health care bill. Democratic senator Pat Kreitlow took a break from his windbaggery to co-sponsor a bill allowing for a tax credit for Health Savings Accounts (HSAs), a concept previously anathema to legislative Democrats. (I can’t wait to hear his fellow Democrats lambaste him for “only wanting to help the rich,” as they’ve done to Republicans for a decade for supporting HSAs.) Kreitlow’s approach marks a stark contrast to the remainder of the Democratic Senate, which a couple of years ago actually tried to sneak in a state health plan that managed to be much worse than ObamaCare.
(Oh yeah, remember the “Healthy Wisconsin” single payer health plan? The one that was SO important Senate Democrats had to sneak it in to the state budget with one day’s notice? The one that we’re all supposed to pretend never happened? In some odd way, state Democrats may have been saved by their own incompetence – had “Healthy Wisconsin” passed, we’d probably be looking at a State Senate in which Republicans outnumbered Democrats 32 to 1. (Madison will continue to elect Fred Risser’s democratic brain in a jar for 100 years after his death.)
So while Democrats at the federal level may have delivered themselves a “victory,” they may have also delivered their colleagues at the state level a death blow. Their “courageous” vote (note: in most cases, taking bribes in order to vote for a bill is criminal – President Obama has now deemed it “courageous”) may now deliver the states the same thing Ted Kennedy delivered to Massachusetts – more Republicans.
Oh, and a final note – I wrote a whole post without making the inevitable “health care is bad medicine for the Democrats” joke. Although I guess I just did.
Filed under: Health Care — Christian Schneider @ 1:26 pm
Ahhh, yes – we all remember the summer of 2009 as if it were yesterday. Politics was still full of Hope and Change. People argued about issues, and not back-waxing or naked intimidation. When we said Tiger Woods was “on the prowl,” we were talking about golf. (SIDE NOTE: How “Naked Intimidation” hasn’t already been used as the title for a late-night Cinemax movie is beyond me.)
In the Wisconsin Legislature, 2009 brought a new state legislature – and with it, a slew of new tax hikes. In order to fill a $6 billion budget hole, the Senate and Assembly approved a new $300 million tax on hospitals, which was supposed to draw down more federal matching money. Republicans roundly condemned this much-publicized “sick tax,” as they called it – pointing out that the tax will just be passed on to consumers, at the same time the legislature was complaining about the high cost of health care. (Under the plan, the new federal matching money would be directed to hospitals with high levels of Medicaid caseloads.) The GOP was actually successful in having a similar plan removed from the 2007-09 budget bill, but it was finally enacted in 2009 Act 2.
One would think that would end the debate about the “sick tax” – but as observers of the legislature know, if elected officials find a tax that the public can stomach, they will bleed it dry. (For example, a single pack of cigarettes will soon cost more than an iron lung.)
That is why a new “sick tax” is quietly working its way through the legislature. Under the original plan, “critical access,” or mostly rural, hospitals were exempt from the tax. Under Assembly Bill 770, that exemption would be gone – and these hospitals would have to begin paying the tax. According to a hospital lobbyist handout sent to legislators, the tax would collect $10.5 million in taxes, $4.6 million of which would go to the MA trust fund. The remaining roughly $6 million would be used to draw down $11 million in federal matching aid. So, in exchange for accepting a $10.5 million tax hike (which they just pass on to patients anyway), the hospitals reap $17 million in payments. To hospitals, it looks like free money.
On March 5th, the bill passed an Assembly committee by a 7-2 vote, with one Republican supporting it. It now makes its way to the Joint Finance Committee.
The problem with this bill is, of course, that it does nothing to address the real problem in health care – the growing cost of care. Instead, it merely raises taxes to fund those increasing costs. Furthermore, it builds in additional state costs with the promise of more federal aid. If that aid dries up, the state is on the hook for the rest. (Someone should ask Jim Doyle how his recent attempts at getting federal funds is going.)
What’s perhaps most troublesome is that this bill, while being rushed through while no one is looking, doesn’t appear to have significant Republican opposition. In fact, three Republican senators (Olsen, Lasee, and Schultz) and a handful of GOP representatives (Ballweg, Bies, Murtha, Spanbauer, Townsend) are actually co-authors of the bill. These Republicans are all rural, and likely believe this new tax will be a boon for their hospitals.
But if Republicans are counting on 2010 to be a big year for the party, they should be extremely careful about lining up to support tax increases to prop up unsustainable spending levels.