I admit to having groupie tendencies and team loyalties. The liability of being committed to a favorite entertainer, author, philosophy, religion, type of music, or team is that each is bound to have its problems, inconsistencies, or failures and then those shortcomings can become confusing or disorienting to the fan or follower. At best you are profoundly disappointed and vulnerable to becoming a cynic when the object of your devotion fails you. I can give you plenty of examples of how I suffer from my loyalties in ways that go way beyond the misery of the moment, as I suffer through the woes of the current Red Sox.
A good example of the downside to fandom is my long term commitment to Garrison Keillor and his Prairie Home Companion weekly radio show on NPR. The show began in 1974, but I was slow to catch on. By 1981 I was recording every show, every Saturday evening, on two hour cassette tapes, and listening to them over and over again on my clunky Sony Walkman on my daily runs. If my wife and I were to be out at six PM on a Saturday evening, the babysitter’s most significant responsibility was to start the tape on time, and turn it over at the intermission. Failure to do so had its consequences for both the babysitter and me. I even recorded the reruns, or the Sunday rebroadcast hoping to make up for babysitter and other technical errors. I always hoped the “second take” of a rerun might be of better quality.
I was not surprised when Garrison recorded his “final” show in June of 1987. I could see it coming as I “read between the lines” in his weekly “News From Lake Wobegon” monologues. I listened to the replacement show, “Good Evening” with Noah Adams, but it never did fill the bill for me like Garrison did with his urbane knowledge disguised by humor, poetry, musical guests, skits with a political point, and humorous monologues that were essentially about the way we all struggle with the adaptive changes the world forces us to individually and collectively experience. Garrison was, is, an unabashed liberal Democrat, and for a long time that, plus the facts that he was just a year or so older than me, so talented, and had become so familiar to me, made him feel like a wise and worldly older brother. I was a fawning fan. He could do no wrong, and what he implied became my point of view also.
You can imagine my delight when he returned to the radio in a tentative fashion in 1989, and then full time in 1993 until 2016. Despite the fact that by the time Garrison finally retired, most of the shows from the mid eighties forward were available on line, I continued to do my weekly recordings until the end. I now have hundreds of those tapes. I guess that I should mention that I also bought T shirts, sweat shirts, all of his books, CDs, attended live performances when possible, and still occasionally listen to his little daily piece, “The Writer’s Almanac.” You can imagine my despair when Garrison was controversially fingered in the “Me Too” movement for ill defined abusive behavior against at least one of his employees. Tom Ashbrook of “On Point” and Senator Al Franken were two of my other heroes who turned out to have feet of clay.
As you might have noticed from the frequent references to his podcasts, my latest hero, and emotional replacement for Garrison Keillor as a frequent companion whom I enjoy via podcast which I frequently hear on my walks, is Ezra Klein, one of the founders of Vox and an incredible writer and podcaster. Klein is younger than three of my sons, and just as I sometimes have trouble following the flow of their conversations, I sometimes don’t quite connect or follow where Klein is going with an idea. He sees connections that I frequently don’t get. In both circumstances, with my sons and with Ezra, I tap into the Internet and repair the deficiency in my fund of knowledge that their casual, but informed, conversation has revealed. Like Garrison’s show, Klein’s podcasts are long, rarely less than an hour and twenty minutes and some are over two hours, so I can match my walk to the conversation he is offering. Klein speaks and writes with a clarity that I admire. Whereas most of us know a fair amount about what interests us, and almost nothing about most everything else. Klein seems to have an in depth knowledge of almost everything, which makes him the perfect guy to do a political and cultural podcast, especially when he picks the people that he interviews.
This last week he interviewed Matt Bruenig, a policy writer from the far left. He is a Social Democrat who worked in Ralph Nader’s political campaign in 2008, and is a fan of Bernie Sanders and Elizabeth Warren. Bruenig is a guy who seems to be able to get into arguments with almost everyone, including those on his own side. He founded the online opinion magazine, the “People’s Policy Project”, and is now a staunch defender of Medicare-For-All. What better person to get into a discussion with a true liberal? Klein, who is sensitive to history, revels in the craft of policy formation, and is a student of what really can make things happen in a world where the Earth gets hotter every day as it circles the Sun under an atmosphere with rising levels of CO2, and is populated by human beings that have opinions that are often illogical as well as contradictory.
I hope that if you care about fully understanding the healthcare issues before us you will listen to their conversation. I was not far into the podcast when I began to think of the discussion about the animosity between liberals and the far left in Adam Gopnik’s little book, A Thousand Small Sanities: The Moral Adventure of Liberalism. In a chapter entitled “Why the Left Hates Liberalism,” Gopnik points out that the far left, like the far right, is willing to be illiberal, or if you prefer somewhat authoritarian, in order to shape the world the way they want it to be, and they are frustrated by liberals who insist on process and the incrementalism it produces. The far left does not see much room for compromise, and has very little patience for a deliberative process in achieving “what ought to be,” or more specifically “what they think out to be.” It doesn’t take but a few minutes of listening to Klein and Bruenig to see and understand the validity of Gopnik’s point. In fact, the difference between liberals and the far left is the whole story behind the schism in the Democratic Party right now. There is an intense argument between those who want to immediately move to Medicare For All and those who are trying to imagine a coexistence with, or at least a more orderly migration from, employer sponsored commercial coverage. In their debate both Klein and Bruenig score points. Klein uses Bruenig as a foil to reinforce what he has written about a more moderate concept he favors from the Center for American Progress, Medicare Extra.
As I thought about this debate and my current “groupie” relationship with Klein, I was reminded of two other recent Klein podcasts that I must confess to having heard that have partially framed my thinking. One is with Elizabeth Bruenig, Washington Post columnist and wife of Matt, and the other was with Adam Gopnik, and that podcast was the reason that I read his book. Many people do not realize how the gradations left of center create more than differences in opinion about policy. There are huge differences in preferred processes, and philosophy, as well that create the tension in the conversations between Klein and Matt and Elizabeth Bruening, or as Klein says in the introduction to his Conversation with Elizabeth Bruenig:
Sometimes, arguments that are framed as deep ideological disagreements seem to actually be about differing political judgments about what public and political institutions will permit. But perhaps those political judgments are just ideology posing as pragmatism.
He could have said exactly the same thing before the conversation with Matt Bruenig. What he did say in his introduction to Elizabeth’s husband was a very nice set up along the lines that I have tried to describe:
The Democratic primary has been unexpectedly dominated by a single question: Will you abolish private health insurance?
Wrapped in that question are dozens more. Why, if private health insurance is such a mess, do polls show most Americans want to keep it? What lessons should we take from the failure of past efforts at health reform? What does it mean to say “if you like your health insurance plan, you can keep it?”
Matt Bruenig, the founder of the People’s Policy Project, is firmly in support of true single-payer. No compromise, no chaser. He’s frustrated by those, like me, who try to work around the public’s resistance to disruptive change, who treat past failures and current polls as predictions about the future. And, in turn, I’m often frustrated by Matt’s tendency, mirrored by many on the left, to treat people with similar goals but different theories of reform as villains and shills.
In this podcast, Matt and I hash it out. The questions here are deep ones. When are political constraints real, and when are they invented by the people asserting their existence? If you already believe the political system is broken and corrupt, how can you entrust it to take over American health care? Can you cleave policy from politics? What would the ideal health care system look like, and why?
That was a very brave introduction by Klein, and both men are good debaters and make a valiant effort to fulfill the promise. They also treat each other with respect and usually allow the other to complete his thoughts without interrupting before speaking. That curtesy alone is welcome change. If you have already devoted a couple of hours to the Democratic debates, or as I have, more than four hours, with a sense that you might have been wasting your time, I promise you that theirs is a more informative discussion than the jousting between Sanders, Warren, and possibly Harris on one side, and most of the others on the other side. If you care about the future of healthcare and the next election, this podcast is a better investment of your time.
If you would prefer to read rather than listen, I am going to try to summarize their individual positions, so read on. I would also refer you to recent articles that each has written which together are shorter than my commentary. Klein’s article, “Why aren’t voters more willing to abandon a health system that’s failing?: Medicare-for-all needs a better answer to the public’s fears,” was published in late July before the conversation was aired, but after it was recorded. The Bruening article, “People Lose Their Employer-Sponsored Insurance Constantly,” was published last April.
Key to understanding a significant part of the conversation is familiarity with the concept of Overton’s Window and the assertion that Bernie Sanders’ “Medicare For All” has moved that window significantly to the left in the conversation between the Democratic candidates for the presidency, and possibly in the minds of a majority of American voters. Chris Weigant published an opinion piece in the Huffington Post in September of 2017 that has a nice description of the Overton Window plus the assertion that Bernie Sanders had moved it, like it or not. The reality is that without Medicare For All we would probably be debating the ACA versus tweaks to the ACA. Since Sanders has captured the imagination of so much of the public, we are debating a public option or Medicare For Those Who Want It, versus a single payer system that abolishes employer sponsored commercial health insurance. That is a big deal. Here is Weigant’s explanation of the Overton Window.
Joseph Overton came up with this concept to describe how there is a “window” in politics of what is considered politically viable. He posits a spectrum of ideas between “more free” and “less free” to describe government’s role, which he intentionally placed on a vertical axis to avoid the inevitable “left/right” comparisons. Since it was introduced, however, the concept has indeed been adopted to the left/right, liberal/conservative political spectrum. But whether you’re talking up or down, or left or right, the basic concept remains pretty easy to grasp.
The spectrum’s center is labeled “policy.” This is where current policy exists on any subject. Moving away from the center, in both directions, is a scale of viability:
- Policy
- Popular
- Sensible
- Acceptable
- Radical
- Unthinkable
New ideas move from the outer edge of the scale (unthinkable) to the center, if they turn out to be successful politically.
Bernie Sanders’ Medicare For All has pulled the conversation on healthcare reform so far to the left that issues like insurability despite pre existing conditions, and keeping young adults on the family policy until age 26 are almost “settled law.” Bernie has also made the concept of “healthcare as a right” almost as generally accepted as public education or free speech. The “window” has moved and healthcare “as a right” is not debatable among Democrats. We now debate how to best do it, not whether we should do it.
Bruenig’s recurrent argument throughout the conversation was that without someone like Sanders on the far left pulling the center of the conversation toward real progress, it would never move, and we would still be in an old and limited conversation. Klein’s recurrent point is that without attention to politics, policy is just a discussion that goes nowhere.
The most significant new idea that made their conversation, and the papers cited above, interesting is a fuller discussion of how the more market oriented, conservative, elements kowtow to the center as expressed by polls, and bend the truth in the latest iteration of “if you like your current health plan you can keep it.”
They review how the “framing” of the presentation of Medicare For All is important. Both acknowledge that Medicare For All presented as an abstract idea gets thumbs up from a majority of people. If you add that Medicare For All will increase taxes on many middle class individuals, and for most employers, the number who like it goes down to around 50%, or a little less. If you add that Medicare For All will raise taxes and do away with your employer sponsored insurance plan then only around 40% of people still want it. Those realities make a difference to Klein and the majority of the Democratic presidential candidates.
I chose the header for today with care. If you look closely you will see in the bottom left corner a sign that says “End Corporate Control of Healthcare.” That’s Bruenig’s point. He makes a very good argument that if your employer is paying for your health insurance, it is constantly changing and you have more than a 25% chance of losing it. That is called “churning.” In essence he accuses Democrats and Republicans who hide this fact from the public of lying, or at the least, of making a deceptive presentation when they allow people to feel safe with their current program. His argument is that only a federal program that treats everyone the same is both stable and equitable, and that any other system will always be changing more than a government sponsored system. Furthermore, a two tiered system that allows the wealthy to buy better care, will always disadvantage the poor.
Klein pushes back on the instability of employer financed healthcare in his paper more effectively than he did in the podcast. Perhaps he had some time to get his thoughts together. In the paper he divides “churning” into two separate categories and accuses Bruenig of mixing them into one entity. It’s a bit wonky, but here is what he says:
The key idea in Bruenig’s argument is something experts call “insurance churn.” Importantly, though, the term is being used to refer to two different things:
- Researchers use insurance churn to refer to any change in health insurance plans. If I lose my job and become uninsured, that’s churn. If my employer switches insurance providers, that’s churn. If I move from my current job and insurance coverage to another job with a different insurance plan, that’s churn. And so on.
- In punditry, though, people will often simplify churn to the question of losing and gaining health insurance. In this meaning, it’s not churn if my employer switches coverage providers, but it is if my employer fires me and I become uninsured.
You can see the way one definition slides into the other in Bruenig’s post. For most of the analysis, he’s using the first, more technical, definition of churn. He relies on a study of insurance churn in Michigan, for instance, to write:
Among those who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months. This means that 28 percent of people on an employer plan were not on that same plan 1 year later. You like your employer health plan? You better cross your fingers because 1 in 4 people on employer plans will come off their plan in the next 12 months.
The study he’s referencing found that “Ninety-four percent of respondents with employer-sponsored plans maintained coverage continuously all year.” The lower, 72 percent number includes data showing that “16 percent directly switched to a different employer-sponsored plan and 6 percent gained coverage through either an individually purchased plan, Medicaid, or Medicare.” So that’s the first type of churn, which includes changes to the plans people use, not just changes to whether people are insured or not.
But at the end, when Bruenig says that Medicare-for-all is “a seamless system where people do not constantly churn on and off of insurance,” he’s quietly switching to the second definition of churn.
I have looked at Bruenig’s presentation from April, and my take is that Klein is right, but so what? The insight that is new is that whether or not you are getting insurance from your employer or from the government, you are vulnerable to change, but no one ever presents the instability of employer based insurance as a problem. The shifting of cost to consumers, and the overall cost of healthcare, are also at least partly related to self serving decisions of corporations, but those sorts of abuses seem to go unchallenged compared to any shifts associated with an expanded role of government as a payer. Our debaters spend a lot of time agreeing that if perchance the Democrats do gain the presidency and both houses of congress, and somehow pass Medicare For All sometime in the next four years, it will experience the same assaults that the ACA has experienced from those who have any change in their coverage, whether it is the result of the new law or the choice of their employer. They also agree that the moment Republicans regain control of the government, there would be attempts to roll back the gains. Uncertainty in coverage, cost, and benefits will remain a problem for us all, and we should always be on guard for qualifications in the fine print, or disappointment in the experience, when we hear, “If you like your insurance plan you can keep it.” Most people distrust the government. Bruenig says we should also distrust our employers who have their interests, and not ours, as their central concern. What is implied is that more of the failings of the current system are attributable to employers and insurers taking care of their own interests rather than yours. Klein continues in some agreement with Bruenig’s point:
The core insight here is real: So long as a third party is providing your health insurance, you don’t have full control of its future. You may like the health plan your employer provides now, but they could change that plan, or you could change jobs, or be laid off. The problem is that point applies to public insurance too.
I am sure that I will be returning to this and similar discussions in future posts. The subject is complicated as noted by President Trump in his famous statement about healthcare when he said either, “Nobody knew that healthcare could be so complicated.”, or “Who knew healthcare was so complicated?” Based on some interesting exchanges between the two near the end of their conversation, I am not sure that either Klein or Bruenig understand the difference between Medicare “wrap around” products and the variety of offerings under the title of Medicare Advantage, but then many physicians don’t either. We all have a lot to learn.
