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Don't confuse a plan that will score with a plan that will work


Ross Douthat's post defending Rep. Paul Ryan's health-care plan veers into some rank anti-intellectualism, which is uncommonly cheap for Douthat. The criticisms that the Economist and Jonathan Cohn are making of Ryan's plan isn't that its cost controls are are dumb while liberal cost controls are smart, and the difference between the plans isn't, as Ross would have it, that Ryan's plan will work while liberal ideas will fail. Saying that you're going to slash the generosity of Medicare benefits isn't, in any sense, guaranteed to work. A bill that works in theory but can't pass is not a bill that works. Just ask supporters of single-payer.

Douthat is confusing something that will score with something that will succeed. The difference between Ryan's proposal and a lot of other ideas is that it exchanges policy difficulties for political difficulties. It would be easy enough for liberals to bend the curve by cutting payments to insurance companies and hospitals and doctors and pharmaceutical manufacturers and device manufacturers. This, in fact, is how Jacob Hacker's EPI proposal functioned. But that bill has no chance, so they're trying very hard to create an infrastructure that, on the one hand, gets a lot better at identifying the 15% to 30% of treatments that do no good, and on the other hand, ends the incentives doctors have to always do more. You might actually be able to pass and implement that.

Will it work? Hard to say. The theory is sound, but this stuff is difficult to do. That's why CBO can't score it: No one has done it before. Conversely, CBO can score a bill that simply says "the federal government will spend less money in the future than it does in the present." And if that bill was implemented, it would probably work. But that bill won't be implemented and so it won't save any money.

I'm obviously a guy who likes radical proposals. It's why I've paid a lot of attention over the years to Wyden-Bennett, international health-care systems, and, more recently, Ryan's plan. But it's a terrible mistake to think that the people proposing the radical proposal are the ones doing the hard, intellectually rigorous, work. The people trying to pass a proposal are, in general, the ones making the tough compromises and doing their best to come to grips with the reality of the situation. It's why I've so respected Wyden's willingness to participate in this health-care reform process, even as he knows he's got a better idea in his pocket.

In his post, Ross is comparing fantasy proposals with real proposals, and that's always a mistake. The relevant comparison for Ross is between Ryan's plan and various types of single-payer proposals. I'm sure the fine folks at Physicians for a National Health Program could help him out.

Photo credit: Chip Somodevilla/Getty.

By Ezra Klein  |  February 9, 2010; 9:04 AM ET
Categories:  Health Reform  
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Shorter Ezra: If I like the plan, it can pass (even though it hasn't); If I don't, it can't pass.

Posted by: Philly213 | February 9, 2010 9:15 AM | Report abuse

Its kinda like saving up your Spermatozoa Americans for real Reese Witherspoon instead of accepting that "chunky Reese Witherspoon" is as good as its gonna get.

Posted by: flounder2 | February 9, 2010 9:28 AM | Report abuse

"A bill that works in theory but can't pass is not a bill that works."

Which is why the whole scoring of Ryan's bill is silly. A bill that privatizes Medicare and Medicaid is not going to pass. I don't think it would pass with a 98% majority in both houses. Indeed, I expect you will find the Republican's a lot more timid in their policy proposals, if and when they find themselves in the majority again.

Posted by: Kevin_Willis | February 9, 2010 9:35 AM | Report abuse

I actually think it would be funny to see the voting pattern on this. I guarantee you there would be more Democrats crossing the aisle to vote for a plan that gutted Medicare benefits than there are Republicans willing to vote for the current reform. Joe Lieberman and Ben Nelson would suddenly cease to be sticking points.

I have to kind of disagree w/ Ezra's point about passage. The fact is that the Republicans just have underlying institutional strength that Dems don't, such that Republican policies are much more likely to actually get enacted into law. I'd really like the Dems to put their house in order, but it doesn't look like it's going to happen.

Posted by: NS12345 | February 9, 2010 9:36 AM | Report abuse

How does proposing a plan that is theoretically sound but (if you say so) politically challenging possibly count as "anti-intellectual?"

Isn't the real anti-intellectualism on the part of those who, like, say, the President, pretend that there is no Republican alternative to the--um, not at all politically popular and as yet unpassed Democratic bill?

Posted by: FrBill1 | February 9, 2010 9:37 AM | Report abuse

Actually, how you can tell when Republicans have good, solid conservative policy ideas that they are trying to pass: they are lukewarm, incoherent, and cave at the first sign of opposition. Social Security Reform, for example.

When Republicans are in lockstep and gung-ho and can't be stopped, or can barely be stopped--impeachment of Bill Clinton, the Iraq war--it's probably a bad idea.

Posted by: Kevin_Willis | February 9, 2010 9:38 AM | Report abuse

I don't think Obama is pretending the Republicans don't have an alternative. Yes, the whole "party of no" thing is a political convenience (and, apparently, worked for Lyndon Johnson, as the exact same thing was said about the Republicans during the implementation of The Great Society, which was supposed to solve all our problems, and still hasn't), but Obama has acknowledged the Republicans have ideas, and the Democrats have included many Republican initiatives (some not that great to begin with, others watered down to where they are essentially neutered) in HCR.

Political hostilities don't equal anti-intellectualism. I think it's more a case of the ends justify the means.

Posted by: Kevin_Willis | February 9, 2010 9:43 AM | Report abuse

a brief browsing of the single payer plans on the pnhp website doesn't reveal any that solve our deficit problem. ezra, can you direct me to one that does?

also, how is it anti-intellectual to advocate a bill that would be good policy if passed, just because it can't pass (at the current political moment)? Remember, there's no guarantee that Ezra's favorite health care bill can pass either.

Posted by: jfcarro | February 9, 2010 9:51 AM | Report abuse

Bill: the anti-intellectualism is in suggesting that the distinction being drawn is between complicated plans, which are smart, and simple plans, which can't possibly be smart.

Posted by: Ezra Klein | February 9, 2010 10:06 AM | Report abuse

More clown ideas from the clowns that brought us a budget without numbers. Privatize social security and give people vouchers that are guaranteed not to pay for needed medical care.

This idiocy deserves no respect. They are not serious. They are dangerous clowns.

Ryan has merely dressed the clown ideas up in a spreadsheet that projects out 70 years or so. Dumb. Stupid. And as has been mentioned around here, the CBO didn't co-sign this hot mess, they just said it would work within the circus framework of Ryan's clown assumptions.

On the Other hand the PNHP single-payer proposals would work and cost less and cover more than the current Senate Bill. But thats a non-starter because it makes sense to get profit out of health-care and you just can't make that kind of sense on corporatized capitol hill.

Posted by: perhapsnot1 | February 9, 2010 10:11 AM | Report abuse

Hilariously ironic title for this post, given that you and so many others continually point to the CBO score of the Senate bill

Posted by: ab13 | February 9, 2010 10:19 AM | Report abuse

Ezra would prefer the government keep the money and decide which 70-85% of health care is worth keeping. I'd rather have 70-85% of the money and decide which health care is worth buying.

Posted by: petertuuk | February 9, 2010 10:24 AM | Report abuse

It's a freakin idea - where were the articles ripping single-payer for being a waste of time? Where is the article discussing how the CBO scored the current passed bills including the assumptions regarding only 4% increases in med. spending (out of thin air)

Posted by: Holla26 | February 9, 2010 10:27 AM | Report abuse


Got it, sorry for eliding your own point about political feasibility with the Douthat reply to Economist and Cohn. On that, though, I think Douthat is right with respect to the Economist post--it's certainly rhetorically built upon the idea that the Republican plan is crude and that the critiques of the Democratic plan are also crude (it's too long! (which is, of course, a crude point, as you've oft noted).

I agree that Cohn is making a different point, albeit while employing the simple/complicated comparison.

Anyway, correction taken as to your use of anti-intellectualism, though I think Ross's major point is basically fair: it's not quite responsive for the side defending a less fiscally responsible plan to say "but yours involves hard choices!" without revealing the hard choices necessary to make their plan more fiscally responsible in the long run. But I suppose that depends upon whether you think (for example) Groopman is correct or whether you think the "complicated" measures are worth giving a try before deciding you need either higher taxes or lower benefits.

Posted by: FrBill1 | February 9, 2010 10:30 AM | Report abuse

Douthat's fundamental argument seems to be that there just aren't enough inefficiencies in the American system for a high standard of care to be consistent with low(-ish) taxes and budget neutrality. So, according to him, there has to be pain: ever-widening deficits, tax hikes, or reduced care.

The counter, as ever, is that every other country in the civilised world manages it. It's amazing how destructive American exceptionalism has become.

Posted by: vagueofgodalming | February 9, 2010 10:48 AM | Report abuse

I missed this whole Douthat/Rep. Ryan thing, but I notice that not a few days before his plan was unveiled, this study came out in NEJM re: Medicare:

"Cost sharing and increased co-pays, even if it's just a few dollars, can lead seniors to put off visits to the doctor and result in increased hospital admissions and longer hospital stays, according to a new study."

Posted by: ThomasEN | February 9, 2010 11:11 AM | Report abuse

Although I don't support the measures in Ryan's budget, I have to firmly disagree with your entire framing.

A bill that works best in theory is what should be strived for. Passing it might require you to reframe the debate, to shift the Overton window to one direction or the other, and that takes time. But ultimately, the result is a solution that works, rather than a solution that could pass.

Real solutions take leadership. Leadership is not bending yourself to political reality, it is bending political reality to yourself. As George Bernard Shaw said, "The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man."

I don't agree with Ryan's budget, but I do respect it for it's audacity. I believe it was you who said roughly the same thing here a week or so ago. We are facing increasingly radical problems in this nation, and we've spent the entire last generation taking advice like yours, worrying about what will pass, rather than what will work. It's why our Congress hasn't passed a major piece of legislation since the '60s.

It's time to stop worrying about finding the lowest common denominator to a passing cloture vote, and instead time to start picking some fight and bloodying some noses. The American people need big solutions to the big problems, and all you need to do is look at the Democratic poll trends to see what they think about leaders who think that tinkering around the edges is enough.

Posted by: burndtdan | February 9, 2010 11:27 AM | Report abuse

This is a smart and spirited 'take' by Ezra. I like his analysis here as well as his defense.

He is right.

Those who think any plan as radical as like Ryan's plan can even get tabled, do not want to understand Politics. Looks at Wyden plan - did it get ever tabled?

What happened to Bush's radical plan of privatizing Social Security? Even Republicans themselves could not handle the heat despite Politically they being strong.

Look, GOP is the party which always wanted to crush Medicare and still could find politically so cheap to cry wolf for any minor cut in Medicare. And you want us to believe Dems will not find 'electability nirvana' in defending Medicare against Ryan's plan? What a baloney!

Folks, this is about Politics, this is about electability, this is about getting votes, this about people backing candidates who will at least try to protect what they have today when the harsh reality is that they are loosing everything else.

How many times do we have to get reminded about 'political viability' of a policy proposal trumps infinitely 'any economic credentials of policy'. Otherwise why are we having a thing called Democracy when we could have done with Technocratic rule like China?

Posted by: umesh409 | February 9, 2010 11:46 AM | Report abuse

Um, Ezra: this is a deeply ironic post, given your attachment to the EXCISE TAX.

Posted by: andgarden | February 9, 2010 12:04 PM | Report abuse

burndtdan, single payer advocates have been advocating a plan that works in theory over a plan that passes for decades. In the mean time, the status quo has gotten worse and worse. Going for a plan that can pass is to hope for small, incremental steps forward. Going for a plan that works perfectly in theory means accepting that our system doesn't do pieces of legislation like that unless and until there's a major catastrophe. Even then, it's entirely likely that the perfect plan won't pass exactly as proponets would like. It also means that you have to accept the negative aspects of the status quo getting worse over time. More people will be forced into bankruptcy by medical expenses, more people will lose their employer coverage, and more people will die from lack of insurance.

We should strive intellectually to find perfect policies and to make a perfectly functioning government that supports perfect policies. In reality though, no government functions perfectly and opposing political parties will almost always ensure that perfect policies never make it through the system without major changes.

Ezra's main point, other than the anti-intellectualism thing, was that Douthat's comparing plans that are theoretically sound but will never be law to plans that aren't perfect but have a chance to be law. A bill that will never be law does not work as its plans say it should.

Posted by: MosBen | February 9, 2010 12:21 PM | Report abuse

I think this is all silly. Twitter, Vonage, texting, blogging, kindles are all just different tools. Who cares if you use a brush or a roller to paint your walls- as long as the job gets done?
And my kindle came in very handy over this forced confinement. My kindle was charged up so when the power went out I used my battery operated book light, downloaded a brand new book called The Checklist Manifesto and happily waited for the lights to come on!

Posted by: cminmd1 | February 9, 2010 1:06 PM | Report abuse

Ryan's plan is stupid on its face. The republicans who think its a good idea to hand social security over to wall street and then give vouchers to old people that aren't worth using should not be given the time of day. It is foolish to bargain with greedy corporate fools (tools).

Please do not dignify their plan by comparing it to plans that have worked in the real world like single player.

To compare the two is a false equivalence.

Posted by: perhapsnot1 | February 9, 2010 3:03 PM | Report abuse

Thats> single-payer:

Taiwan (implemented in one year)

and various permutations including non-profits:
UK (fully govt.)

Posted by: perhapsnot1 | February 9, 2010 3:07 PM | Report abuse

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