Category Archives: Public Policy and Governance

Food, Water, Air and Government

Okay. Sunday sermon time.

For the past 30+ years, self-described “small government” conservatives have waged a propaganda war on the legitimacy of the state. While that war has rarely been as explicit as Grover Norquist’s famous threat to make government “small enough to drown in a bathtub,” or as intentional as the campaign I blogged about yesterday, the constant focus has been on what government does badly and the constant refrain has been that “we don’t need no stinkin’ government telling us to [fill in the blank].

Let’s stipulate that, yes, there are many things government at all levels does badly, and yes, we need to monitor its operations and correct its mistakes. Yes, there are good forms of government and oppressive forms, and thoughtful citizens should opt for—and attempt to institute— the former. But that is very different from the irresponsible attacks on the very existence of established political authority.

The shock that has accompanied the water crisis in Flint, Michigan demonstrates the extent to which even the most anti-government among us depend upon a well-functioning bureaucracy—not to mention the extent to which ill-considered ideological decision-making poses a very real threat to the well-being of citizens. (Especially citizens who lack the means to remove themselves from the polity and retreat into privileged enclaves where they can pay for clean water and other “amenities.”)

There’s a lot that might be said about Flint’s situation, and a lot of blame to go around, but  the lesson to be learned goes well beyond the idiocy of “penny wise, pound foolish,” stubbornly ideological policies, or even official misconduct.

America is no longer a country of family farmers and small merchants scattered along the eastern seacoast. The overwhelming majority of Americans no longer grow and preserve our own food or draw our water from a pristine nearby creek. Cars and factories discharge pollutants into our air, airplanes criss-cross the skies, and we live in densely populated cities where—among other things— we can’t just toss our garbage out the back door. The list is endless.

American citizens are utterly dependent on the institutions of government to provide services we cannot effectively or efficiently provide for ourselves. We expect government to assign air lanes so our planes don’t crash into each other, to inspect the foods we buy at the local grocery so we don’t get ill, to prevent the local factory from discharging its toxic waste into our waterways so we don’t drink contaminants, and much more.

The private sector cannot protect even the richest gated communities from polluted air.

There are certainly areas of our communal life where government need not and should not intervene. Debates about the necessity and/or propriety of programs and initiatives is entirely appropriate, as is criticism of poor performance of government agencies or officials.

But.

When self-serving political rhetoric encourages our dimmer citizens to fear a “government invasion” of Texas, when the slightest effort to curtail gun violence sets off hysterical accusations of “confiscation,” when loony-tunes cowboys try to “take back” land held in trust for the benefit of all citizens, when efforts to ensure equal treatment of the nation’s more marginalized groups is rejected by zealots who claim exemption from the laws of the land “because God,” we have not only weakened the bonds of citizenship, we have endangered our own safety and well-being.

If we don’t retreat from our bipolar “government bad/private good” approach to complicated issues, there will be a lot more people drinking brown, lead-filled water and breathing toxic air.

Among other things.

Playing with Fire

Every once in a while, I read something that makes me want to pound my head against the nearest wall.

A few days ago, this was the “something.”

The article addressed the dogged determination with which Republicans in Congress have opposed any and every proposal coming out of the Obama White House–even, as we have seen, proposals that had originally been theirs.

That strategy was eventually articulated publicly by former Republican Congressional staffer Mike Lofgren.

A couple of years ago, a Republican committee staff director told me candidly (and proudly) what the method was to all this obstruction and disruption. Should Republicans succeed in obstructing the Senate from doing its job, it would further lower Congress’s generic favorability rating among the American people. By sabotaging the reputation of an institution of government, the party that is programmatically against government would come out the relative winner.

…There are tens of millions of low-information voters who hardly know which party controls which branch of government, let alone which party is pursuing a particular legislative tactic. These voters’ confusion over who did what allows them to form the conclusion that “they are all crooks,” and that “government is no good,” further leading them to think, “a plague on both your houses” and “the parties are like two kids in a school yard.” This ill-informed public cynicism, in its turn, further intensifies the long-term decline in public trust in government that has been taking place since the early 1960s – a distrust that has been stoked by Republican rhetoric at every turn.

I know this is an era of exceptionally strong partisanship. I also know that both parties routinely engage in behaviors that do not serve the common good.

But I also know–and there is ample research confirming—that trust in the enterprise of government is absolutely essential to the operation of that government. To deliberately undermine popular belief that government as an institution is both necessary and (in the main) beneficial is to intentionally destroy its ability to function.

Accountability is important. No one in her right mind would suggest that every government program is well-run (or even necessary), or that every government official is a wonderful person devoid of self-serving motives, or that we should turn a blind eye to ethical and legal transgressions. We need to identify and correct the very real problems that exist. But with all its imperfections, with all its opportunities for mischief, the American administrative state has served us well.

Making governance impossible in order to gain political advantage so that you can ultimately control  the institution you have neutered is rather obviously short-sighted.

If true, it is also–and I use the term advisedly–evil.

 

Political Gamesmanship from Indiana’s Governor?

As regular readers know, I posted a critical review of Governor Pence’s “State of the State” address. I certainly wasn’t alone–editorial writers and columnists around the state panned the presentation.

Critics focused particularly on the Governor’s unwillingness to endorse civil rights protections for LGBT Hoosiers, and his declaration that he “would not sign” a bill he considered insufficiently protective of religious liberty.  Like most critics of that pronouncement, I assumed that the lack of specifics–the Governor certainly didn’t say what provisions he would or would not accept–was tantamount to a veto threat.

We may be wrong—but not for reasons that are particularly comforting to those on either side of this debate.

Over the past two days, in separate conversations, people with broad political experience observing Indiana government have parsed the Governor’s language and arrived at a different conclusion. They point out that what Pence said was “I will not sign a bill…” He did not say “I will veto a bill.” Under Indiana law, the two are not the same thing.

In Indiana, when the state legislature passes a bill and sends it to the Governor,  there are three actions that Governor can take: 1)he can sign the bill, after which it becomes law; 2) he can veto the bill and send it back to lawmakers, who can then sustain or override the veto;  or 3) he can allow the bill to become law without his signature.

Politically, as everyone has pointed out, Pence is between a rock and hard place. His reelection prospects are utterly dependent upon the loyalty of his base of “Christian Soldiers.” He cannot afford to lose them, and they will leave at the slightest sign that Pence is softening his stance against equal rights for LGBT Hoosiers (and that would include any statement suggesting that he might allow an expansion of civil rights to become law).

Unfortunately for Pence, the number of these religious warriors is steadily declining, so he also needs significant support from the business wing of the Republican Party— and the business community is virtually unanimous in its support for civil rights expansion.

As the Democrats have pointed out (almost daily), Pence spent some 175 days avoiding taking a position—desperately trying to placate those on either side of the issue.

As one of the lawyers I talked with observed, the “non-position” communicated to the legislature in Pence’s State of the State address had two possible interpretations: 1) please don’t send me anything that will force me to decide what to do; or 2) if you send me a bill, I won’t sign it–but I won’t veto it, either. It will become law without my explicit endorsement.

The carefully noncommittal framing of the Governor’s statement in the State of the State was even more cowardly than it appeared in the moment, because it allows people on both sides to believe that he shares their concerns–that he is “with them.”

Disingenuous as it may have been, however, it gives some small measure of hope to those of us who want to see genuine civil rights protections for LGBT Hoosiers enacted in Indiana.

The State of the Governor

So–I poured a stiff drink and listened to Mike Pence deliver (his version of) the “State of the State.”

The word “smarmy” comes to mind.

There is much that might be said about this particular effort to put lipstick on a pig–the state he described is not one I recognized, nor the state that widely available data describes.  (My son, with whom I was watching, asked what grade I would give a student whose assignment was to deliver an accurate assessment of Indiana’s economic and social well-being and utterly failed to do so.)

There were some truly cringeworthy moments. The Governor, you may be surprised to learn, is “honored to be the Commander in Chief” of Indiana’s National Guard. At the conclusion of the forced, wooden speech—a pastiche of talking points and trite adages that met with dutiful but definitely not enthusiastic applause—he declaimed several lines from  “On the Banks of the Wabash.”

The part of the speech that the entire state was waiting for—the Governor’s position on extending state civil rights protections to LGBT Hoosiers—came at the end, and the Governor’s discomfort was palpable.

Pence assured everyone that he had “prayed” about the issue. (Clearly he hadn’t thought about it—but then, nothing in the speech gave evidence of much thought.) He reprised his “Hoosiers are good people who don’t discriminate” mantra and then engaged in a rambling discourse about the importance of religious liberty.

Bottom line: he won’t sign a bill that deprives religious folks of their ability to act on their beliefs everywhere—including at work.

There are two rather obvious responses to that declaration, one legal and one political.

First, the Constitution protects citizens’ right to believe anything. Full stop. It does not, however, protect an untrammeled right to act on the basis of religious doctrine. If my sincerely held religious belief requires me to sacrifice my first-born, or take drugs, or murder abortion doctors, or cheat nonbelievers, the government has the right to step in and say “too far.”

People of good will can disagree about the specific rules that are necessary to a fair and functioning society, but the Constitutions of the United States and Indiana have never been interpreted to privilege socially harmful behaviors simply because those behaviors are religiously motivated.

Second—and here, I admit to more than a bit of shadenfreude—Governor Pence has wedged himself firmly between a political rock and hard place.

The religious extremists who have always been his base will desert him in a heartbeat if he signs any bill that, in their eyes, “legitimizes” LGBT Hoosiers. Meanwhile, polls confirm that a solid majority of Indiana voters support adding “four words and a comma” to the state’s civil rights statute. And given this administration’s other blunders—its unremitting war on public education and  Glenda Ritz, the proposed “news bureau,” the lack of attention to Indiana’s crumbling infrastructure, etcetera etcetera—Pence simply does not have political capital sufficient to weather widespread disapproval of this particular culture war battle.

The wooden and forced delivery of last night’s platitudes suggests that the reality of his position is beginning to dawn on our “Christian soldier” Governor.

 

 

 

Medicare for All

I’ve been interested to see how frequently the comments to this blog end up discussing (and debating) America’s health care system–even when the ostensible subject of that day’s post is something entirely different.

(As I was typing the phrase “healthcare system,” I was reminded of a graduate student—a hospital administrator—who corrected my use of that term. “America doesn’t have a healhcare system,” he said. “We have a healthcare industry” and it’s not the same thing.)

I often share insights from my cousin, a respected cardiologist who also spent many years teaching medicine. He recently sent me a thoughtful analysis of that healthcare industry, and the prospects for fixing what everyone realizes is unsustainable. I particularly like his introduction to the issue:

When considering the best way to solve our country’s medical care woes, I am reminded of Churchill’s famous statement about democracy as a form of government, in which he stated in effect: It’s a terrible system, but everything else is worse. This same statement might apply to a single payer system in medical care, for it probably beats everything else, as I explain below.

He noted that a truly effective system will require cost controls, including tort reform, the excessively high cost of drugs, inappropriate use of expensive tests and treatments, and several others. He is convinced that these issues can be resolved, and that a single-payer system (for example, “Medicare for All”) is both inevitable and the best solution:

In an article on why a single-payer system would be our best solution, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been “a step forward for the country,” it “does not deal with the problem of waste and complexity in the system,” as he feels a single-payer system would. I can personally attest to the complexity of the system with the many headaches provided by a dizzying array of differing insurance forms pertaining to treatments, hospital admissions and a multitude of other issues.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book Talking About SINGLE PAYER!, argued that a single-payer system is “a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.” Of course, as he pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. (Maybe these same workers could be involved in more productive work such as restoring our nation’s wobbly infrastructure!) But Dr Burdick also maintains that a single payer system would likely restore doctors’ authority. And those who favor this system say that for all practices, administrative costs would plummet because there would be only one set of payment rules and forms, with the result that prior authorizations, narrow networks, and out-of-pocket payments would be eliminated.

He also reports that there is growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.

Interestingly, a majority of the population (51%) now supports Medicare for all, according to a national poll released this past year.

In reality, a government-run single-payer system is the only way to provide effective basic medical health therapy and management, but for those who desire a higher level of care—and can afford it—there should be a private-pay system, contrast with the Canadian system. This would, de facto, constitute a two-tiered system. This might be objectionable to egalitarians that wish to have a “one size fits all” system, but would be the most pragmatic approach.

Usually those against single payer system trot out the usual vague objections that we are becoming “socialistic.” But what about our current Medicare system, is that not socialistic? I might add further that I personally have worked at a VA hospital, and, despite all the current noise, found that once patients were able to access the system, the care is quite good. Its main problem seems to be gaining initial entry into an overburdened system in a timely manner. By contrast, it is highly unlikely that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of our veterans.

His conclusion–with which I concur:

Whether we like it or not, basic healthcare is like a utility—something everyone needs, and, in the best interest of our society, everyone should receive. Although there are many variations of the general theme as I have enumerated above, we are moving inevitably toward a single payer system. When it finally arrives, I believe everyone will be relieved, if not pleased, even including the Republicans!