The cries and whispers of liberals
Alan Brinkley
Good Friday morning, Fellow Seekers.
It's been a tough week to be a liberal and/or an Obama believer. Professor Alan Brinkley of Columbia University is both, and also a leading historian of U.S. liberalism. So it was timely and slightly painful that Brinkley happened to be speaking at the Humphrey Institute yesterday. His presentation was lightly historical, with references to U.S. presidents from FDR to the present. But mostly, Brinkley laid out his thinking about the current Obama moment, one year into the term. Listening to him, I had an overwhelming sense that he was channeling the pain and confusion of liberals in the post-Coakley moment. Here were some of his comments:
If health care fails, it could lead to "a real unravling" of the already fragile Obama administration, Brinkley said.
The parallels to the 1993-94 moment, when Bill Clinton had to pull down his ambitious health care bill because it was going nowhere in Congress and was unpopular and confusing to the country, are strong. The Dems got clobbered in the 1994 midterms, losing control of the House. One can imagine that the Dems are on a trajectory to lose their congressional majorities in 2010 and that Obama will be defeated for reelectionin 2012, which Brinkley views as "almost too grim to imagine." Clinton recovered sufficiently to be reelected, but gave up on the more ambitious elements of his agenda. Will Obama also have to scale back his ambitions?
Brinkley describes himself as a big Obama admirer, but he can't help expressing the many mistakes he believes Obama has made or is in danger of making. The economic stimulus package was much too small and poorly designed, with way too much middle-income tax relief and not nearly enough aid to state and local governments and big public works projects, which is the most effective way to quickly reduce unemployment. Brinkley doesn't consider the current recovery a recovery. "Healthly banks surrounded by struggling families is not a recovery." "Just because the stock market is going up, it's not a recovery unless unemployment is coming down."
Obama needs to ignore the calls of deficit hawks (he mentioned Peter Peterson by name) and forget about restraining spending until the recovery is real. FDR in 1937 listened to the fiscal conservatives in his circle and tried to balance the budget, setting off a severe new recession. Unemployment, which dropped steadily during Roosevelt's first term thanks to government spending, shot back up. (Full disclosure: I am a debt-and-deficit hawk myself and worry about this approach. Brinkley does not.)
A few of Brinkley's other recommendations to Obama:
- Don't get totally preoccuped with health care. Go after strong financial system reforms. (The recent bad economy was "entirely created by reckless and irresponsible speculation." No serious reform is now in sight and the the determination to bring it about is declining.
- Embrace real populism. (I gather this means don't shy away from seriously calling out the entrenched economic interests.) During his 1936 reelection effort, Brinkley said, FDR employed such strong denunciations of the plutocrats that opposed his program that Roosevelt's own advisors were shocked and worried. But that year, he won the biggest landslide in U.S. history up to that point.
- Don't tolerate the filibuster. There's no practical way to do away with it (as I said in my filibuster piece yesterday). But "no administration should submit tamely to the idea that you need 60 votes to do anything," Brinkley said. The Dems have to fight back, perhaps by forcing the Repubs to actually conduct an old-fashioned filibuster, where you talk all night. (I've been hearing this a lot lately, but I fear it may be a liberal fantasy that Republicans would be embarrassed by this. They are not ashamed of the arguments they have been making against the health care bill, and they seem to be winning the argument.)
- "Be less like JFK and more like LBJ." I gather this means less aloof and eloquent, more ruthless and effective. Obama, Brinkley said, seems to naturally see himself as the level-headed conciliator, bringing two sides together to find an outcome acceptable to both. But he needs to understand that the Repubs won't play that way. They are out to defeat his agenda, not improve it. "It's the time to fight," Brinkley said. But populism and fighting are apparently "not in his termperment."
What think?
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Comments (44)
Where were the tea-baggers when Reagan, Bush and Shrub were tripling the debt as a percentage of GDP from 30% to 90%.
Here's two reasons why voters feel bad. They're told all is well but know it is not. The federal government keeps changing the way it keeps its statistics. If they used the same standard they used in the 90s, then our unemployment rate would be 21% not the 10% they say now, and inflation would be growing at 9.7% not the 2.4% they say today. The citizens feel this, it is a basic pocketbook issue.
There is an opening for liberals and democrats to take advantage of the seething anger of the common man. Yesterday's SCOTUS ruling should be rousing the sleeping populists and taking them to the streets. The Court has basically decided that corporate interests are as important as the people's interests. It is time for the people to set things right & refocus the government on what it is supposed to be: of, by and for the people. This is what the TEA people are doing; and while I think they're misguided, they are rousing support from people that don't necessarily agree with their ideology. It is time for the liberals to start going after the voters that are mad as hell & inspire them to stop taking it sitting down.
"They are out to defeat his agenda, not improve it." This is entirely correct. No matter how rational the arguments, every change that takes form those who have, to give those who have not, will be met with resistance that is either guile or force.
I have the simple answer for distressed elected liberals: Try remembering that you are not there simple to promote your own agenda, but to represent the thinking of your constituents.
If this were to happen, the current health care bills would be scrapped, and much smaller bills that address the concerns of their constituents would find a bipartisan embrace. And we would all benefit.
Big bills only provide cover of the kind of pandering to special interests that these health care bills abundantly illustrate -- which is why they are so popular in congress.
For example, a bill that simply bans insurance companies from dropping clients who get sick would be almost impossible for the insurance lobby to defeat.
Or a bill that simply prohibits them from using demographics to slice and dice the population into micro groups so they can apply discriminatory pricing would solve most of the current rate problems. No "red zones" allowed, as in real estate loans.
After all, insurance is SUPPOSED to be sharing the risk by all, to reduce the risk for one, and shrinking the "all" to allow lower prices for some defeats the very purpose of it.
Of course, it might cause unemployment issues for some nerds, but they could go back to marketing surveys for retail sales where they would not do so much harm.
And for ivory tower idealogues who believe they "just did not get their ideas out", it may be time to realize that sometimes their ideas are just so much "pie in the sky" baloney.
And the man in the street may not understand what they say, but he has a pretty good feel for baloney.
Our founders suffered from the fond notion that what the educated class thought was best for us was likely to actually be best for us.
Fortunately, they formed a government structure that forced that thinking to bu subjected to the will and boots on the ground thinking of the common man. We would be in pretty bad shape if all the ideas that float through academe became every day reality. We suffer from that enough as it is.
Very good article Mr. Black your format here is so much more interesting than at the old strib. Please use a different headline your editor or whoever writes the headlines has caused me a few cringe moments. Pain and confusion don't exist here yet. I do not think this historian has had a hand in governing but his gut instincts and head are probably better than mine. I think healthcare is still #1 and that we have to allow the republicans to filibuster and then govern anyway. Republicans don't get embarrassed, they drink highly caffinated drinks and take prozac not the best thing for a democracy, I'm sorry but I think bachmann needs full disclosure urinalysis and all. And honestly I don't mean this disrespectfully allow others to speak. But coalese dems coalese. not easy I know.
It's time for the Democrats to put Dennis Kuccinich up at the podium. It is someone like him that can connect to those in the US who are angry. Here in MN, we should be putting Tommy Rukavina up in front of the audiences to rally people.
The GOP is just so much better at opportunistic messaging. It was not long ago that they attacked the Democrats as the angry party. Democrats did not embrace that image. Now the GOP has harnessed that anger in the Tea Party movement. They make it cool to be angry.
Why wouldn't people be angry? Through the Bush years, the government was inept and the corporate culture was corrupt. So far, unfortunately, we went for the hopeful candidate. Let's hope for a better message at the State of the Union. Unfortunately, the GOP will be prepared with an attack message before he even speaks. If he stays the course, they will attack that as ignoring the will of the people. If he strikes out in a different direction, Obama will be attacked as pandering and insincere.
At least we avoided Edwards as our candidate!
John Iacono writes
"After all, insurance is SUPPOSED to be sharing the risk by all, to reduce the risk for one, and shrinking the "all" to allow lower prices for some defeats the very purpose of it."
That understanding of insurance seems to support one of the 'baloney' ideas near & dear to so many liberals: universal insurance coverage. The best way to share the risk over the broadest pool is to put everyone in the same pool.
That liberals are poor at constructing the arguments in favor of such a program does not make the idea 'baloney'.
I think it's great that the world is finally coming around to what I've been saying for a year and a half to two years on the economy. I wish I'd been listened to more, but what's one lonely blog out in the wilderness, eh?
It's good to be a trendsetter, but I hope we can all see that we have a lot of work to do. Keynsianism isn't a permanent solution - it only buys us time. We've wasted a lot of time but we can still get at it.
Restructuring is painful, but we can do it and provide needed jobs now. It's the only way out for the long haul. Are you finally with me, DFL?
To the President - with all due respect..
Lead, already!
To our Senators -- what is it that you don't understand about 59-41 being a majority? So the Republicans threaten to or actually dofilibuster? So what?
Pass the two items that will benefit the most people on health care (pre-exisiting conditions/no "red zones" and "no drop" if you get sick). Premiums will have to be means-tested and the industry will adapt to survive.
Then, move on to the economy. We do not have a sustainable recovery yet. Too many people are underemployed or unemployed. Do a few things to get money flowing to businesses that can put people to work (infrastructure?).
Lead. Do. Now.
Brian Simon says “That understanding of insurance seems to support one of the 'baloney' ideas near & dear to so many liberals: universal insurance coverage. The best way to share the risk over the broadest pool is to put everyone in the same pool.”
Brian, exactly what do you think universal coverage MEANS?
John E Iacono
So elected representatives are supposed to do what their constituents want. Name a single Republican Senator who is currently putting his constituents above the Republican political goal of just beating on Obama. You can’t because there isn’t one. NOT A SINGLE ONE.
Let’s look at some of the things Republicans did the last time they were in charge and let’s examine how many of those are things their constituents wanted. Privatizing Social Security, lying to the public to start a war, torturing people in the country’s name, debating Terri Schiavo’s life for political gain, letting millions suffer in Katrina.
In all honesty, both people push their political goals. But when the Republican goal is to do ABSOLUTELY NOTHING. ZERO. It really isn’t a level playing field.
Mr. Iacono, the Republicans aren't going to vote for any health care reform. You're not gonna any bipartisan plans, just stalling. At the end of the day the Republicans just don't believe there's really a problem the government should address aside from protecting corporations from lawsuits.
I think it important to examine the notion of "fail" when it comes to health care reform. I think some Democrats are deluded into believing that passing something define success, it doesn't. Whatever they pass has to actually work, and whey they've got in front of them at this point won't work. It won't provide universal, affordable, health coverage. So the problem for Obama here is really huge, he's in a lose lose situation. He got into by failing to lead as Diane points out. He had a plan when was campaigning, what happened to it? He gets into office and suddenly he's got no plan, he'll just sign whatever congress comes up with. That was never going to be a success whether it passed or not. I honestly think he'd be better off letting this bill die, or even vetoing it if it does pass. He should then come back swinging for a single payer system, it's simple, sells itself, and would actually work. He could hit congress over the head for producing the same old same old and get back on the populist wagon of real change. He could say they had their chance and blew it, now it's time for a different approach. Even if this bill (or worse a watered down one) passes it's not going to do the Democrats, the country, or Obama any good. The only problem with Mr. Iacono's smaller bill approach it that congress never passes water tight bills. Even if they did pass a bill that say prohibited denials for existing conditions or cancellations, it would be so full of loopholes insurance companies would drive trucks through it for years, I suspect that's what going to happen anyways.
Gregory Stricherz asks
"Brian, exactly what do you think universal coverage MEANS?"
Gregory, please see Mr Iacono's earlier posts for the full context.
#12-Jeremy:
Because I state the dem are not listening to the people does not mean I believe the repubs did better when they had power. I think they should listen, too, and in the cse of health care I think they are.
On the points:
>Privatizing social security - they did not pass it.
>Lying to the public about war - liberal attempts to make this case notwithstanding (Goebbels: "Tell a big lie often enough and people will believe it") we all know that the claim about wmd's was based on faulty intelligence, not on "lying to the public."
>Torturing people... - one man's "torture" is another man's "enhanced interrogation". Either way, naming it does not make it so.
>Debating TS's life... - just because one may not agree does not make another's sincere convictions simple maneuvers "for political gain" unless one is sipping beers with one's political buddies.
>Letting millions suffer in Katrina -- this one really stumps me. It's as if you can completely ignore the disruptive roles of incompetent dems who led the state and caused much of the failure by their failure to act promptly, decisively and effectively when they easily could have, and who impeded FEMA efforts for political gain. Not that FEMA is blameless, but they were most emphatically not alone in the mess.
>"Republican goal is to do ABSOLUTELY NOTHING" -- apparently, like many to the left, you have turned a deaf ear to the constant efforts of repubs to get a hearing for their valid ideas for health care reform, before an arrogant majority. The LAST thing they want is to do absolutely nothing. They just want to do different things than the majority wants. It is the majority that will have it their way or no way.
#13-Paul U:
Perhaps you are right that repubs will not vote for ANY health care reform, but I believe otherwise.
I suspect that a bill to limit jury awards in medical malpractice cases to $250,000 beyond the actual damages would get more repub votes than dem votes.
I believe that any bill that tackles MEANINGFULLY any one of the broadly agreed upon abuses by the insurance industry would attract repub support.
I agree that loopholes are a problem, but believe smaller bills would limit them.
I may be mistaken. We'll soon see, I suspect.
//The LAST thing they want is to do absolutely nothing. They just want to do different things than the majority wants. It is the majority that will have it their way or no way.
Yeah Jeremy, have you forgotten already? Remember all those huge attempts the Republicans made to pass health care reform during the Bush/Cheney era? I mean those guys practically killed themselves trying to get something done but the Democrats just blocked em at every turn! And now all they want to do is work together and still the Democrats just won't play nice. It's a dirty rotten shame I tell ya. Look at Bachmann, all she does is bend over backwards to accommodate the Democrats and they just cruelly rebuff her every time. Crazy man.
John e, then why didn't it get done, why did citizens vote for the dems, why do you always dream so small and ineffective. Oh I know trial lawyers and academia are the root of all evil. Even with implementing your baby steps we'd have major probs. Bush I (God bless him) passed some good bills. Bush II passed many but he seemed most concerned with passing a deficit onto the american people (who cut the tax rate and then went golfing,biking or whatever aerobic exercise he did)
John I.
I'm curious, do you really the Republicans would vote for a law that requires insurance companies take all comers who pay the premium regardless of preexisting conditions? And what about a law prohibiting them from canceling any policy or denying payments for anything other than lapsed policies or outright criminal fraud? How bout a law that limits anyone's out of pocket expenses for health care to $10,000 or less depending on household income? How bout a cap on premiums?
By the way, do you really that a 20 year old who's a quadriplegic for life because of a Doctor's malpractice is only entitled to $250,000? That won't even pay for one year of care let alone a lifetime of care. Of course if we had a national health plan that paid for care in any event you wouldn't need to sue a Doctor, but that's another story.
John I: "...we all know that the claim about wmd's was based on false intelligence, not lying to the public." No, sir. See the Downing Street Memo, in which the Brits discussed invading Iraq and learned that the intelligence was being "fixed" to match the desire to attack.
Torture is defined in the United Nation's convention to which we affixed our signature. We DID torture beyond any doubt, no matter what Dick Cheney might say.
Letting New Orleans suffer. Do you not recall that people with cars were able to leave before the levee broke, after which trains stopped running and the school buses were all under water. People without transportion (poor people) were herded into the football stadium, where they went without foot or water for about five days. Other people died on the street, shot by overly-zealous cops (Blackwater guys, many of them), or from untreated medical conditions like diabetes.
FEMA's leader was more worried about how his jacket looked on TV than about New Orleans, and didn't even know people had been shoveled into the SuperDome.
Far from this being the state's/city's fault, Washington refused to let New Orleans and Louisiana handle reconstruction lest there might be "corruption." Instead, FEMA spent untold billions on trailers that stank of formaldehyde and on reconstruction contractors like Halliburton/KBR who, instead of hiring local construction firms and workers, imported poor workers from Latin America, housed them in truck trailers, and paid them slave wages. Which they were able to get away with by calling the "independent contractors."
How quickly the true history of events like this get lost. How sad that some New Orleanians are still without homes, although I think we can bet that the corporations hired by FEMA did really well.
Eric B: Several years ago I read (and can't at the moment remember where) of a study showing that every Republican president from Nixon's second term on had grown the deficit faster than the economy, while every Democrat grew the economy faster than the deficit - thus wiping out the deficit while making our country stronger.
Paul U (#19):
Minor point: most tort reform proposals distinguish between punitive judgments (which would be capped) and compensation for loss, such as lost future earnings or medical care costs in your example, which would not be.
It's interesting that most of the discussion here is the usual Dem vs. Repub stuff. While the Repubs obviously benefited from Senator-elect Brown's election, with all due respect, this was not a pro-Republican outcome so much as an anti-incumbent (anti- current leadership) outcome. It was the Independents who elected Brown - the same voters who voted for Obama just over a year ago.
Republicans ought not to get too cocky. The Independents have shown the willingness and the ability to give any politician of any stripe the heave-ho, they'll turn against Republicans again if they don't come up with new ideas and solutions. Independents are generally in favor of fiscal restraint, but also support liberal social policies. They're concerned about the public debt and don't want to pile more onto it, but they believe basic human needs should be met. Above all, they want their representatives - and the President - to pay attention to them and take care of their pressing needs, and right now that is jobs and the economy.
By the same token, Dems need to take heed. If they appear to be out of touch with the Independents, they will be tossed aside en-masse next fall and Obama will face a hostile Congress and likely a one term presidency. I was delighted with Obama's election, but I too have been frustrated with his leadership style on his big issues - the failure to sell his plan to the American people, the back room deals by the leadership, the kowtowing to financial and health care special interests. I have to give all that a poor grade. As Diane said, he needs to step up and lead! And yes, less cerebral oratory and conciliation and more LBJ style strong-arming is in order. But pay close attention to the populist mood and address, directly, the pain people are feeling now, or suffer the consequences of ignoring it.
It's a shame there isn't a viable 3rd party, one not in the pockets of the lobbyists. Whatever one might think of Jesse Ventura's time as governor, his greatest failure was that he didn't use his personal success to help build a viable 3rd party here in Minnesota. He had the opportunity, but he was unwilling to the do the heavy lifting to build a party to leave as a legacy. It was all about him, and that is just a shame. We could use that 3rd alternative now.
You guys crack me up. The MinnPost writers, all liberals, go into hiding the day after MA's latest tea party, letting the CSM write all the stories about the big day. Eric follows up with a whiny (albeit interesting) story bemoaning the filibuster. Now he follows up with another woe-are-the-liberals article that starts a therapy session for liberal commenters.
Gee, how about looking at this subject from the point of view of the winners? Or from the point of view of the game changers ("independent" voters)? Why is it always the point of view of the liberals, whether they're winners or losers? Yeah, we know why, but I'm just sayin' ...
And you're all banging the same drum you always bang whenever things don't go your way: "We didn't communicate so people could understand." In other words, "We're a lot smarter than the people who disagree with us. If only they could be taught."
The numbers don't lie. In just 15 months, liberals go from winning solidly with Obama to losing reliably blue states. The swing among "independent" voters has been HUGE in VA, NJ and MA! Obama is personally popular, but his ideas (liberal ideas) are quite unpopular.
A 50-year-old man who works for me came in today and said, "I have voted for both parties over the years, but I usually vote for the Democrats, and I voted for Obama. But I really don't like that the Democrats today just seem set on having the government take over everything."
Read what Peggy Noonan wrote in the WSJ today. She's always got a good sense of the pulse of the country, regardless of which way it's leaning.
http://online.wsj.com/article/declarations.html
Regarding torts,
In practice I don't think it's quite so easy to separate damages from punitive amounts in terms of arriving at a fair compensation. If corporations know it will only cost them $250,000 to damage people and the environment they'll just pay their money and take their chances. Most judgments are reduced on appeal anyways. In health care, malpractice suits and insurance account for less than 2% of spending, so even if you eliminated malpractice entirely it would have a negligible effect on the health care economy, but a huge effect on individuals who have been injured by malpractice.
This reminds of a story my dad tells about a guy he used to know. Not a popular guy, not well liked. Got punched out one day by someone and went to the city prosecutor demanding charges be filed. The prosecutor (now this was maybe 50 years ago) told the guy: "well, if you want I'll charge him, but the fine for simple assault is only about $25.00. Frankly, if the word gets out that it only costs $25.00 to punch you out, people may line up around the block, you may want to think about that".
Bernice-nice post.
If tort reform was that important to the GOP (also, don't forget that all important selling health care insurance across state lines), they should have promoted those items as areas of compromise so that we could have a public option.
The biggest joke is when the GOP attacks the Democrats for reining in costs for Medicare. The GOP as a defender of Medicare!! And they get away with it! Darn liberal media!!
It's amazing to see Helpless Harry essentially concede to Mr. McConnell and the Republicans who now apparently control the U.S. Senate with a 41 to 59 majority.
While I won't totally agree with Mr. Johnson, he is fundamentally correct in the sense that the House passed a lot of bills that went over to the Senate and languished. And this pile continues to grow.
If the Democrats lose their majorities in one or both chambers in November (and it is a good chance), it is not going to be a result of what they did...it is going to be a result of what they did not do.
CROOKED TIMBER had a good post in praise of humility since saturday is the lord's day.
1) The democrats need to be more humble not unlike the unarrogant republicans (hope we got it rite)
2)The democracts need to abandon the scorched earth politics which the noble, self sacrificing enlightened republicans never use.
3)The democrats need to abandon the GLBT lobby. In MASS. opposition to Obama's "queering coupledom" rose to 90% when voters were informed that state officials would dissolve existing heterosexual sanctified marriages and reassign husbands and wives to state sanctioned same sex marriages by inner city bathhouses.
4)Obama nationalized the baks and froze global assets even coldier and all we got was a lousy unemployment check.
Thank you, Bill C.
Al J: I believe that independent voters who saw the damage done by eight years or more of market fundamentalism joined with Democrats to elect Obama.
Both groups may have been showing their disappointment with the industry-written-and-pleasing Senate health care bill (that closely matches the Massachusetts plan in that it will achieve neither cost reductions or universality) and essentially voted Republican in protest.
I hope sincerely that the Obama administration recognizes a call to move to the left when it sees one. They were elected to serve the people instead of corporations, and health care reform COULD BE the place to demonstrate that.
#27
//You libs had a year to do something constructive and you failed. Time for a changing of the guard in 2010
I don't think this is the tidal wave some Republicans are hoping for, but it is important to realize that it was Democrats, NOT republicans that killed any real chance at health care reform. Hard to say how much difference a narrower majority is really going to make since a large majority was apparently irrelevant. With any luck the Republicans will run Palin in 2012. It's just so frustrating to constantly be in this situation with the Democrats where they only win when people are sufficiently frightened by the Republicans. And then when they win they talk themselves out of doing anything and we're back where we started.
#19-Paul U:"By the way, do you really that a 20 year old who's a quadriplegic for life because of a Doctor's malpractice is only entitled to $250,000? That won't even pay for one year of care let alone a lifetime of care. Of course if we had a national health plan that paid for care in any event you wouldn't need to sue a Doctor, but that's another story."
My post: "$250,000 beyond the actual damages"
What part of "beyond the actual damages" did you not get?
And the costs of medical malpractice awards are only a minor part of the costs they impose: the defensive medicine practiced because of them adds HUGELY to the costs of medical care.
Bernicce says:"I hope sincerely that the Obama administration recognizes a call to move to the left when it sees one."
"Make my day!"
Maybe we are all to blame somehow. Who among us has declined a test when there was a grey area or not thought of ourselves first. I know in my heart that republican friends of mine always seek the least costly alternatives even if it means stitching up your own wounds with a little vodka and thread.
@#32 John I--
Inconveniently, there are two different factors influencing excessive medical tests and treatments: defensive medicine and financial incentives. Both are probably active in most cases; I don't see any way of separating their effects short of removing one of them by legislation and seeing what happens to medical costs.
My personal bias is 'cherchez le funds' -- I doubt that tort reform will have much effect absent a basic change in the basic financial structure of our medical system.
//And the costs of medical malpractice awards are only a minor part of the costs they impose: the defensive medicine practiced because of them adds HUGELY to the costs of medical care.
Shoe me some figures John, I don't know any insurance programs that currently pay for defensive medicine. Providers fight hard enough to get paid for legitimate care. Tort reform is a solution in search of a problem.
Nice short little examination of tort/defensive medicine claims from FactCheck.org
http://www.factcheck.org/president_uses_dubious_statistics_on_costs_of.html
Interesting referral, Paul U, but a little outdated (1994). I did not recall that he addressed the issue. I believe the CBO response was a little too limited in its examination.
I suggest to check on that state (was it Louisiana? I'll look into it) which limited claims and required suits to be filed there, and saw liability premiums drop drastically.
Or one might check with the various states suffering from lack of obstetricians due to the prohibitive cost of liability insurance.
Ultimately, of course, whether an expense was incurred primarily to gain revenue or to provide a defense must be determined by reading the mind of the prescribing provider -- a difficult task.
Perhaps one example might illustrate:
I went to the urgent care with a concern. The MD sent me to the ER for a test. When I asked what it would cost, as usual he had no idea (profit motive?). When I arrived at the ER, I asked what the procedure would cost. No-one had any idea, so I was sent to bookkeeping to find out. They had no idea, and I had to wait for them to research it. When they did, I discovered that the test would cost @2,300.00, and my share would exceed $800.00. I called the urgent care and reached the MD. When I explained what the cost would be and said I was inclined to skip the test, he expressed surprise, agreed with me, and suggested I just watch it for a week or so.
Conclusions here are debatable, but in my thinking the total unawareness of the cost is the common case for physicians, the ordering of multiple tests does not necessarily have any connection with medical necessity, and that leaves...cya.
//Interesting referral, Paul U, but a little outdated (1994).
John, the article is Jan 29, 2004. They're talking about W. Bush not H.W. Bush. Again, if you have numbers of your own let's see them, but don't pretend no one's looked into this.
As to your anecdote, there's nothing about this story that suggests defensive medicine. You refused treatment, that's your right, the doc can't force you to have a procedure you don't want without taking you to court, he's not going to argue with you about it. You describe this as a "concern", well unless it's an emergency or a mental health issue no one's going to be more concerned about it than you are, especially in an E.R. People come in with complaint, figuring out what's causing the problem requires an examination, depending on the nature of the complaint that means running whatever tests or procedures your training indicates.
Of course the doc had no idea what the procedure costs, they're not selling procedures, they're treating patients. I worked in a hospital providing direct patient care for twelve years and I never had any idea really what the hospital was charging for anything be it a tooth brush or an MRI. Once and while you'd hear that something or another cost this or that amount but such information was rather unreliable, more like a rumor than anything else. You never see any patients bill and frankly it's just not your concern. Even if you knew what the hospital charged, you'd have no idea what anyone was actually paying. We didn't even have any way to look it up, that's why you had to go to the business office. At any rate none of this has anything to do with defensive medicine, you go to the doctor what do you expect to get, a comedy routine? Tests and procedures, that's what they do.
By the way, if we had the national health care system I've described elsewhere you'd a gotten your treatment, with maybe a $25.00 copay if anything. Let's hope you didn't really need that procedure.
Paul,
The article was 2004, but the study being spoken of was 1996. Sorry. Got my last digits switched.
Still seems to me outdated. I'm up to my elbows in research on this (thanks!), and so far it seems the studies come up with "inconclusive, due to insufficient data", or "a billion here, a billion there -- pretty soon it adds up to real money." Seems to depend on who's arguing. I do note, however, that it appears 37 states have decided that such tort limits are necessary, so maybe a federal bill will not be needed. (Minnesota is not yet among them, though Wisconsin is.)
The link to defensive medicine in my experience is that I did NOT refuse the test: I called the MD to advise him of the cost and to get from him an opinion as to whether he still thought I should pursue it. It was HE who made the cost/benefit decision once he knew the cost. So it seems to me that it was not MEDICALLY necessary for me to get it, leaving cya as the only other reason I can think of.
What I find problematic about this typical medical situation is that this seems to be the ONLY profession where it is considered acceptable to profess total ignorance of the cost of services, so that cost/benefit can be part of the doctor's as well as the patient's judgement. It HAS to figure in to the appropriateness of medical decisions but it does not. Medical costs will never come under control until it changes, by patient or government demand. Interestingly, the ER desk people agreed with me, and said they were developing a spreadsheet of the 100 most common procedures. I don't know what became of it.
Concerning my "out of pocket", as an old cost accountant I am GREATLY concerned about the COST of medical services, regardless of what my copay might be. What I see is bean counters like me figuring out how to charge a dollar for an aspirin to take advantage of government rules, with no care for the overall COST to the individual or society. And on the government side, concern only for the PAYMENT amounts, with no concern for underlying legitimate costs, which are not the same. Both sides must change, or health care will go the way of the US auto industry.
As for needing that procedure, I am still here some years after that event. And I think if he thought I really needed it he would have said so.
John,
Again, the article I posted mentions four studies, 1996, 1999, and 2004. It also mentions an earlier study done in 1994. All but the 96 article concluded that Tort reform would have a negligible effect on the health care economy. The fact that no once published a study since 2004 doesn't mean your right.
//What I find problematic about this typical medical situation is that this seems to be the ONLY profession where it is considered acceptable to profess total ignorance of the cost of services, so that cost/benefit can be part of the doctor's as well as the patient's judgement.
There are a lot of reasons a Dr. may not insist on a procedure. At the end of the day it's your choice, not the docs. If you seem more concerned about how much it costs than you are about the original complaint, again, no ones going to argue with you. The fact that the Dr. agreed with your decision to not have the procedure doesn't mean it was a frivolous order in the first place.
As to this stuff about the costs, frankly this is why you guys are so clueless about health care economies, and it why you can't be trusted to come up with a solution. You've created this market with a million actors involved in every transaction. And you don't seem to realize that medicine is not a business like a car dealer. People are dealing with pain, suffering, and death. No two human bodies are identical, nor are the reactions to any given insult or injury, or treatment. Standard practices are constantly being revised according to thousands of studies being done every year. Treatment recommendations are constantly being revised, and not all of the revisions are a good idea. Doctors have to sort this out at any given moment and make a decision right now. In the middle of all this you want them to walk around with some kind of price list? I repeat, even if you know what the hospital charges for something, you have no idea what any given patient will pay because that's all worked out with the insurance companies. What do you want from your Doctor John, you want them studying your insurance formularies or want them studying the medical journals so they know how treat you when you need it? I worked on psychiatric units, you want me watching the patients or studying price lists?
As for cost benefit analysis, for one thing it's done every day by every doctor. Anyone who thinks Doctors treat without considering economic factors is simply naive. At the same time, again, providers aren't selling procedures, they treating illness and injury, these decisions are unique, it's like deciding whether or not to get rust proofing on your new car. What value to you place on your own pain and suffering? What's your financial cut off point for life or death?
The truth is while health care costs in this country are out of control, good health care is never going to be cheap. Very few people are ever going to be able to actually pay for health care out of their own pocket, that's why we pool our resources to pay for it. Health care treatment decisions are too complex to fit into consumer models that pretend patients can control health care dollars like they control the dollars they spend at the grocery store. And putting people in a position where they even have to make medical decisions based on their income is fundamentally immoral. One thing it is to drive the car you can afford, another it is to only get the health care you can afford.
We have a health care crises, the problem is systemic, we're not going to "consumer" our way out this by spending wisely. The problem is not too much health care. The problem is not that patients get too much free health care and don't know how much anything costs. The problem is we have a fundamentally perverse system of distribution and financing of health care.
About #41,
I meant to say health care choices are NOT like getting rust proofing.
To bring this back to subject, the Democrats have blown health care reform, if anything they've managed to make it even more complex and inefficient. And the Electorate senses it even if they don't have the facts and figures at their fingertips.
Paul,
I guess we'll just have to agree to disagree.
I still think my DOCTOR'S decision (NOT mine -- I would have had the test done if he felt it was needed) to pass on the test was a good one, and based on his being made aware of the cost.
I would agree that if a decision actually involves life or death it would affect the cost/benefit ratios (e.g., heart transplant or death). Most medical situations, however, although they involve lots of tests and related costs, do not involve life or death, as mine did not.
I like my favorite mechanic's saying: "If it ain't broke, don't fix it", in health care as in all other aspects of life. And if at some point the doctor want's to do something for me which will leave my family impoverished for years so that I can live a few more months, I will opt not to do it and go for graduation into real life.
One other thing:
You seem to suggest that "defensive medicine" is "frivolous". In this litigeous environment I believe it is far from frivolous. It is absolutely necessary because of the legal wolves at the door.
That's why I would like to restrain them.
John,
I still don't see why you think this is a case of defensive medicine instead of a doctor trying to figure out what's going on? If he were protecting himself from a lawsuit the cost of the procedure would be irrelevant, why would he agree not to protect himself when found out how expensive it was? Obviously the Doc didn't think the situation was serious enough to press the issue, that doesn't mean he was just trying to cover his rear end or make extra cash. It's the doctor's responsibility to figure out what's causing your symptoms, if there's a procedure or test that she/he thinks will do that they order it. Just because your outcome was good without the procedure doesn't mean the doctor was doing anything other being a good doctor when she/he ordered the procedure. I'm glad things worked out for you.
The danger here is your going make a big attack on defensive medicine and end up interfering with good medicine, and medicine isn’t real estate, you interfere with good medicine you kill people. The calculation you’re NOT doing is how much additional suffering and death less than 2% of the health economy is worth? We can control costs, but you do it systemically, not at the doctor/patient level. Doctors and patients need to be focused on health care. My personal experience as a health care provider is that the more you try to make economics a direct patient care issue the more damage you do. I’ve seen people discharged after 72 hours because insurance didn’t think it was an inpatient situation, I’m telling you, you kill people that way, they don’t come back for a refund.
If you really want to do something about the cost of malpractice lawsuits you make over-all health care more affordable and less catastrophic for individuals. We have 3.5 times more malpractice lawsuits (per capita) in the US than Canada for instance, primarily because Americans are trying to recover out of pocket costs and stave off bankruptcy. People like John think they advocating efficiency but efficiency in health care doesn’t work the same way it does in mattress factory. There’s a fundamental, I mean fundamental difference between a patient and a customer. The more you try to treat patients like customers the more perverse the health care system. Making doctors and patients think about the costs of individual procedures, tests, and treatments, isn’t going save you money or get you better health care in the long run, it just adds complexity to an already complex situation.
Then of course there are practical issues. The truth is doctors don’t have time to sit down and discuss your finances, they barely have time to examine you. If you’re in an E.R. unless it’s a slow day or night your doctor is treating 5-10 other patients at the same time he’s treating you. Believe me, you want your doctor focused on your medical issues, nothing else.