Russ Roberts

Brady on Health Care Reform, Public Opinion, and Party Politics

EconTalk Episode with David Brady
Hosted by Russ Roberts
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David Brady of Stanford University talks with EconTalk host Russ Roberts about American public opinion on changing the health care system. Brady discusses the impact of taxation on public opinion toward health care reform--if the poll includes a measure of the likely increase in taxes necessary to pay for expanding coverage, support for expanding coverage drops dramatically compared to generic polls that ignore costs. He also discusses the role of the party system and partisanship for the health care issue and more generally, how partisanship has changed over time. The conversation concludes with Brady's views on how much science there is in political science.

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0:36Intro. [Recording date: July 27, 2009.] Politics of change, and in particular the politics of health care change. Going back into the 1990s, polls indicate a desire for health care reform, yet little change gets made. Why? Two reasons. People say it needs change, but if you ask people, "How is your health care?" in the 1990s about 87% felt their health care was either very good or good; small proportion thought not so good. Even at present time, 83% pretty satisfied with their health care. Anything that shifts the status quo is problematic. Second, most surveys don't properly value or ask the tradeoff. Studies of the Grand Canyon when it's cloudy or if you ask people what are you willing to pay to clear the Grand Canyon. Public good. Article with Kessler coming out, ran a sample of 1000 Americans three times, doing contingent valuations converting into dollars, asked how if people are willing to pay this much: turns out everybody's in favor of reform but no one's willing to pay for it. More depth on survey, methodology and outcome. Start with methodology: Internet-based survey, overview with Doug Rivers, podcast; but this is long-standing survey, know a lot about the people, panel sampled on particular questions. Know their income; regular and don't go out of the pool. Can still conduct a random sample. Also have an idea of what the taxes are that they would pay on their income. Ask them a general question to begin with; they say they are in favor of whatever--expanded Medicaid coverage, chronic illness being covered, and health care to the uninsured. Then can give them a dollar amount based on the actual taxes they would pay and a cost estimate of what these programs would cost. Support falls away as soon as there is any amount of tax. Assumed each proposal would be financed by an equi-proportional increase in people's income tax burdens. Taxes are raised from all kinds of sources; but a lot of Americans pay zero income tax; not surprisingly they are in favor of reform. Rational, won't cost them anything; could cost them something down the road. Static testing. Find any proposals that would get majority support? Continuing chronic illness--borderline, 51-52%. Can't be held responsible for their condition. Suggests reality down the road that change in the health care system is unlikely, because people are either sufficiently happy with their own or sufficiently unconcerned about other folks given the costs they perceive they'd have to pay. Depressing. Nobelist Mike Spence, Dan Kessler, Brady have argument: in Mike's view, why can't the United States have some minimal level of support as they do in Italy or France, and then let people have health insurance for a level above that, as in Australia? Counter: that would be the best thing to do if you could do it, but Kessler and Brady argue that when those programs started, the cost of health care was quite low. Britain after WWII, Italy; Germany earlier; able to create public boards, institutions which deny certain treatments. In United States at the present time, expectations are so high that if you went in and said here's a certain treatment and here's the minimum, claims would be it would be bad for the poor, technology so much better now. Couldn't get agreement on what the minimum standard would be. Would immediately start out with a plan that would deny certain technologies.
10:19Puzzle: Don't we have such a system? Hybrid of public floor and private do-whatever-you-want, subsidized by tax exemption? Medicaid to cover the poor, Medicare to cover the old; rationing sometimes explicit, sometimes implicit within those systems; but there is a floor, pretty generous, using best technology; poor get stints, balloon angioplasty. Gap is group of folks who are not poor enough to qualify for Medicaid and choose to have employment that has higher compensation in wages and salary and less in benefits. That's what people want. The 43 million who are uninsured takes a lot of people who are eligible for Medicaid and don't sign up, plus a lot of young people under 30 who make over $50,000 who are optimistic about their own health so they don't buy health insurance. So, we are not far from that program. Actual numbers who are uninsured debated. Anyone who goes to a health clinic or emergency room is taken care of. John Cogan paper, not out yet: why the emphasis on access rather than coverage; most people have access. Why focus on health insurance rather than health care? Don't have insurance to cover changing the oil in car; don't always remember to do it, costs poor person same as rich, unwise to delay. Obsession with health care insurance. Add to oil example, if well-to-do get oil changed every 500 miles; would overuse insurance if it doesn't cost anything. Pin-striping, new stereo; plastic surgery still iffy. McCain plan, wanted to take health plans from various states and make them overlap: Arizona plan bare-bones minimum, California plan includes acupuncture, massage therapy. California plan: if you offer insurance through your employer you have to include these coverages. Problem is making it work across states; how do you get to a basic low-cost plan.
15:01Political dynamic is to always expand it. Reality: due to tax changes over last 25-30 years, we have removed more and more families from the income tax. Political economy of that is unhealthy; any expansion to government starts off with 40% support because it doesn't cost anything out of pocket to those off the taxes, unless they worry about the dynamics of higher tax rates. People more in favor of health care reform are those who won't pay for it. Gallup poll data, estimates of how much tax people pay; go back to late 1930s. Look at who is paying taxes, in aggregate change over time. Gallup poll data have asked for a long time if your taxes are too low, too high, just about right; small percentage think they are too low, under 5%; too high category pretty healthy. Estimates on how much people make, use that as estimator of how much taxes they pay. Income tax is only a small portion of taxes. Payroll taxes, the portion the employer pays, 15%-16% taxes on everybody who is working, whether they are low or high income. Close to a flat tax. Average American struggles to understand the payroll tax; don't think of it as coming out of their own pocket though most economists think that it is. Often think their side, the 7-8% that support Medicaid, Medicare, and disability is going into their own account in the proverbial lockbox. Of course, it's not--it's going to support the war in Iraq, the stimulus package, and everything else. People think income taxes funds the government; payroll taxes--that's for me. Distorts the dynamic. Have to add the health care benefit that comes out of the employee's salary. At any time you do the polling, 2/3 of Americans are in favor of lower taxes, more taxes, and a balanced budget. Why shouldn't they be when politicians tell them these problems can be solved, told there are no tradeoffs. No reason to take them into account in a poll even if they do see the tradeoffs. Contingent valuations in environment and now in health care very important.
20:30Gridlock in Congress generally: Congress unable to move forward--good or a problem? 1992 health plan that did not succeed. Gridlock: political science and business school classes, Clinton had been elected, end of years of gridlock between Republicans and Democrats; expected tsunami of change, peace dividends. What the objective meaning of gridlock be? Duncan Black, median voter: in order to pass legislation, you need 50 votes, 51 with Vice President; 218 in the House of Representatives. Super-majority institutions: Presidential veto; Senate Rule 22, filibuster, if you have 41 Senators willing to stick together, you can't vote. Drew up graph, straight line, say, take minimum wage: where ever the status quo is, say if the minimum wage is $4/hour and you want to move it to $5/hour, even if the 50th senator were there, if the 41st Senator was at $2/hour they could stop from moving it that way. If the status quo is between the 40th and the 60th Senator, hard to move it out. Only an election can change that. When that is invoked, Senators with different preferences would come in. Possible that an exogenous shock could come in and opinion would change without an election, but the normal way is to shift policy through an election result. Looked at 1992 result, Clinton replaced George Herbert Walker Bush; veto pivot shifted to liberal side; but on the House side Republicans picked up 10 seats and in the Senate there were a large number of conservative Democrats; Alabaman later became a Republican. Didn't have the votes to shift to universal coverage. Clinton said he wouldn't sign it unless there were universal coverage. Bill that Mrs. Clinton wrote couldn't even clear the committee. Only bill that started to work was Cooper of Tennessee, Moynihan, Chafee; started dropping coverage to get it closer to passable. Session ended; couldn't get it done. Lost the 1994 election. Likelihood of fundamental change? Think they will get a bill; bill at this moment in House committee that will cost $1.2 trillion over a decade, which doesn't count the Medicare; blue dog Democrats will not be able to vote for it. In the Senate, Arkansas and Louisiana Democrats can't vote for it. Cost is too high. Will probably get a $600 billion bill; through the states, not an entitlement, will increase coverage. Cost of the present bills are too high for the public to stomach them. They have 50 votes, but they don't have 50 Democratic votes. Second, no cost control. Director of the Congressional Budget Office (CBO) says there's no cost control. Senate won't vote till after the recess; nor will House.
28:38Step back, look differently. Those Senators who won't be able to stomach these cost increases--and all this predicated on economy remaining about the same--politicians don't really have any opinions, just trying to stay elected, will listen to the folks back home. Where they are in the left/right spectrum irrelevant, depends on their constituents? Yes, when you look at preferences, largely induced. Experiment: imagine all the interest groups happy; on any given vote imagine an experiment where half the members of the House and half of the members of the Senate get to vote but it's not recorded. Outcome will be recorded but not the votes. Would the legislation be more left or right? Hypothesis: Senators and Representatives have private views, and if they are Democrat their private views are further left and if Republican further right than the legislation that passes. So it's the public vote--they are trying to calculate whether they will get re-elected. Cost matters, mostly independents. Democrats in favor of the legislation, Republicans opposed, 36% of people who are independents are starting to trend down; independents always worried about costs. Clarification: It's not that the Senators or Representatives don't understand what a single payer plan will do. What they're uncertain about is if "If I pass a single-payer plan, how will that affect me in terms of re-election?" Go back to 1993, Harry and Louise commercials very effective but only because they increased uncertainty. Because people are happy with their health care system, the Harry and Louise commercials said if this bill passes, they might pick your doctor for you. If I vote for this and it doesn't work out, two or four years from now, it will affect voting. Lesson learned: Proposals before Congress today all emphasize that you can keep your current policy. But then you can't deal with the costs. Dilemma--members of Congress understand that and are worried that the costs will go out of sight. Trying to calculate, what are the next election consequences. Not easy to calculate. Under conditions of uncertainty, fall back on the status quo.
34:28Implicit methodology, where how people actually pay as voters translates into how they actually feel about legislation which translates into how legislators take positions--challenge. Stimulus bill was $800 billion over 10 years. Basically said you as a family will pay hundreds of dollars, and of course for some folks thousands, for stuff that is vague and indeterminate, in the name of keeping the economy from going into recession. Likely the average person is a Keynesian, has the idea that there is a multiplier from government stimulus. But very expensive. Why did that bill pass? Another example: General Motors bailout--probably didn't have majority support among the American people. Why did that happen? When a member's thinking about what will happen if I vote or don't vote for some legislation, in regard to the stimulus package, the President was in favor of it; the Democrats in committee chairs out of power for 12 years and anxious to do what they hadn't been able to do, give out money. While there was opposition, not much in the press that took it on and said this is a bad idea. Public opinion stayed favorable. With the bailout of GM and Chrysler, started to see public opinion falling away, passed by smaller margins. Makes sense but agreed it's ad hoc. Why is it that relatively smart politicians.... In 1992, Clinton overestimates what he can do in terms of gays in the military, health care, etc.; and Republicans get in in 1994 and overestimate what they can do in terms of the contract with America--what leads to excess expectations? Politicians in the flush of winning. Why did stimulus and GM bailout pass is a question about timing; need to find out about induced preferences and the timing of them, which may have something to do with how long Presidents have to get stuff through before the normal political processes start to work. Model is simple, left/right spectrum. Obviously not every voter is equally weighted; GM is a particular group, want to help particular group. Slack; not every issue counts equally; over time representatives build trust so voters give them some leeway. Though if that were true they could do what they want. Canes-Wrone, Brady and Cogan paper, "Out of Step, Out of Office"--if you vote too much out of step with your district they will get you.
40:56In 1992 and today within a party there are people who are not as liberal or not as conservative, e.g., blue dogs. Impression that people have that that phenomenon is decreasing and that there is much more polarization than 20, 30, 40 years ago. Decried. But is it true? There has been a sorting process. Goldwater vs. Rockefeller Republicans; Boston/Austin nexus: conservative Southerners and Liberal northerners and only Texans could vote for a mild civil rights bill. There's been a sorting now. Doesn't mean that the distribution is any different, not a fundamental change in the distribution or the outcomes. But things more polarized because no crossover voting. Reform Act of 1974 gave the leadership more power to structure the vote; voting records that force left and right on members. Still a lot of bi-partisanship, but takes place in different ways. In 1974, at the same time they were forcing the votes and increasing sorting, introduced co-sponsorship of bills; if you trace co-sponsorship of bills there's been a lot more bi-partisanship on co-sponsoring. If you come from one of those districts that has evenly divided Democrats and Republicans and a bunch of Independents, you can't win re-election being either Republican or Democrat. Have to show your constituents that you are a moderate; do it by co-sponsoring. Driven by the nature of the constituency being representative. Do we know anything about that sorting image being due to migration patterns in the United States? Partly result of migration of Republicans into the South, and partly the result of a transformation. Paper with student, beginning in 1950, started with Democrats but then Republicans learned to do it, Democrats learned to run on their own. Any sane Democrat knew by 1956 knew Adlai Stevenson was not going to lead them to victory. Lost control of the House in 1952; began to run in a different way. Barratt O'Hara, Chicago's 1st district, sign; suddenly became O'Hara, Chicago. Personal vote. Candidates were able to have personal loyalty to them, not to their party. About 8%. Big swing. Explains the following: from 1948 on, common for a President to face a Congress of the other party. Eisenhower, Nixon. Not until 1980, Reagan, a Republican, gets a Republican Senate, but even then the House remains Democrat. Then Clinton. Learned to run as individuals and then protected. Southern Democrats were replaced by Republicans; liberal Republicans in the Northeast were replaced by Democrats--because the new candidates didn't have that personal loyalty at first. Look at retirement--when a member retires, what happens to his party's share of the vote. Random until the 1950s. After that, retirement slump averages about 7%. What happens the first year after a new member comes in, the first year they can run as an incumbent? Sophomore surge--on average about 8%. That personal vote didn't come in until the 1950s and hasn't gone away, still about 6%. Members do what they need to do to get elected.
49:56Brand loyalty in product markets. People had brand loyalty to cars; auto makers squandered some of that as well as improvements by their competitors. How do politicians build that personal loyalty? Spend a lot of time back home; district offices. Of the 20 or so staff members they can have, the more insecure you are electorally, on average the more people you have as staff back home. Those just elected have much higher proportions back home and fewer in Washington. Schedule is now Tuesday-Thursday, so if you want to see the California delegation, you get a flight with many others on the same flight. Families. Send out franking--surveys; blue book when baby is born; get a flag that is flown over at the capital--go up every 30 seconds and come down. Press set up to do local coverage. Some of the effect is incumbency per se. Political innovation: somewhere in the 1950s they got better, but some is that incumbents have an advantage, better name recognition. Exogenous innovation of polling forced different behavior. 1932, 1936, 1938 Johnson, back Roosevelt all the way. As polling got better, Democratic Congressman in 1956 already been beaten, Eisenhower in 1952. Clear that Stevenson won't win. Can't be a Stevenson Democrat. Split vote, President on one level and Congress on another, doesn't begin to develop till post-WWII period. Eisenhower first President to face a Democratic Congress of the other party since Zachary Taylor, 1848; Free Soil Party ran with only a Presidential candidate, took away votes from the Whig Party. Since Eisenhower, common. Incumbency has always been strong. Between 1920 and 1932, 98% of incumbents who ran for re-election won. But difference was they ran and won because there were no opponents to the Southern Democrats, and on Republican side, economy doing mostly well. But in 1932, when economy bad, incumbents lost like crazy. Incumbency that matters, but attached to the party. In latter period attached to individuals who can go home. Incumbents of the opposite party of the President do better. If you are in one of those mixed districts, you can vote with the President when you need to, against the President when you have to; can go back and explain that to your constituency and they view you as an independent, principled guy. Republicans are not voting with the current President, though.
57:51Bi-partisanship is somehow viewed as an inherent good, like brothers and sisters getting along at a picnic. Strange romance about bi-partisanship. Belief that you get more done. Some truth to it; after WWII, isolationists became more global. Great issues have always been solved by partisanship--Republicans ending slavery in Civil War; in 1890s kept the United States on the gold standard; Democrats in 1930s moving more toward social welfare state. In each case, one party took the progressive position, other party stayed with old position; took them quite a while. William Jennings Bryant ran in 1896 and lost, ran in 1900 and lost by a bigger margin, didn't get the nomination in 1904, got the nomination in 1908 and lost again. In 1932, Roosevelt, Roosevelt, Roosevelt; in 1952 when Eisenhower won, some of the Republican party wanted him to repeal the New Deal. Prior to the New Deal, question was welfare or no welfare. After, the question was how much welfare. Partisanship. Climate change: ethanol policy, government vs. markets. Elections give parties ability to govern, works or doesn't work, get to vote them out; that's the great thing about democracy. Connection between how people vote and how things are going. Some welfare vs. none became some versus a lot: the default, minimus position changes. We don't understand very well how those broad, big positions change over time. Best if you can get good time series on public opinion. In 1932, number of people opposed to topless bathing is the same as it is in 2004; difference is that in 1932 it was topless bathing suits.
1:04:33Challenging economics as a science. Nobel Prize in economics--technically in economic science. Political science also has the word "science." How much science is there in political science? Progress in the last 50 years? Will we continue to make progress? Voting studies, electoral studies through polling. There are areas where you are able to quantify and bring in assumptions from economics. Assuming Congressmen want to be re-elected is kind of like a price variable, not as tidy, but gives you a motivation. Some progress on that. Some because of game theory, which came into political science through economics. Second area of progress, but conflict with the first, is area of psychology, behavioral economics, people don't want the full plate. Tversky and Kahneman, relevant for voting--set up experiments, framing analysis. Morris famous for getting the wording so that everybody would agree with it. Ultimately, in regard to political science, you've adopted economics or using psychology to temper that economic model or you are an historian--analytic, looking at past elections. The rest of political science: political theory, Aristotle, Rawlsian analysis. Better than 30, 40 years ago, but still a lot of art. More science in economics than in political science.

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COMMENTS (12 to date)
Brooks Wilson writes:

Dr. Brady,
Your comments suggest that, at least on health care and clearing the Grand Canyon, voters vote their pocketbooks. In “Myth of the Rational Voter,” Bryan Caplan writes, “Ordinary cynics—and most economists—compare voters to consumers who shrewdly ‘vote their pocketbooks.’ In reality, this is atypical. Empirically, there is little connection between voting and material interests.” Caplan gives examples of the elderly being less supportive of Social Security and Medicare that the rest of the population to support his conclusion. Do you believe that voters are self-interested or public minded?

Billy writes:

When you and Dr. Brady were discussing the current safety net for the poor and uninsured I didn't hear any mention of community health centers. In Alabama, for instance, there are several non-profit health clinics that offer care as long as you show proof of income. Some individuals are able to receive care for only $20. These clinic do, however, rely on federal and state grants. Are these the "co-ops" that have been mentioned in the news recently?

Miles Mullin writes:

As usual, a great podcast. However, in regards to the discussion of this kind of dialetical process in which one party took the progressive position and another the conservative and then adjustments took place, it should be mentioned that, in spite of the caricature of William Jennings Bryan (no -t) that we get from Inherit the Wind, Bryan was quite progressive. (If I remember right, Bryan even got the support of the Progressive Party in some states.) In fact, it was the conservative, genteel, wealthier Eastern Elements of his own party that were opposed to his sort of progressive populism. In fact, in his fine biography of Bryan, Michael Kazim of Georgetown University argues (in part) that it was Bryan's sort of grassroots populism that invigorated what was to become the New Deal democracy.

Ward writes:

I wonder how lamentable it is really that there is not more science in either political science or economics. It makes things messy and uncertain of course but it also makes them human. At the end of the day, it seems to me, if economic models worked perfectly it would mean that human nature was perfectly predictable. I'm not upset to live in a world where that is not true. I think the subject of last week's podcast Orwell would agree with me.

Finlay MacNab writes:

As a materials chemist with an interest in economics, my view is that economics is not a science. An assertion that Dr. Roberts makes with increasing frequency.

My view is that economics cannot be studied scientifically due to the fact that too many uncontrolled variables exist in society to ever make accurate predictions. Unfortunately, the situation is even worse than that because the laws and constants of economics can change due to changes in the people that make up society.

Instead of the familiar analogy of an three blind men feeling different parts of an elephant and coming to different conclusions about its nature, economics is more akin to a situation where three blind men are trying to probe an ever changing amorphous blob. The problem is insoluble. If the laws and constants of physics changed in an unpredictable way my field of study would not be a science.

Finlay MacNab writes:

Dr. Roberts,

I have a critique of your treatment of healthcare. I have noticed in your podcasts on the subject that you devote most of your questions to the demand side of the problem. What about the supply side?

How does the regulation of health care providers by the government and professional associations like the AMA effect prices? Can a system where the supply side is so heavily regulated be made efficient by subjecting the demand side of the problem to market forces?

Is the problem even worse than that? Given that the insurance industry is actually paying out to doctors and hospitals and that the patient is relatively removed from the transaction, is it more realistic to imagine that market forces are at work in the exchange between insurers and doctors and hospitals and that the "healthcare industry" is nothing of the sort? That market forces work to increase insurance and hopital profits with little impact on quality of care?

Your observations on Lasik eye surgery, simple checklists at hospitals reducing death rates from surgery, the anecdotal experience of one of your guests when his father suffered from cancer, and the study you quote which shows little difference in outcome for patients with and without insurance, suggest that the problem of healthcare is not a demand issue.

It is also worthy of note that insurance company incetives to pay for provided care are heavily influenced by the fact that the insured can often be denied care once they become ill, but that the insurance consumer can be unaware of this fact for long periods of time while paying premiums.

Given that the United States has close to the lowest performance/dollar spent metric in the world (including third world countries). A more balanced and realistic treatment of the problem is called for.

H. Green writes:

Dr. Roberts,

You mention that for whatever reason, most people are Keynesians. I think there are two reasons for this. First, people have that "do something" attitude for all problems and government. Second, most economic education that citizens have comes in high school. Lots of states only require that the Keynesian view be taught. For example here is a link to the Georgia High School Performance Standards for Economics.

https://www.georgiastandards.org/standards/Georgia%20Performance%20Standards/Economics%202009-2010%208-14-2008.pdf

Notice that Macroeconomics is taught from a Keynesian view of Fiscal Policy. Most states are similar to this. I remember taking High School Economics in Alabama and being taught a very similar view. I teach Economics in high School in Georgia. Due to time constraints and a standardized test that is given to all students in Georgia at the end of Economics, the only thing I can say is that this is one theory and that competing theories say this is the wrong thing to do and mention there are many economists who disagree with Keynes. I don't pretend to think that every American remembers this stuff from High School, but the education coupled with the media and politicians presents a very convincing argument.

emerich writes:

Yes, another very nice podcast, with a relaxed yet intelligent "ambience" to it. Also really liked Brady's and Green's comments.

Stephen writes:

If you are talking about surveys, you cannot fail to mention Sir Humphrey's masterclass on priming your survey as given to his underling Bernard in "Yes, Prime Minister":

Sir Humphrey Appleby: Mr. Woolley, are you worried about the rise in crime among teenagers?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Do you think there is lack of discipline and vigorous training in our Comprehensive Schools?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Do you think young people welcome some structure and leadership in their lives?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Do they respond to a challenge?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Might you be in favour of reintroducing National Service?
Bernard Woolley: Er, I might be.
Sir Humphrey Appleby: Yes or no?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Of course, after all you've said you can't say no to that. On the other hand, the surveys can reach opposite conclusions.
[survey two]
Sir Humphrey Appleby: Mr. Woolley, are you worried about the danger of war?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Are you unhappy about the growth of armaments?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Do you think there's a danger in giving young people guns and teaching them how to kill?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Do you think it's wrong to force people to take arms against their will?
Bernard Woolley: Yes.
Sir Humphrey Appleby: Would you oppose the reintroduction of conscription?
Bernard Woolley: Yes.
[does a double-take]
Sir Humphrey Appleby: There you are, Bernard. The perfectly balanced sample.

JohnH writes:

Wrong survey question! Try this one next time... Would you rather your tax dollars went towards providing basic health care for all Americans, or, that it go towards the purchase of F-22 Raptors at a cost of $339 million per aircraft?

James A.M. Smith D.O. writes:

I am a cardiovascular physician practicing in Wichita, KS. I feel that Mr Obama has convicted me and my colleagues of practicing bad medicine and accused us of medical fraud and abuse. He has recently instituted RAC's which are a review of past services that have been provided to my patients in an attempt to detect fraud and abuse in the Medicare system. These reviews are being conducted by individuals whose remuneration is determined by how much they claim to have determined was inappropriately paid to physicians. The basis for this is 'inadequate documentation' which essentially questions our decision making efforts in the practice of medicine.

While there are undoubtedly some doctors who may try and abuse the system, I am not one of them. I took an oath, "Hippocratic Oath" when I completed medical school and pledged to always practice in a way that kept the patient's best interest in mind. I TREAT EVERY PATIENT with equal respect,and spend INNUMERABLE time documenting my services and decision making in the patient's charts. IT IS IMPOSSIBLE to write everything down that is covered and discussed during an office or hospital visit, and it is insulting to have to call the insurance company or 'third party' every time that I want to order a test. It is MORE insulting to get a notice that a test that I have requested will not be paid because it does not meet criteria outlined by the insurer as a medical necessity.

More tham one third of every dollar in my practice is eaten up by administrative costs, and much of the time spent by my office staff is used to appeal claims, get medical permission and making phone calls to allow me to practice 'good medicine'. At the same time the minimum wage has just been increased, a 21% reduction in physician reimbursement is about to take place, and my fixed costs to run my business continue to increase.

I am greatly offended that the president insinuates that many of us are guilty of abuse in the medical profession. I have sacrificed time with my family, take calls all night long and am at the mercy of 'third parties' to tell me just how much my services are worth. At the same time the legal climate for malpractice has been intensified and the rewards for malpractice provide a 40% return for lawyers.

My daughter recently graduated Magna Cum Laude from Wichita State University with a dual major...Music theater and pre-med. When I asked her recently what kind of doctor she would like to be she replied that she has decided to take the LSAT (law school admissions test) instead. She feels sorry for me in that the lifestyle I lead is a sacrifice that NO ONE in her generation is willing to make.

Can anyone blame her?

Erik writes:

Ethanol, CO2, energy policy: as with welfare, the debate for a long time has not been "energy policy or no energy policy" but "how much energy policy, and what kind." Saying that liberals would rather have the government try to solve our energy problems while conservatives would trust the market is a canard. The price of a gallon of gas does not reflect the full cost thanks to government transfers in the form of favorable tax regimes and military expenditure.

Dr. Roberts and Dr. Brady dismissed bipartisanship very summarily. Here are two thoughts I have on inter-party cooperation, and why I get scared when it breaks down.

First of all, partisanship grows particularly well in the dung of polarization. Polarization sucks. It kills thoughtful debate by creating more litmus tests, and it empowers fringes. It is often a sign that a society is not doing all that well. As a German, when partisanship increases I am always afraid of what's around the corner.

The other obvious thing about bipartisanship is that you can't dance if you don't come to the ball. No bipartisanship means no representatives coming together from both sides to negotiate over how far to turn the dial. So the internal politics of the party in power have a greater impact on where the needle ends up pointing, which means a more extreme outcome than if the other party had had an input.

As a European whose formative frame of reference is the Cold War politics of the 1970s and 1980s, I have a fondness for technocratic muddling through, and this undoubtedly colors my judgment.

No one would be talking about the collapse of bipartisanship if voters in the US had more than two parties to choose from. Two-party vs. multiparty democracy could be a great topic for a whole show, since Russ and his guest end up geeking out on the ins and outs of constitutional/representative democracy at the end of almost every podcast anyway these days.

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