Dolan Letter
At America’s blog, Vincent Miller has a terrific post up that pretty much captures my own views on Dolan’s letter to Rep. Ryan:
On matters concerning abortion, and now marriage, the bishops are quick to react and don’t shy from direct public confrontation. In 2008, when Nancy Pelosi opined on her understanding of the Church’s teaching on abortion in the patristic period, a sharply worded correction was issued within 48 hours signed by the chairs of the USCCB committees on Pro-Life Activities and Doctrine.
Under Cardinal George, the USCCB waded fully into the weeds of policy interpretation and lobbied heavily against passage of the Senate version of the Affordable Care Act. Experts in the field were skeptical of their legal interpretation. But even as they publically argued against the legislation around the clock and lobbied Rep. Stupak and others to reject a compromise based on an executive order, no public pressure was brought to bear on Catholic Republicans in the Senate, who could have easily provided the votes to include the Stupak amendment in the Senate bill, and voted for cloture to allow Democrats to pass it.
One side always receives loud, pointed, public criticism; the other always gets a free pass.
I think this about sums it up. It’s well and good to point out — as Dolan rightly does — that resolving issues of economic policy almost always call for the exercise of prudential reason. But, as I’ve argued before, there must be some economic policy proposals whose alleged tendency to benefit the poor is so implausible that those who support them bear a heavy burden of justifying their professed belief that the proposals are consistent with the preferential option for the poor. (And here, I mean justified both in the sense of proving that they are not lying when they claim that their primary interest is in helping the poor and of demonstrating that, even if they are not lying about their motives, their beliefs meet some minimum threshold of rationality.)
Ryan’s plan seems to fit the bill for a set of proposals that calls for the application of this heavy burden, if anything does. To cut taxes for the rich and for corporations while effectively eliminating two of the pillars of the post-War social safety net is, on its face, a policy that appears to favor the interests of the rich over those of the poor. The only argument to the contrary appears to be that (1) addressing the national debt is essential to the long-term well-being of the poor and (2) the standard supply-side mantra that the best way to accomplish (1) is by cutting taxes, which will unleash economic energy, creating a rising economic tide that will lift all boats, and reducing the national debt at the same time. Although (1) is probably correct, the real heart of the matter is (2). And there is simply no credible empirical support for the idea that, given the baseline of present levels of taxation in this country, cutting taxes on the rich will benefit the poor in any meaningful sense.
The weak tea that Dolan offers in response to the Ryan plan suggests that, unlike issues of sexual morality, when it comes to economic policy, politicians mouthing the words of Catholic social teaching is enough to satisfy many in the hierarchy, no matter how much the actual details of the proposed economic policies appear to belie claims of fidelity to the principles that lie at the heart of that teaching. As Miller observes, and Dolan’s protestations notwithstanding, that imbalanced approach is hardly likely to make both political parties unhappy.
I liked Miller’s post too. He’s responding not just to the letter Dolan sent to Rep. Ryan but also to the blog post he wrote as a follow-up, in which he might have (and, I think, ought to have) simply said “No, I did not endorse the Ryan plan” — but didn’t. This wasn’t really about bishops being “both blessed and blasted” because of their great integrity; it was about the bishops conference being used and misrepresented for political ends. But instead of saying so, Dolan’s post just dug in deeper — the invocation of “grandma on her death bed” (yikes) makes me wonder how aware he is of the political games he’s being drawn into.
“As Miller observes, and Dolan’s protestations notwithstanding, that imbalanced approach is hardly likely to make both political parties unhappy.”
Therefore, the status quo remains entrenched. And there is either little motivation or hope for politicians to budge on these issues. At best Archbishop Dolan and company are being manipulated and played like fiddles by people vastly more skilled in politics. At worst, they don’t fit into the cheerleader outfits provided by the GOP.
OK – What’s the answer?
The reality is that these entitlement programs will, if not changed, destroy the economy. There will be no preferential option for the poor left.
The reality is that you could confiscate every dime made by every millionaire in the country and it would not come close to fixing the problem. Besides, the goal should always be raising needed revenue – not raising taxes. They are very different things. Two of the biggest periods of revenue increases of the last century occurred after rates were cut. Also, the Ryan plan includes simplification measures that would result in the rich paying more without raising rates.
The reality is that people over the age of 60 are the wealthiest in the country – wealthier than people under 35 by orders of magnitude. Medicare is not a preferential option for the poor, it’s a preferential option for the aged.
For all the criticism of Ryan’s plan (which does not eliminate the safety net) at least it aims at structural change, and structural change is necessary. Obama’s answer is to simply cut or presume future efficiencies and reduction based on nothing. Ryan’s plan is based on a principle that placing the spending decision at the point of purchase will result in competition, choice and efficiencies – a principle that works on everything else in our economy – I don’t see people clamoring to have their next smart phone designed by the government.
Also, for all the grief about the GOP favoring the rich, the Ryan Medicare proposal would have the wealthiest Americans responsible for more of their health care expenses while subsidizing the poorest the most – that’s a real safety net. The Dems answer, don’t touch my medicare and Paul Ryan’s rolling grandma’s wheel chair into a lake. They aren’t concerned with a safety net, they are concerned with the next election.
What serves the poor is what works, not what sounds good.
What about Ryan’s plan here: http://www.roadmap.republicans.budget.house.gov/Plan/#Healthsecurity constitutes “eliminating two of the pillars of the post-War social safety net”? That description seems like gross oversimplification at best.
The problem is the Ryan plan does none of the things conservatives say it will — it won’t decrease costs or improve service or coverage or health care, and it won’t reduce the deficit. So it penalizes the poor and working class and middle class while sparing the rich and increasing the deficit. That’s a neat trick.
A negotiated compromise of structural changes and taxes and the like would be possible and preferred, but that would require negotiation and compromise, taboo terms for the GOP today.
All sensible people agree by now that “cutting taxes, which will unleash economic energy, creating a rising economic tide that will lift all boats, and reducing the national debt at the same time” is nonsense.
Nobody knows how to make an economic tide that will lift all boats. Probably it can’t be done.
Criticizing is easy. Proposing an alternative is hard. If nobody has a better idea, Medicare and Medicaid as we know them have to go.
And “just tax the super-rich” is every bit as idiotic as the boat-raising-tax-cut-tide thing.
@Studebaker (9:38 am) I think Prof. Penalver is referring to Medicare and Medicaid. The House Republican budget would end Medicare as we know it (a universal, single-payer, social insurance program for health care for the elderly), and Medicaid as we know it (a means-tested health insurance program for the poor, the disabled, and for long-term care for the elderly in which the federal government pays 50% of the costs, as do the states).
“Eliminating two of the pillars of the post-War social safety net” isn’t “gross oversimplification at best”; it’s merely a description of what the Ryan plan does.
The gross oversimplification lies in just saying “eliminating” without noting the obvious fact that Ryan has quite a few ideas about how to provide what he seems to think is a better safety net. If a Democrat proposed restructuring the armed forces (such as by combining the Marines and the Navy, along with putting Navy fighter jets under the Air Force, etc., etc.), it would be highly misleading just to say, “He wants to ELIMINATE the Armed Forces!!!” as if unaware that he wanted to provide the same functions in what he thought a more efficient way.
@Sean Hannaway (9:01 am)
“What’s the answer?”
1-Control health care inflation. (The ACA makes a decent start at that; Ryan’s plan makes no attempt and instead would, according to the CBO, actually increase total health care costs.)
2-Reform the tax code. This hasn’t been done since 1986, and many tax code experts think it should be done every 10 years.
3-End the Bush tax cuts & end the Afghanistan and Iraq Wars. The CPBB has an analysis http://www.cbpp.org/cms/index.cfm?fa=view&id=3490 showing the impact of those policies on federal deficits throughout the coming decade.
4-Stimulate the economy to get unemployment into the 5-6% range. This would decrease government expenses (unemployment, food stamps, Medicaid, etc.) and increase revenues (income, corporate and other taxes).
What do you think of those ideas?
P.S. For what it’s worth, the ACA is projected to reduced federal deficits and decrease health care inflation. It’s not perfect, but it’s something.
I continue to remain dismayed at the outright statement that Ryan (and presumably by extension those finding Ryan’s plan somewhat good/needed/etc albeit flawed) are both lying and hypocrites when it comes to their concern for the poor, but cest la vie. But I guess civility and partisanship is in the eye of the beholder, yet I don’t think it acceptable for conservative Catholics to doubt the sincerity of pro-choice Catholics, so what’s good for the goose should be good for the gander IMHO.
I agree with your first pillar, but your second pillar is a mischaracterization of Ryan, or at least is not an essential feature of Ryan. Ross Douthat and Reihan Salam, for instance, have both criticized Ryan’s tax proposals, yet continue to believe the nuggest of his plan re: entitlement reform remains worthy of consideration. Neither of them can be considered supply-siders.
http://douthat.blogs.nytimes.com/2011/05/25/the-ryan-budgets-unforced-errors/
http://www.nationalreview.com/agenda/267596/gingrich-vs-ryan-and-intra-conservative-medicare-reform-debate-reihan-salam
As they (and others) convincingly argue, there is a distinction between a supply side argument and the argument that raising marginal rates on a relatively small percentage of taxpayers (as the President suggests) could have larger economic consequences that we should be aware of; if increasing tax revenue is the name of the game, there is more than one way to do that. The criticize Ryan’s tax proposal, but also argue for a different approach to increasing revenue than simply relying on rate hikes for a small percentage of taxpayers that won’t create that much more additional revenue to begin with. In short, kicking out your #2 above doesn’t really solve the issue (anymore than going on about Ayn Rand).
http://www.nytimes.com/2011/05/05/opinion/05feldstein.html?_r=2
Its dismaying that you seem to have ignored intelligent conservative commentary criticizing Ryan, although I suppose if you view them as lying hypocrites, one is excused.
“The House Republican budget would end Medicare as we know it (a universal, single-payer, social insurance program for health care for the elderly)”
Every single viable reform plan does this in some way.
http://douthat.blogs.nytimes.com/2011/05/19/were-all-rationers/
“Stimulate the economy to get unemployment into the 5-6% range. This would decrease government expenses (unemployment, food stamps, Medicaid, etc.) and increase revenues (income, corporate and other taxes).”
We already tried “stimulating the economy.” Unemployment hardly budged and we added a huge wad to the already-astronomical debt. How much debt do we need to run up to get unemployment into the 5-6% range? Are we really going to come out ahead from decreased expenses and increased revenues.
This is another free-lunch solution. Just like the tax cut powered universal boat elevator.
“Stimulate the economy to get unemployment into the 5-6% range. This would decrease government expenses (unemployment, food stamps, Medicaid, etc.) and increase revenues (income, corporate and other taxes).”
Just as ideological a claim as the most ardent supply sider, for what its worth.
Britain is showing the exact opposite to be the case. http://www.thedailybeast.com/blogs-and-stories/2011-05-29/democrats-havent-learned-the-economic-lessons-of-europe/?cid=hp:beastoriginalsR9
@Felapton (10:50 am) and @Jeff Landry (10:50 am) All I said was “stimulate the economy”. I made no suggestions about how best to do that. It’s hard for me to understand how you characterize it as “another free-lunch solution” or “just as ideological a claim as the most ardent supply sider”.
I assume you both agree that if unemployment were in the 5-6% range that would:
1-be an improvement on the current state of affairs, and;
2-result in decreased social expenditures and increased tax revenues (all else being equal)?
@Jeff Landry (10:47 am) Jeff, I’d suggest that one useful distinction to be made among the various Medicare reform proposals is between those that keep it as a universal social insurance program and those that turn it into a voucher program.
Ryan’s plan ends Medicare as we know it (i.e., a universal social insurance program), and replaces it with a privatized voucher system. In addition, Ryan’s plan takes money out of Medicare to help pay for more tax cuts for the very wealthy. (Again, this is description, not criticism. This is what Ryan’s plan does, by design.)
As you correctly noted, all reform proposals make changes to Medicare. Not all of them end Medicare’s structure as a universal social insurance program. Here’s what the (admittedly imperfect) Affordable Care Act does:
“…under the terms of the Affordable Care Act, Medicare will change. Specifically, the government (which runs Medicare) will take corporate welfare away from some insurance companies. It will reduce payments to providers while introducing payment reforms that encourage efficiency. It will create a series of budget targets for the program – and then empower an independent commission to enforce those targets, unless super-majorities in Congress overrule it.” (from Jonathan Cohn, health policy blogger for “The New Republic”) http://www.tnr.com/blog/jonathan-cohn/89260/medicare-mediscare-von-drehle-republican-budget
I’m perfectly willing to have a debate about whether Medicare should continue as a universal social insurance program or not. Can we at least agree that Ryan proposes ending Medicare as we know it, so that we can have that debate?
“Not all of them end Medicare’s structure as a universal social insurance program”
I do not agree with this assertion, hence the Douthat piece. All viable plans for reforming Medicare involve shifting some costs, whether that is by means of vouchers, means-testing, etc. So you have a distinction, but as Douthat argues, I think its a distinction in theory. I wasn’t disputing that Ryan’s plan changes Medicare as we know it, only that one can reform Medicare without shifting some costs, i.e. ending Medicare as we know it. Ryan builds, as I’m sure you know, on long-time reform plans proposed by Bob Kerry, John Breaux, Alice Rivlin, etc. As for the argument about whether or not it should be a single payer system, we can debate it, but it will be a matter of ideology I suppose. I support means-testing to ensure the poorest get served best. I also support revamping Medicaid along the lines that my state (Louisiana) is proposing: a more localized delivery system that focuses on primary care rather than emergency care in big “Charity” Hospitals. I’m not sure an extended debate (that we’ve engaged in before) is responsive to the Penalver piece.
As to your 2 questions @11:04, I would say yes to #1, and maybe not, or it depends to #2. Very difficult to track.
@Luke Hill, as to your 11:04 statement re: stimulating the economy, I did assume that you were implying government stimulation, i.e. the “Stimulus Bill”, although obviously there are various means for “stimulating” the economy, as Niall Ferguson’s piece argues. My bad.
I think it is much more fruitful to examine our political parties for how aligned their policies are with Catholic teaching and universal standards of justice than it is to evaluate whether the bishops are harder on one side than the other.
As for means-testing Medicare, here’s a slightly different take on it from Kevin Drum—do the means-testing after people have died. http://motherjones.com/kevin-drum/2011/05/letting-dead-pay-medicare-part-2
(I don’t know enough to endorse or criticize Drum’s idea, but I thought it was interesting.)
Vincent Miller’s post was excellent. He is right. After really appreciating the sophistication of the UCSSB’s 2008 Faithful Citizenship document, I was extremely disappointed with their performance after that. Attacking Obama for Notre Dame, and not raising a peep when EWTN starts saying that torture is perfectly fine. Misrepresenting the Affordable Care Act (following the utterly disreptutable NRLC) and telling Catholics that they had to support this particular prudential judgement about a particular piece of legislation, and now Dolan tries to provide cover for a Ryan budget that is based on what the Church calls the “poisoned spring” of the “evil individualist spirit” (Quadragesimo Anno).
I don’t know what is motivating the US bishops. Do they want to lose credibility? What happened to the strong voices that came through in Economic Justice for All? Why are they so silent on the economic teachings of the Church? At the least Irish bishops have found their voice – see their pre-election document.
Here’s a reference to that Irish bishops document: http://vox-nova.com/2011/02/22/the-irish-church-is-back/
Regarding whether “one side always receives loud, pointed, public criticism; the other always gets a free pass”, could it also have something to do with how lay Catholics themselves speak out on these issues?
I follow Archbishop Dolan’s blog. When he posts on important programs helping the poor, there are very few comments on his thread. But let him write about abortion, same sex marriage or anti-Catholicism in the media and there are hundreds of comments.
Maybe those of us who feel the Church should be a more outspoken advocate for the poor, should be better advocates ourselves to help make that happen.
To put my post another way, if your complaint is that the bishops are more strident in criticizing your political party’s support of policies contrary to Catholic teaching than they are to the other party’s, then it seems to me that the thing to do is work so that your party no longer supports policies contrary to Church tradition.
Or I can complain and dwell on how Dad is harder on me than on my sister, and that This Is So Not Fair!
I must admit, the latter does seem like more fun.
Since Ryan plan is mostly about Medicare read NYT link
http://www.nytimes.com/2009/02/26/business/26health.html?scp=2&sq=Medicare%20costs%20Miami%20vs%20San%20francisco&st=cse
Now tell us why Medicare per recipient is twice as high in Miami vs San Francisco. SF doctors and nurses make much more in wages; offices, hospitals, land is twice as high in SF vs Miami. answer is
Fraud fraud and fraud …as in Rick Scott Repub Governor in Florida whose for-profit HCA was fined almost a billion for Medicare fraud..,
T W Tilley has an excellent comment on the America site.
OK, good point. Stimulus that doesn’t increase the debt (not even temporarily, with some ephemeral promise of future magical repayment) is good. Yes, I agree getting unemployment down to 5-6% is good financial policy and good social policy as well (“For Satan finds some mischief still for idle hands to do,” as old Dr. Watts put it.)
But when we talk about a “preferential option for the poor,” we should remember that the poor are disproportionally children and parents of children. Any policy that runs up a debt and hands it on to them is hardly an option they would prefer.
“Any policy that runs up a debt and hands it on to them is hardly an option they would prefer.”
Agreement, in principle. However, we need to reform the tax code, and end Bush adventurism in southwest Asia. The debt has already been run up and somebody’s going to have to pay. Do we send every individual and corporation who makes more than a quarter mil their share of the bill? Or try to frack the blood out of stones?
Does anyone have any comments about what the Ryan plan actually says about how Medicare would work for poorer people? I’m interested in hearing rational arguments backed by specific citations and evidence.
Who decides whether a policy meets a “minimum level of rationality?” A neutral body like the CBO? – - 5 Harvard economists? – - Nobel prize winners? – - the opposition party? – - the Bishops and their staff of social science experts?
IMHO if a policy doesn’t provoke charges of irrationality, then it’s probably just reinforcing the status quo. The requirement put forth in this post would serve only to embalm the unsustainable reactionary liberalism that even many sensible Democrats realize must be substantially redesigned.
As Herbert Stein’s law has it, If a trend cannot continue, at some point it will stop.
By the way, it seems lost in all this focus on Ryan that the plan failed in the Democrat-controlled Senate, and even if by some miracle it would have passed, Pres. Obama would have vetoed it, with even Republicans backing off of it. Which raises the point- with Democrats controlling both the Senate and the White House, and if they believe that Medicare is such a valued program that it needs to be saved, where is their plan? (ACA, while part of the solution, it alone not sufficient). So where’s the progressive outrage at the failure of leadership? If we’re so concerned about the poor in these reforms (as we should be) where’s the progressive pressure to craft a plan that protects them that does anything other than run ads showing Paul Ryan pushing an old lady off a cliff? If progressives don’t like the debate, maybe you should show some leadership and change it.
By the way, it seems lost in all this focus on Ryan that the plan failed in the Democrat-controlled Senate, and even if by some miracle it would have passed, Pres. Obama would have vetoed it, with even Republicans backing off of it.
Then, by the standards of this website, those raising concerns about it are ginning up outrage over a phantom issue, just like pro-lifers were with FOCA (http://www.commonwealmagazine.org/blog/?p=2543) in 2008-2009. And, again by the standard of that post, a measured response from the bishops is exactly what is called for.
Right? Should those concerned about what the Ryan Plan would do to the social safety net sit down and shut up because it is very unlikely to pass in the current political environment? And if they don’t, should they be criticized for stoking rage over phony issues?
Or is it actually important that bad ideas promoted by politicians in positions of power be forcefully confronted, and that those politicians be pressured to abandon their support for those ideas, regardless of the political viability of those ideas?
John: Did someone suggest that FOCA had the blessing of a Catholic bishop?
@ John McG (11:42 am & 12:21 pm) Thanks for your thoughtful (and thought-provoking) posts.
Here are a couple of my thoughts provoked (in a good sense!) by what you wrote:
1 – It’s helpful (for me at least) to be reminded of the importance of attending to the movement of the Holy Spirit in this, as in everything in the Body of Christ. So, for example, where is the movement of the Spirit in Ryan’s plan? in Dolan’s letter? in our online (and offline!) conversations? in the experiences and examples of the Church in other countries? I don’t have an answer, but I find it helpful to meditate on and pray over.
2 – While any of us (bishops included!) may be prone to defending our favored political party or movement, it is perhaps helpful for us as the laity to let our brother bishops know when we think they are failing to (or succeeding in) articulating the Church’s teaching and applying it to the wider society. So, to take the current example, the concern expressed by Mr. Miller and echoed by Prof. Penalver is, in my reading of it, at least partly a concern that Archbishop Dolan’s statement may lend itself to a weakening of the Church’s teaching and witness in American society by contributing to the impression that the urgency and tone of the Church’s teaching on (again, for example) health care varies depending on which political party is proposing a reform rather than on the merits of the proposal itself.
You are right, nobody claimed that FOCA had the blessing of any bishops or the magisterium.
If that some have claimed the Ryan plan has some kind of imprimatur, then that is a significant difference that I did not acknowlege.
It is probably inevitable that most bishops will appear to favor Republicans over Democrats. In the Republican Party’s base, people of strong religious conviction predominate, so most Republican politicians feel under pressure to behave deferentially toward religious authorities. The Democrats’ base includes a significant plurality of secularists, so Democratic politicians often feel under pressure to avoid appearing unduly deferential to religious authorities. Bishops are only human; they like it when people treat them deferentially.
These are generalities, of course. Exceptions occur; for example, the Republican in New Hampshire who called his bishop a pedophile pimp. That was not very deferential.
Luke,
1-Control health care inflation. (The ACA makes a decent start at that; Ryan’s plan makes no attempt and instead would, according to the CBO, actually increase total health care costs.)
If I had a dollar for every dollar the CBO missed the cost impacts of major legisaltion, I’d be able to . . . well probably pay off the national debt. In a word I say, horse-hockey (maybe that’s two words. We have Obama care writ small in the Commonwealth of Massachusetts and it has done nothing to make anything more afordable. In fact, we have the highest health care costs in the country and they are growing faster than the national average. In short, we are trying it and it ain’t working.
2-Reform the tax code. This hasn’t been done since 1986, and many tax code experts think it should be done every 10 years.
Wow – we agree, and so does Paul Ryan.
3-End the Bush tax cuts & end the Afghanistan and Iraq Wars. The CPBB has an analysis http://www.cbpp.org/cms/index.cfm?fa=view&id=3490 showing the impact of those policies on federal deficits throughout the coming decade.
Again – consider the source – CPBB. I doubt the impacts are this high, and again, they don’t do very much to address the problem. Only changing the entitlement structure will.
4-Stimulate the economy to get unemployment into the 5-6% range. This would decrease government expenses (unemployment, food stamps, Medicaid, etc.) and increase revenues (income, corporate and other taxes).
No kidding. But how? That’s what Ryan wants, but he wants to rely on market forces more. How has government stimulation worked so far?
Put all church property on the tax rolls. Enough to fund Medicare and Medicaid for eternity.
This strikes me as utterly sensible: “If your complaint is that the bishops are more strident in criticizing your political party’s support of policies contrary to Catholic teaching than they are to the other party’s, then it seems to me that the thing to do is work so that your party no longer supports policies contrary to Church tradition.”
Or utterly political.
Sean –
You say that health care costs have risen in Massachusetts. I wonder whether that is due at least partly to the quality of medical care in Massachusetts I’m thinking of Harvard Medical School and its associated hospitals They probably raise the standards of medical care in Massachusetts as a whole raise the standards in northern Louisiana), and, this is my main point, high level medical care is probably more expensive because of, for instance, greater complexity and use of more high tech stuff.
I”ve never read of any studies comparing the cost of medical care in a region with the quality of that care, though I strongly suspect they are related.
Oops — should be: The standards of the medical care in Cambridge probably raise the standards of care in Massachusetts as a whole, just as the two very good New Orleans medical schools raise the standard of care in other parts of this State.
Archbishop Dolan’s blog post has not changed the view I had when I posted on this subject on May 20:
http://www.commonwealmagazine.org/blog/?p=13681
In a friendly way, Dolan’s letter to Ryan corrected Ryan’s analysis of Catholic social teaching by filling in a big hole – the principle of solidarity. He also noted another aspect of church teaching missing in Ryan’s analysis – that under the principle of subsidiarity, larger units (i.e., the federal government) still have duties to the smaller units of society. He also told Ryan that if he wanted to discuss it further, it would be done along with the two bishops who had written to him previously (in a letter that raised questions about the morality of his budget). Dolan didn’t disown the earlier USCCB letter. Ryan wrote a thoughtful letter, if flawed. A scathing response would have been out of line. A year ago, Glenn Beck was urging churchgoers to “run” from any church using the words “social justice.” In comparison, Ryan is willing to engage in a debate about how the teachings apply.
We’ll see how it develops as the budget battle intensifies. That’s what I got from Dolan’s letter – that it’s one thing to state the principles of Catholic teaching, and quite another to follow them.
@Sean Hannaway (6:16 pm) Thanks for your thoughtful reply. (I’m glad we’ve found at least some common ground.)
As for Massachusetts’ health care reform, my recollection is that Romney, Kennedy, et al, made a more-or-less conscious choice to go for universal coverage, and not deal in any significant way with cost controls. I believe their thinking was that 1) they could create near-universal coverage with the available funding, and 2) that the political will for cost controls would grow if universal coverage was achieved first. (We’ll find out fairly soon if they were right.)
The ACA took a somewhat different approach (as I understand it) by including both cost controls and near-universal coverage.
Bill M says: “Put all church property on the tax rolls. Enough to fund Medicare and Medicaid for eternity.”
If the point is to show the arrogant SOB’s who’s boss, then I’m all for it. But I doubt it would be enough to make a significant contribution to Medicare funding. It might, though. My Redemptorist parish is a large square block of property is a moderately expensive part of Boston, and mostly unutilized. There’s about ten Redemptorists rattling around in there and about seven qualify for Medicare.
Taxing it isn’t going to be easy, politically. But public attitudes are shifting. It could happen in our lifetime.
Ann,
I will admit that we started from a higher baseline because of our urban/teaching hospitals, but the rate of growth is faster and the rate of growth is across the board not just at these hospitals. Interestingly, a recent report on Mass health care indicates that the fancy and more expensive care at these hospitals as to most ailments is no better than in our suburban community facilities at something like 60 or 70% of the cost.
Luke,
The centerpieces of Mass Health Care are an individual mandate with tax penalties/fines, no pre-existing condition refusal for coverage and health care insurance pools. We were told these pools and the buying power that came with them and Commonwealth Care (the state health plan) would drive costs down. There may be some differences, but the essentials are the same. What is different about Obamacare is the dozens upon dozens of boards, commitees and offices that are supposed to oversee the system and drive down costs while keeping quality. I don’t know about you, but I can think of no example where some government committee or board successfully did this. When government gets more efficient or cheaper it is almost always because it follows, not leads, a market trend.
I was thinking about the debate about the Ryan approach to medicare this morning, and the idea that it was some draconian and alien concept, and it occuirred to me that if you used the Medicare model for anything else, it wiould be considered ridiculous. Take food stamps as an example. Imagine if instead of letting food stamp recipients participate in the market like everyone else, we dictated what stores could charge them. What would you expect to happen to costs – especially if you wanted to maintain quality?
@Kathy: “This strikes me as utterly sensible . . . it seems to me that the thing to do is work so that your party no longer supports policies contrary to Church tradition.”
Agreed, Kathy. But how to do that, when there are Republicans who are convinced that their party embodies Catholic values, despite abundant evidence to the contrary? It’s not an easy task, methinks.
And the Dolan love letter to Ryan makes it harder.
@Sean Hannaway (8:34 am) Thanks again for your response. I fear I’m wandering off topic here, but I want to respond to your last paragraph, because I think it get to the issue of markets as a means of distributing goods and services.
Markets are one of several means humans have developed to provision our societies. (Barter, guilds, unions, corporations, command-and-control economies are some of the others.)
Markets work well in some circumstances, not so well in others. For example, the US instituted government-controlled rationing for certain goods as part of the mobilization during World War II. It worked pretty well—no mass starvation, and resources diverted successfully toward the war effort. (A counterexample: the Great Leap Forward in late 1950s China which led to mass starvation. Among democracy’s many benefits as a form of governance is its apparent ability to prevent famines.)
Let’s take your two examples of food and health care in the contemporary US. Generally speaking, in the food “market”, there are many buyers, many sellers and relatively equal access to relevant information. Government regulates weights and measures, health and safety of food production, shipment and storage, display of pricing and nutritional information. For most food, government does not set prices. Given those conditions, food stamps make sense as a means of preventing hunger and providing access to the food “market” for poor people.
In health care, by contrast, there are many buyers, few sellers, and relatively unequal access to relevant information. When, for example, at a routine checkup my doctor says my heart is beating so irregularly it’s not safe for me to walk or drive, and therefore she’s called an ambulance to take me to the hospital where her colleague will implant a pacemaker, that’s not a situation in which a “market” model works efficiently.
It’s also not a situation in which a “health care stamps” program would work well. I went to the doctor’s office expecting to pay for a routine visit. I ended up with major surgery and a hospital stay. I would not have had enough “health care stamps” to cover those expenses. This is, arguably, the type of situation in which a social insurance model (like Medicare, or some other large-scale insurance system) works more efficiently—from both an economic and a health perspective.
I guess the other assumption that underlies this type of analysis that bothers me is that 35 years of consistent, unequivocal support for legalized abortion is roughly of the same severity as a proposed marginal degradation of the government-provided social safety net, and therefore any difference in the espiscopal response to these things reveals some sort of political treachery and back-dealing.
Is it possible that the bishops have prayerfully considered these issues, and have come to the conclusion (even one you may disagree with) that the legal abortion regime, under which a million unborn children are killed every year and declares a class of people as outside the protection of the law, is the more pressing issue, and thus demands a more robust response than something like Paul Ryan’s budget?
Or do we really think that a discrepancy in the responses can only be explained by nefarious political back-dealing?
–
To be clear on my own position, I am not in favor of the Ryan budget, and less a fan of the Randian philosophy that may be behind it. I welcome a strong debate about how we can balance the social safety net with the government’s fiscal crisis.
I just don’t think comparing the bishops’ response to the budget to the bishops’ response to the bishops’ response to abortion is a particularly fruitful path to that discussion.
It may be that the bishops are harder on Democrats for their support for abortion than they are on Republicans for their breaking solidarity with the poor. Just like my parents may come down harder on me for wrecking the car than they did on my sister for breaking curfew. As I said, I think the mature response is to confront my own sin, rather than work the refs.
“In health care, by contrast, there are many buyers, few sellers, and relatively unequal access to relevant information. When, for example, at a routine checkup my doctor says my heart is beating so irregularly it’s not safe for me to walk or drive, and therefore she’s called an ambulance to take me to the hospital where her colleague will implant a pacemaker, that’s not a situation in which a “market” model works efficiently. ”
I don’t think the conclusion that because there is no efficient market for health care there CANNOT be or OUGHT not to be market mechanisms in health care. Its a perfectly legitimate argument, but it is not necessarily the only outcome and a point on which rational people can legitimately disagree. One can argue (as I think Sean does above) that it is precisely government monopolization in certain areas that has prevented the flowering of an efficient market in health care. This is partily premised on the claim that “health care is a basic right”, which is fine in principle, but a very difficult principle to carry out. When does “health care” cease to be a right? Breast implants? Life support? Who makes those decisions? IPAB? Consumers?
Now it is right I think to say that SOME types of health care are not susceptible of efficient allocation (perhaps end of life care especially), but make no mistake that all credible reform plans involve introducing SOME market mechanims into the Medicare program. Opponents have slapped the label “voucher” on these plans, but they’re properly termed “premium support plans” and they ALL involve tying the costs of health care more closely to the payers. All these plans have been around for years since they were first introduced by (Catholic) Democrats John Breaux and Bob Kerrey, and most recently by Alice Rivlin and Pete Domenici. So there is a bipartisan consensus (in my view) that SOME market mechanism have to be introduced, that separating the payers from the end users of health care has been disastrous. Interestingly, the other Republican proposal to change health care involves abolishing the employer tax credit for health care, which induces employers to pay for more health care than is needed; surprised I don’t see more progressives supporting abolishing this tax provision.
The bottom line for me, with respect to Dolan’s response and the progressive criticism of it is that I still don’t see what progressives are SUPPORTING; do they object to premium support in principle? Is anything short of Medicare’s current structure morally objectionable? The same is true of spending in general – is the current configuration a morally acceptable baseline? The President hasn’t provided a credible plan yet (although he proposes to cut some $5 trillion in spending too; is the moral analysis of those cuts somehow different from Ryan’s $6 trillion?); not a SINGLE Democrat voted for the President’s OWN budget last week. So what’s the “progressive” plan that goes beyond just sticking it to rich people and cutting defense? Until I have a better understanding of what entitlement reform looks like for progressives, I’m afraid they’re the ones who look overly partisan to me by calling people like Ryan lying hypocrites and objecting to Dolan’s engagement with him.
Bill said, “Put all church property on the tax rolls. Enough to fund Medicare and Medicaid for eternity.”
I wonder how much you’d get from taxing the property and how much you’d get from taxing the sale of property, as churches go out of business in droves.
John said, “Just like my parents may come down harder on me for wrecking the car than they did on my sister for breaking curfew. As I said, I think the mature response is to confront my own sin, rather than work the refs.”
You’ve slightly cooked the books here, presuming we agree that wrecking the car is a lot more serious than breaking curfew. If the original complaint were that the bishops were tougher on politicians outright favoring abortion than on politicians who eat meat on Friday, then I’d bed with you. But the actual cases have been more nuanced than that.
More generally, I agree whining is unappealing. But I hope my kids call me on it when my behavior toward them seems to reveal values different from the ones I actually say I hold (and I hope I’m a good enough parent to listen).
@John McG (10:05 am) First, thank-you again for injecting fresh perspectives into our conversation here. (You may well be right about how at least some (many?) of our bishops view these issues.)
Second (warning: another tangent), and this is in the category of “talk to me like I’m stupid” (because I truly don’t know): how do the Brazilian bishops (in particular, and the Brazilian church in general) deal with the issue of abortion?
I ask because my understanding is that 1) abortion is illegal in Brazil, and 2) despite that, there are an estimated 1-2 million abortions a year in Brazil.
“I guess the other assumption that underlies this type of analysis that bothers me is that 35 years of consistent, unequivocal support for legalized abortion is roughly of the same severity as a proposed marginal degradation of the government-provided social safety net, and therefore any difference in the episcopal response to these things reveals some sort of political treachery and back-dealing.”
First, I disagree that it is only a marginal degradation of the safety net. In my own field, housing, core programs have been eliminated in their entirety; folks in other social services areas have been telling me that there are equally drastic cuts in child care and senior services. Basic safety net programs are being devastated and destroyed.
But I would like to consider issues other than abortion. Archbishop Dolan has pulled out all of the stops to inject himself into the current NY legislative debate on legalizing same sex unions- he is unequivocally opposed to them, for all people, including those who do not share his religious beliefs.
So how is it okay to weigh in aggressively in a political debate involving civil marriage- and to advocate on that issue according to our religious beliefs-but to provide a less robust response, again based on our religious beliefs, about society’s obligations to the poor?
I think there is some inconsistency in the level of response.
@Jeff Landry (10:58 am) I think we agree that there can be (should be?) some market mechanisms in health care. I guess I would argue that fundamentally, in a highly industrialized, technological democracy, health care is a part of the economy in which the conditions for fair and efficient markets don’t exist. As evidence, I would point to every highly industrialized, technological democracy of which I am aware—none of which treats health care as a good/service in a market the way they treat food (for example).
Having said that, one of the market mechanisms Massachusetts established is a (state-run) website that lists and categorizes health insurance plans so that individual and small business consumers can shop more efficiently and effectively for health insurance.
P.S. I’m glad you agree that it’s “fine in principle” to define health care as a right—since that’s a longstanding aspect of Church teaching (with which not all American conservatives agree, apparently).
“P.S. I’m glad you agree that it’s “fine in principle” to define health care as a right—since that’s a longstanding aspect of Church teaching (with which not all American conservatives agree, apparently).”
Sorry if I gave that impression; I don’t agree with the principle because I reject liberalism (small l)’s rights fetishness. I “agree” that humans must have access to some basic health care as an inimical part of the human dignity of the person, but it is a means to an end, i.e. the dignity of the human person. The language of “rights” is troubling, especially in health care, where it is difficult to draw the precise line. Some might say its merely semantics, but I don’t agree.
“As evidence, I would point to every highly industrialized, technological democracy of which I am aware—none of which treats health care as a good/service in a market the way they treat food (for example).”
I think they’re just beginning to wrestle with the ramifications of this, see, e.g. Cameron’s Britain.
What Irene said.
@Luke, re “how do the Brazilian bishops deal with the issue of abortion”? Here’s one answer: http://edition.cnn.com/2009/WORLD/americas/03/11/brazil.rape.abortion/
(Perhaps you recall the story of the 9 year old mentally disabled girl raped since age 6 by her step-father, pregnant with twins. A physician determined her life/health would be at risk if she carried to term and an abortion was performed (legal in cases of rape). The bishop issued a statement confirming that the child’s mother and the entire medical team were excommunicate. He clarified the step-father was not, since rape is not as grave an act as abortion.)
Looks like Dolan’s equivocations are not new:
” Bankruptcy Judge in Milwaukee Blasts Former Archbishop Timothy Dolan’s Program for Sex Abuse Victims
Judge Kelly describes Dolan’s victim mediation, begun in 2004, as “completely inept”
On Wednesday, Judge Susan Kelly told attorneys from the Milwaukee archdiocese that the church’s so-called victim “mediation” program established by archbishop Timothy Dolan in 2004 to address child sexual abuse by priests was “completely inept” and “not at all what had been described to her” by archdiocesan officials. The archdiocese was asking Kelly to allow the program to continue while they seek bankruptcy protection from the federal court.
Dolan testified before state lawmakers before leaving Wisconsin in 2009 to become the archbishop of New York that his mediation program, which had never been reviewed by outside investigators, rendered changes in the Wisconsin sex abuse statutes under the proposed Child Victims Act, and other institutional reforms, completely unnecessary. Under Wisconsin law, until recently, any civil claim against abusive clergy and their bishops have been barred due to a set of controversial state supreme court decision in the mid 1990’s, which ruled any such case filed against clergy violated the 1st amendment of the US constitution. Wisconsin is the only state with such a provision.
Shielded by these rulings, Dolan and his attorneys devised the mediation program criticized by Kelly today, where victims received a nominal financial settlement in exchange for signing a release and dropping any chance, no matter how remote, of legally obtaining information, records, and testimony concerning the clergy who sexually assaulted them as children or what church officials knew about the abuse.
Clergy sex abuse survivors who testified before Kelly detailed how, instead of receiving healing and assistance from Dolan’s program, they were re-traumatized by it. One victim, for instance, described in painful detail how, if she was to receive any assistance through Dolan’s program, she was forced to travel to the church grade school where she had been repeatedly sexually assaulted and point out to a diocesan official each room and every hallway where she had been molested by the priest.
Dolan conveniently brokered his promotion to New York just in time to leave Milwaukee before the archdiocese filed for bankruptcy. Now that we are beginning to see the results of his seven years as CEO of the archdiocese, the questions Dolan needs to return to answer under oath in Milwaukee are mounting, including evidence that he moved at least 130 million dollars into bogus financial entities before the bankruptcy filing and claiming that he was selling the archdiocesan headquarters while concealing its ownership under a school that has not operated for 30 years. Now, as Judge Kelly has determined, we can add a bogus mediation program to this growing list, where abuse victims had no choice for desperately needed therapy and assistance but to crawl back to their abusers and those who covered up their crimes. ”
Statement by Peter Isely, SNAP Midwest Director
As if on cue to our discussions, Megan McArdle just posted this to her blog. I wanted to share it mostly for her conclusion:
“On the policy level, there is a tendency to assert that because a program contains a lot of proposals to control costs, that the legislators or regulators who enact it should get credit for actually having done so. But health systems, like human bodies, are very complicated. They are not bent easily to our will.”
Mr. Mazzella’s post seems extremely tendentious. What does Dolan’s Milwaukee experience have to do with the issue at hand? Of course, appending a SNAP statement sums it all up.
Yet another one from McArdle:
Why Hasn’t Anyone Signed Up For the High-Risk Health Insurance Pools?
http://www.theatlantic.com/business/archive/2011/06/why-hasnt-anyone-signed-up-for-the-high-risk-health-insurance-pools/239833/
Sorry to multi-post, but trying to broaden the conversation. Here’s an excellent piece from Reihan Salam. I think the following is his salient point:
“What I will say is that the reaction to the Ryan plan from the left has been sobering. Rather than attacking it and moving on to a case for Rivlin-Domenici, Democrats see an opportunity to double down on a deus ex IPAB approach that hands over political responsibility for Medicare cuts to an appointed board with an ill-defined mandate to be formed in the future. They sense that this is a political winner, and that now is decidedly not the time for compromise.
This post is prompted in part by Joe Nocera’s mostly sensible column on RyanCare. The not-sensible part was the following:
The Ryan plan, which would give seniors a fixed amount they can use to buy health insurance, would undoubtedly shift the cost burden over time from the government to seniors themselves, making health care far less affordable for millions of people. Ryan says that “empowering” health care consumers will help control costs, but that’s absurd: Medicare itself has far more pricing power than the people who actually need treatment.
One of the ideas behind the Ryan plan is that Medicare FFS stymies beneficial provider consolidation, and that provider fragmentation and the resulting lack of business model innovation is a powerful driver of cost growth. This might be wrong, but it’s hardly absurd.”
@Jeff Landry (2:43 pm) Sorry, I had a little trouble following your last post. Are you agreeing with Nocera that “Medicare itself has far more pricing power than the people who actually need treatment”, or disagreeing with him?
@Irene
Is it possible that the Abp. Dolan believes (though you may disagree) that marriage is a more fundamental institution than federal government safety net programs, and thus changing the definition of marriage demands a more vigorous response than changes to these programs?
Again, I’m not saying you have to agree with that, but is that a position within the realm of reasonableness and consistent with the values Abp. Dolan has professed?
I am, via Salam, disagreeing with him. The Nocera quote is:
The Ryan plan, which would give seniors a fixed amount they can use to buy health insurance, would undoubtedly shift the cost burden over time from the government to seniors themselves, making health care far less affordable for millions of people. Ryan says that “empowering” health care consumers will help control costs, but that’s absurd: Medicare itself has far more pricing power than the people who actually need treatment.
Salam’s response:
One of the ideas behind the Ryan plan is that Medicare FFS stymies beneficial provider consolidation, and that provider fragmentation and the resulting lack of business model innovation is a powerful driver of cost growth. This might be wrong, but it’s hardly absurd.
Which is actually consistent with the point I made earlier: simply saying “There is not market for health care” does not mean “there can be no market for health care.” Indeed, it is partly the role of government that has prevented such a market, at least according to Salam. Again, just another view.
“marriage is a more fundamental institution than federal government safety net programs,”
… or, to bat the rhetorical ball in the other direction, “the government’s definition of marriage is more fundamental than caring for the poor.”
“I will admit that we started from a higher baseline because of our urban/teaching hospitals, but the rate of growth is faster and the rate of growth is across the board not just at these hospitals. Interestingly, a recent report on Mass health care indicates that the fancy and more expensive care at these hospitals as to most ailments is no better than in our suburban community facilities at something like 60 or 70% of the cost.”
Sean.
It seems to me that comparing the city with the suburb hospitals isn’t exactly a fair comparison, unless Massachusetts suburbs are different from ours. Our suburbs are richer than the city, and when people in the suburbs require more highly specialized care they go to the city hospitals with their med school faculty doctors. Also, the city hospitals treat indigent people who are less educated and no doubt take less good care of their health than the suburban educated population, so they probably need more and more sophisticated care.
In other words, I would expect our suburban hospitals to spend less money than the city ones, because on average their patients are probably not as sick.
At any rate, I think the new thread above about Daniel Callahan’s article about the limits of medical intervention is probably relevant here.
“Generally speaking, in the food “market”, there are many buyers, many sellers and relatively equal access to relevant information. Government regulates weights and measures, health and safety of food production, shipment and storage, display of pricing and nutritional information. For most food, government does not set prices. Given those conditions, food stamps make sense as a means of preventing hunger and providing access to the food “market” for poor people.
“In health care, by contrast, there are many buyers, few sellers, and relatively unequal access to relevant information. When, for example, at a routine checkup my doctor says my heart is beating so irregularly it’s not safe for me to walk or drive, and therefore she’s called an ambulance to take me to the hospital where her colleague will implant a pacemaker, that’s not a situation in which a “market” model works efficiently.
“It’s also not a situation in which a “health care stamps” program would work well. I went to the doctor’s office expecting to pay for a routine visit. I ended up with major surgery and a hospital stay. I would not have had enough “health care stamps” to cover those expenses. This is, arguably, the type of situation in which a social insurance model (like Medicare, or some other large-scale”
Luke Hill –
Excellent analysis! I repeated the text because it certainly bears repeating.
It seems that all the Republican plans want to cut services very, very drastically, cutting out even whole core programs. What will the elimination of those jobs do to the unemployment figures? Will the Republican programs have the unintended consequence of worsening job opportunities?
“Mr. Mazzella’s post seems extremely tendentious. What does Dolan’s Milwaukee experience have to do with the issue at hand?”
I offered specifics. You offer generalities and non sequitors. We can only assess a person from his behavior, past and present. When the behavior continues the evidence is reinforced. He manipulated and equivocated in Milwaukee. Likewise in New York. He is not partisan. He just agrees with one part despite his protestations. He is more interested in preventing same sex marriage than helping New Yorkers get jobs. Unless you can show differently.
Another reason health care is not like groceries is that even the provider does not completely know what product he will end up providing.
A can of pinto beans is essentially the same as the can next to it, and both are essentially the same as the cans at the store across town. But doctors will tell you every patient is like a whole new disease. Tests are often ambiguous, symptoms can have very many possible explanations, diseases are unpredictable, patients differ genetically and physiologically.
It’s more like buying art. If everybody needed paintings to hang on their walls, nobody would suggest giving people “art stamps.”
Felapton,
Nonsense. A lot of health care is exactly like a can of beans. Even as patients are different a large majority of treatments are fungible, and their pricing makes no sense. An MRI of a shoulder is an MRI of a shoulder even if the full raft of treatment is very different from patient to patient. There is no reason that one should cost $500 and another $1000, and they wouldn’t in a market where the consumer had insight and would benefit in making the choice. The “art” of medicine is not a reason that market forces wouldn’t work.
Laser eye surgery and cosmetic surgery have several things in common over the last two decades. Once the province of the very wealthy, they have become technologically more and more advanced, more available, and way way cheaper while at the same time being highly profitable to providers. The same thing is now happening with cosmetic dentistry. They are also some of the only areas in medicine where market forces and consumer choice prevail.
Ann,
The recent studies here account for that. It is in the routine or common treatments that price differences are the greatest. Taking out a gall bladder in Boston shouldn’t cost 50% more than taking one out in Worcester – even in the same system of hospitals. Part of the reason the big urban hospitals charge more is because they are in greater demand. Patients think they are better and want to go there when they are no better statistically than community hospitals. Your point about information is valid, and it’s even more reason to let people who get treatment have more economic responsibility for the choice. You have no motive to get information and the providers none to make it readily available. In a market that’s not the case.
You picked the easiest examples, Sean. Try harder. What about, say, treating cancer?
“It seems that all the Republican plans want to cut services very, very drastically, cutting out even whole core programs.”
This is not an overly partisan issue; all of the major fiscal reform plans involve massive spending cuts, from Bowles-Simpson (which was about 3-1 spending cuts to tax increases) to Pres. Obama’s own suggestion to cut $5 trillion from the budget. Progressives like to point to the defense budget, but aside from the merits of cutting defense, those cuts also entail job cuts (perhaps more directly than other cuts). Again, not a left-right issue.
This is a link to the Pete Peterson Fiscal Summit held last week (where Pres. Clinton agreed with some of Ryan’s proposals). It has a nice summary of all the leading proposals across the ideological spectrum.
http://www.pgpf.org/Issues/Fiscal-Outlook/2011/01/20/PGPF-Announces-Grants-to-Six-Institutions-to-Develop-Solutions-to-Americas-Fiscal-Challenges.aspx
Again, this is my whole problem with the progressive critique of Ryan as a lying hypocrite who doesn’t really care about the poor; show me the morally acceptable spending plan on the table now (that can be passed by the Congress). So far, I haven’t seen one. When the GOP was labelled the Party of No, we heard constantly that it was not sufficient to just criticize, you had to have a plan. Well, where’s the plan? Again, the President’s OWN budget didn’t get a single Democratic vote in the Senate last week. The reality this shows is that Democrats are content to sit back and reap the short-term political gains to get to the next election, and avoid any compromise. But all we hear about is how morally bankrupt Ryan is.
““Generally speaking, in the food “market”, there are many buyers, many sellers and relatively equal access to relevant information. Government regulates weights and measures, health and safety of food production, shipment and storage, display of pricing and nutritional information. For most food, government does not set prices. Given those conditions, food stamps make sense as a means of preventing hunger and providing access to the food “market” for poor people.”
Actually, in the consumer grocery market, there are many buyers and relatively few sellers – just like in health care. The big difference between the two is that in the consumer grocery market, government does not distort the market’s pricing function by unilaterally dictating the price for a huge portion of the market. Joe Nocera is categorically wrong in referring this as government “pricing power”. It’s price fixing, pure and simple, decreed and enforced by the authority of the government. And, as has been discussed here many times and agreed to by folks of all ideological stripes, that price fixing profoundly distorts the market pricing for health care – e.g., it impels hospitals to charge unaffordably high retail prices for its services to those who lack insurance.
“In health care, by contrast, there are many buyers, few sellers, and relatively unequal access to relevant information. When, for example, at a routine checkup my doctor says my heart is beating so irregularly it’s not safe for me to walk or drive, and therefore she’s called an ambulance to take me to the hospital where her colleague will implant a pacemaker, that’s not a situation in which a “market” model works efficiently.”
In fact, your scenario is replete with market-model behavior. Your doctor is one you have freely chosen after doing some upfront due diligence and whom you’ve kept on because you’re satisfied with the services she and her practice render. If you had been dissatisfied with her service – because she or the practice was incompetent, or they couldn’t fit you in for appointments when you needed them, or for any of a hundred other reasons, you would be free to choose another doctor – constrained, in reality, by the supply in your community and quite possibly by insurance affiliations. Also, she is affiliiliated with the hospital to which she sent you because it make mutual economic sense for her and for the hospital.
“It’s also not a situation in which a “health care stamps” program would work well. I went to the doctor’s office expecting to pay for a routine visit. I ended up with major surgery and a hospital stay. I would not have had enough “health care stamps” to cover those expenses. This is, arguably, the type of situation in which a social insurance model (like Medicare, or some other large-scale”
‘Health care stamps’, like food stamps, is, in economic terms, a form of currency, just like dollar bills or Euros. Conceptually, food stamps work just fine for buying any quantity of food from a stick of gum to a pallet of pinto beans – you just need enough food stamps to transact the purchase. Same with ‘health care stamps’. If the proposed program, whatever it is, only gives you enough health care stamps for routine, primary health care but not enough for catastrophic care, then the program is flawed. But it’s a very easy problem to fix: just increase the number of stamps such that catastrophic care is covered, too. What isn’t clear to me is why you would assume that the proposed Ryan plan wouldn’t cover catastrophic health care. I believe that they believe that they’ve got it covered.
FWIW, here’s my view.
I agree 100% with Eduardo and others that we can and must evaluate the Ryan plan according to the principles of Catholic social teaching.
I also agree with Archbishop Dolan (and Eduardo) that such evaluations are exercises in prudential judgment.
Here is an element that I don’t believe has been sufficiently highlighted in this discussion, though: we never evaluate a policy in isolation and give it a simple yes-or-no. Policies are always evaluated according to this criterion: ‘given the range of policy options, which policy option is the best?’
The Ryan plan must be evaluated on that criterion: not, ‘is it good enough?’, but rather, ‘is it better or worse than the alternatives?’
That implies that there is one or more alternatives. What are the alternatives to the Ryan plan?
It seems clear, in the absence of a serious and comprehensive alternative by the Democrats, that the default alternative to the Ryan plan which American citizens are being presented is … the status quo. Democrats are, in effect, saying, “you can have the Ryan plan, or you can have free and unlimited health care, just like you do now, for the rest of your lives.” Well, that’s a no-brainer. Free and unlimited is always better than paid-for and limited.
Returning to the central issue raised by this post—how bishops exercise their role in the public square—I’m grateful for John McG’s observations above. I think I agree with him that we (the laity) owe the bishops some measure of what we might call a “presumption of good will” regarding their statements (e.g., Archbishop Dolan’s letter to Chairman Ryan). (In a somewhat different arena, I though Sr. Elizabeth Johnson’s reply to the bishops’ committee critique of her book was a good example of just such a presumption.)
Having said that, I think some (many?) of our bishops would be well served by a greater awareness of the potential (and actual!) damage done to their teaching authority by the perception that the tone and/or content of their teaching varies depending on political affiliations.
A second, and somewhat related issue is the importance of reason in episcopal statements. Poorly reasoned teaching (“Humane Vitae” is a notable example) will not (or may not) be followed by the laity, and will (or may) weaken episcopal teaching authority on other (particularly related) issues.
Speaking of groceries, here is a metaphor to the Medicare situation that a friend ran past me. I believe it has some merit.
Suppose a village has a very poor harvest. Consequently, there will not be enough food to feed everyone the amount they’re accustomed to from now until the next harvest, still a year away.
One choice would be for everyone in the village to tighten their belts, eat less than they’re accustomed to and less than their stomachs tell them they should. There will be quite a bit of suffering for a year, but with luck, everyone will survive until the next harvest.
The other choice would be for everyone to continue eating as much as they want, whenever they want to. But sometime in winter or spring, the village will run out of food. The strong and healthy may survive. The rich will have food brought in from other regions where the food is plentiful. The old, the poor and the weak will almost certainly die. Naturally, this scenario of inequality and death of a large number of villagers is expected to lead to discord and dissension, perhaps even violence, when it becomes known in the village. So the village elders prevent it from being known as long as possible. They tell the villagers not to worry, that there is plenty of food, that any rumors of a food shortage are greatly overstated.
@Jim Pauwels (10:16 am) Thanks for your thoughtful response. You may well be correct when you write “I believe that they believe that they’ve got it covered,” regarding Ryan’s plan for Medicare and Medicaid. The problem for supporters of Ryan’s plan is that their belief does not accord with reality. Here’s how Gene Sperling, director of Obama’s National Economic Council, put it:
“But from a policy perspective, from a values perspective, we should be very deeply troubled by the Medicaid cuts in the House Republican plan. I want to make clear what they are. This is not my numbers, this is theirs.
After they completely repeal the Affordable Care act, which would take away coverage for 34 million Americans, according to the Congressional Budget Office. After they’ve completely repealed that, they do a block grant that would cut Medicaid by $770 billion. In 2021, that would cut the program by 35 percent. Under their own numbers, by 2030, it would cut projected spending in Medicaid by half. By 49 percent. So, of course– I don’t think– or imply any negative intentions or– lack of compassion. But there is a tyranny of the numbers that we have to face.
And here’s the tyranny of the numbers. Sixty-four percent of Medicaid spending goes to older people in nursing homes or families who have someone with serious disabilities. Another 22 percent goes to 35 million very poor children. Now I ask you, how could you possibly cut 35 percent of that budget and not hurt hundreds of thousands, if not millions of families who are dealing with a parent or a grandparent in a nursing home, or a child with serious disabilities.
[...snip...]
So when we say that there– that the tyranny of the math is that these– these– this Medicaid– program, this Medicaid cut will lead to millions of poor children, children with serious disabilities, children with autism– elderly Americans in nursing homes losing their coverage or being– or– or having it significantly cut, we are not criticizing their plan. We are just simply explaining their plan.”
Hi, Luke, I agree that Sperling is highlighting some major concerns regarding the Ryan plan.
My view is that, from a Catholic social teaching perspective, that Sperling is right to focus on Medicaid. We need to consider Medicare and Medicaid separately. Medicaid is a means-tested program that focuses specifically on the needs of the poor – a group that is, from a political perspective, a minority and relatively disenfranchised. Medicare is a universal socialized-medicine-model benefit open to everyone, rich, poor and in-between, who reaches the qualifying minimum age. Medicaid and CHIPS are concrete instances of the preferential option for the poor. Medicare often is, too – but also in many cases is not. As someone (may have been P Flanagan) noted in a previous thread, Medicare is also a vehicle for enabling 2nd homes and luxury cars for retirees, and conserving their assets for their heirs. I’m not saying that’s a bad thing – it may be a good thing for our society, provided it’s financially solvent.
The Ryan folks would need to reply to Sperling. I’m not enough of a health care policy wonk to know in detail what their reply would be.
Grant,
Laser eye surgery is simple? Besides, what about complex treatment means it would not respond to market forces?
First of all, you hit on one of the fundamental problems with health care “insurance” in the US. A huge portion of it is not “insurance” at all. I insure my car against an accident, I don’t insure it for an oil change. Huge quantities of resources are wasted on routine health care matters because of this system. If we encourage a system in which people are incentivized to plan for and make informed decisions about the routine, it will make more resources available for the complex.
Also, the Ryan plan would still be an “insurance” plan like we have with the current Medicaid system. The central difference will be that spending decisions will be made by lower level health care consumers and not centrally dictated.
@Jim Pauwels (6/3, 10:26 am) I’m struck, with this issue as with so many, at how we all (myself included) can so easily get swept up in the moment and lose sight of the larger context. This observation is sparked by your statement regarding “the absence of a serious and comprehensive alternative by the Democrats” to Ryan’s plan. (Leaving aside for the time being the numerous, well-documented ways in which Ryan’s plan simply doesn’t add up, and thus fails one basic test of seriousness.)
In the early and mid-20th century, poverty among old people in the US was much higher than it is now. Social Security and Medicare are the two main reasons that old people are less likely to be poor than younger people today. Ending Medicare and/or Social Security would thrust more old people into poverty and destitution.
The US does not have a Medicare and Medicaid cost problem. We have a health care cost problem. (Medicare and Medicaid costs are lower than other health care costs.) Up until the 1970s, US health care costs were roughly similar to those in other industrial democracies. Since then, our health care inflation rate has been the highest in the industrialized world. In addition, we are the only industrialized democracy without universal health care coverage; and, by most measures, the industrialized democracy with the health care system most subject to market forces.
The last time Republicans controlled the federal government, their major health care reform was Medicare Part D—which has many merits, but increased the federal deficit. The last time Democrats controlled the federal government, their major health care reform was the Affordable Care Act—which has many merits, but decreases the federal deficit over the next 20 years.
My conclusion from this broader context (both internationally and historically) is that the Democrats don’t lack for a “serious and comprehensive” approach to health care reform and cost controls. We can debate the merits of their approach, but I just don’t think it’s accurate to say they don’t have one.
@Sean Hannaway (6/3, 2:35 pm) Grant can speak for himself as to what he had in mind when he called laser eye surgery “simple”. Here’s what I think:
Laser eye surgery is amazing, near-miraculous stuff, but in today’s medical world it’s pretty basic. Laser eye surgery typically is:
*a scheduled, not an emergency, procedure;
*a day procedure, not requiring hospitalization;
*a procedure requiring one, or at most two, medical professionals;
*performed on patients with no (or few) other major health problems;
*optional in the case of patients seeking to replace or avoid the need for eyeglasses.
Contrast that emergency room surgery on a car crash victim with multiple bone fractures, internal organ injuries and loss of blood.
Or with end of life care for someone suffering some form of dementia.
In both cases, the patient/consumer is—at that moment—unable to (among other things) be an active participant in the health care “market”. She does not have access to the same information as the people caring for her. The car crash victim does not have a “choice” as to which hospital she is taken to (particularly if she’s away on a business trip or vacation). The patient with dementia may not remember a conversation from 10 minutes ago.
I think the market is a wonderful human creation and useful for many purposes and situations. And I think economic incentives play a major role in health care, and can play a major role in expanding coverage and reducing the growth of costs.
But I see no evidence, here in the US or in other industrialized countries, of a “free market” health care system that provides needed, basic health care for all people.
” The US does not have a Medicare and Medicaid cost problem. We have a health care cost problem. (Medicare and Medicaid costs are lower than other health care costs.)”
Hi, Luke, you’ve misstated the problem. We have a deficit problem. That is what Ryan’s plan is intended to address.
The deficit problem is real and must be addressed. Yes, Republicans have contributed to it over many years. So have Democrats. But after we’re done apportioning the blame, we still need to deal with the crisis.
Theoretically, there are many ways that a budget can begin to attack the deficit problem. There are many components to the budget, and changing the math on any or all of them can result in a budget that begins to address the deficit issue. Government health care spending could remain what it is, or even increase, if spending is curtailed elsewhere. All that really matters is that, when one subtracts the outflows from the income, the difference is less negative than it has been for the last few decades.
Earlier this year, our President submitted a budget that utterly, completely, blithely ignored the deficit problem – and this in the wake of his party, under his leadership, getting its clock cleaned in mid-term elections, precisely because of the deficit, just a couple of months earlier! Subsequently, Congressional Republicans shamed him into presenting a revised budget that does a little better, but does nothing substantive to address the primary drivers of the accumulating deficit, which are health care programs and, to a not quite as exigent extent, Social Security.
At this point in time, that revised budget proposal is, by default, the Democrats’ plan.
My summing-up of the President’s (and by extension the Democratic Party’s) plan to address the deficit is: ‘We plan to not address the deficit. We are going to continue with the status quo. Our constituents are happy with Medicare, Medicaid and Social Security, so we will permit expenditures on these programs to continue to pile up federal government debt. Either our children and grandchildren will need to pay it down by drastically curtailing necessary government services (but we don’t care because we’ll be long gone); or the government will default on its debt obligations (but we don’t care because we’ll be long gone); or an amazingly long string of years of amazingly robust economic growth will allow us to pay off the debt (we hope that happens, but at any rate, we’ll be long gone).’
My understanding is that this is the dynamic that played out in the recent special election to fill the vacancy in New York’s 26th congressional district: the Republican supported the Ryan plan, while the Democrat, who was victorious, ran on the status quo.
Do you see the moral bankruptcy of the Democrats’ position? And do you see how galling and offensive it is to observe the spectacle of progressives attempting to wrap the mantle of Catholic social teaching around themselves and trying to claim the moral high ground by critiquing the only concrete plan out there to do something about the serious moral problem of the deficit?
You and I agree that the Ryan plan has substantial flaws. Nobody would be more pleased than I to see President Obama or Democratic leadership in Congress propose a concrete alternative that addresses the moral problem of the deficit at least as well as the Ryan plan, while providing at least as reliable a social safety net. But unless and until they do, it is Republicans, despite their previous sins, who deserve the credit for moral seriousness on this issue.
“Security and Medicare are the two main reasons that old people are less likely to be poor than younger people today.”
Not so fast. You left out the savings of the middle class people in the olden days. They’re old now, and of course they have income investments — they didn’t spend it all their money when they were young.
Young people today are poor mainly because there are not enough jobs for them. Not their fault, but don’t oversimplify. Also notice that Medicare also makes jobs.
Luke –
I apologize for jumping all over you about the reasons old people are not so poor as some other groups. But I feel very strongly that saving is a major problem in the U.S. economy and has been for a couple of generations. But nobody — Democrat or Republican seems to mention it. And when I look at the savings of the Chinese and their (so-far) booming economy, I get really, really worried about my grand-nieces’ generation.
You can say it’s none of my business the way other folks spend their money, but the way the young and the middle aged with jobs buy new cars regularly (I kept my first one 14 years!), take mini-vacations, go out to eat at really good restaurants regularly, etc., even in hard times, amazes me. Yes, if you have disposable income in hard times, then, yes, it’s a good thing to spend some — but it’s also a good thing to pay off debts and save But the middle-aged and young don’t seem to accept the fact that saving always requires not-buying-something-now-that-you-really-really -want.
@Ann Olivier (2:08 & 2:23 pm) No need to apologize. I won’t argue on the importance of saving. It’s worth (I think) noting that a major reason for the high savings rate in China is that they have nothing like Medicare, and so virtually all health care expenses that the elderly incur must be paid for out of pocket.
Middle class people “in the olden days” (by which I assume you mean the mid and late 20th century!) often had the advantage of defined-benefit pensions, which have mostly disappeared for today’s workers.
More to the point, the bottom half (economically speaking) of today’s senior citizens—those who were working and saving (or trying to) in the “olden days”— depend almost entirely on Social Security and Medicare to keep them from destitution. (That’s a fact I fear gets lost in some of our discussions of these issues.)
@Jim Pauwels (10:08 am) Okay, if the larger problem is deficit spending (and the resulting growth in federal debt), I’m happy to reflect on that.
I’ll start by quoting a brief rant on the subject by Kevin Drum (a neo-liberal who somehow has ended up blogging and writing for “Mother Jones” magazine):
“Republicans didn’t care about the deficit when Reagan was president, they didn’t care when Bush Sr. was president, and they didn’t care when Bush Jr. was president. They only get religion when a Democrat is president and they need an all-purpose reason to oppose everything Democrats want to do. Is this really too complicated to understand? It’s a political tactic — and a good one! — not a genuine reaction to anything in the real world. In the real world, stimulus spending is winding down, Medicare was reformed a mere 14 months ago and is solvent for at least another decade, Social Security is solvent for two or three decades, and the deficit is very plainly not a domestic spending problem. It wasn’t a problem at all until 2001, and after that it was caused by two gigantic tax cuts, two unfunded wars, and a finance-industry driven recession. If we just let the tax cuts expire, get out of Iraq and Afghanistan, and get the economy moving, the medium-term deficit will disappear. In the meantime, grinding unemployment in the United States is really a wee bit more important than continuing to humor Republican political posturing.” (For the full context, see http://motherjones.com/kevin-drum/2011/06/five-things-im-tired .)
Second, I’ll again reference work done by the Center for Budget and Policy Priorities (using CBO data and projections). (And yes, I’m aware CBPP is a liberal think tank, but so far as I know, nobody has questioned the accuracy of these numbers.)
CBPP finds that by 2019, under current law, the Bush tax cuts and the Iraq and Afghanistan Wars will account for nearly half of total federal debt. The current economic downturn, spending for recovery measures, and for the rescue of the financial system (TARP, Fannie Mae, Freddie Mac) will account for a little over a quarter of total federal debt. All other spending in the 200+ year history of the Republic accounts for the rest. http://www.cbpp.org/cms/index.cfm?fa=view&id=3490
Luke Hill writes:
“The last time Democrats controlled the federal government, their major health care reform was the Affordable Care Act—which has many merits, but decreases the federal deficit over the next 20 years.”
But this is only potentially true. The CBO scored the plan ASSUMING all parts of the bill become effective, and as I’m sure you know, the biggest cost-saving features of the plan require FUTURE Congresses and Presidents to act. This is espcially true of IPAB and the so-called “Cadillac” tax, or surcharge. BOTH require future Presidents and Congresses to take action. So you can’t ague that ACA IS cutting the deficit, only that it MIGHT cut the deficit IF and only IF these future features are enacted.
He further writes: “Ending Medicare and/or Social Security would thrust more old people into poverty and destitution. ”
Of course this is a straw man; no one is proposing “ending” Medicare or Social Security. Rather there are various bipartisan proposals to significant re-constitute some of these programs to ensure their survival AND their effectiveness. You are right when you say “My conclusion from this broader context (both internationally and historically) is that the Democrats don’t lack for a “serious and comprehensive” approach to health care reform and cost controls”, but I would also submit that from the Ryan (and other conservative plans) that the Republicans don’t lack for a “serious and comprehensive” approach to entitlement reform, and so far, the Democrats only believe that you can cut the much-lamented “waste, fraud, and abuse” from the programs, tinker with tax rates on a small percentage of taxpayers, and maybe cut some from defense, and the party can go on. That belief, I think, is just as mistaken the conservative belief that health care costs will be brought down by the magic hand of the market alone.
Furthemore: “CBPP finds that by 2019, under current law, the Bush tax cuts and the Iraq and Afghanistan Wars will account for nearly half of total federal debt.”
Ok, then why didn’t the Democatic President end these with the support of the Democratic-controlled Congress during the first years of his administration? I mean the finger pointing can go on and on and on and on…let’s get serious and do something about it. Kevin Drum’s beef isn’t with Republicans, but rather politicians, who being politicians are only motivated by the short-term. I can point out, as I have before, the curious newly-found silence of “anti-war” liberals when it came to the President’s Libyan adventure. But it seems disingenous or at least unhelpful to point to past behavior as a way of discrediting current arguments and proposals.
I meant to post this again with my response, but forgot. I think they go to Luke’s points about ACA.
Why Hasn’t Anyone Signed Up For the High-Risk Health Insurance Pools?
http://www.theatlantic.com/business/archive/2011/06/why-hasnt-anyone-signed-up-for-the-high-risk-health-insurance-pools/239833/
Medicare Pilot Program Fails to Achieve Significant Cost Control
http://www.theatlantic.com/business/archive/2011/06/medicare-pilot-program-fails-to-achieve-significant-cost-control/239830/
“Middle class people “in the olden days” (by which I assume you mean the mid and late 20th century!) often had the advantage of defined-benefit pensions, which have mostly disappeared for today’s workers.”
Luke –
I’m not sure how many people had pension plans then, at least not in the South. You had to work for a pretty prosperous company to have one or the government. That’s why Social Security was laterf so terribly important — for many people it was SS or real hunger, even starvation.
I suspect that the main reason people of my generation saved so much is because they knew what a depression could do — wipe out everyone, including much of the middle class. I”m not known as a skin=flint, but I do remember seeing what no money does to many, many people, so I saved, even given the meager salaries of women then. I expect this new younger generation — as soon as they get jobs — will feel somewhat the same way. They aren’t sure of Soc. Sec. anymore. Which is a national disgrace.
Luke –
Also, you’re right about the bottom half of the old folks contingent. They’re the lower-middle class, and as usual they pay thru the nose for everything, and what do they get in return? Federal taxes that pay for Medicaid for people who don’t work, and, if they’re under 65, no themselves have neither insurance or Medicare to pay for their own illnesses. No wonder they’re cynics about government.
The Republicans were surprised at New York 26, but they shouldn’t have been.
By the way, does anybody know what percentage of the Republican party is lower=middle class financially?
Luke,
The scenario you describe is one in which a true “insurance” market would work. Unfortunately, what we call health insurance is really pre-paid (or borrowed for) health care with an insurance component. It’s like bundling the cost of replacing my air filters and and pumping my septic system with my home owners insurance – and then having it subsidized and heavily regulated by the government. It’s not efficient and distorts the market. The competion I am speaking about, moreover, would be for the insurance, not the market choice for which hospital to choose after an accident.
@Sean Hannaway (6:18 am) Thanks for this post. It brings us to another episode of “talk to me like I’m stupid”: what do you mean by a true “insurance” market?
I ask because it seems to me that there are significant differences between insuring and maintaining, say, houses, and insuring and maintaining human health. Human health (and the related costs) seems much more variable and unpredictable, no? In addition, we tend to value human life differently than we value property. So what’s a true “insurance” market? How does it work? What’s the best national example of a true “insurance” market in health care?
Like I said, talk to me like I’m stupid.
“By the way, does anybody know what percentage of the Republican party is lower=middle class financially?”
I don’t really think you want to go here in light of Bunny Mellon and John Edwards. Or Goldman and Team Obama.
I’m wondering if Pelosi’s position passes moral muster?
http://thepage.time.com/2011/06/05/pelosi-draws-line-on-medicare/
Jeff Landry posted this link to a Megan McArdle column:
http://www.theatlantic.com/business/archive/2011/06/medicare-pilot-program-fails-to-achieve-significant-cost-control/239830/
… which is well worth reading.
Brief summary: Medicare funded an experiment – authorized by the Bush Administration – to incentivize doctors’ groups to control Medicare costs: the doctors’ groups receive a bonus if they are able to reduce their Medicare costs by 2%. The Affordable Care Act includes a similar incentivize-the-doctors approach to control Medicare costs.
The results are disconcerting: a couple of practices did very well, a few did very poorly, and the rest had mixed results. McArdle’s view seems to be that the experiment failed: 10 doctors’ groups who seemed to be well-positioned to attain a very modest goal couldn’t manage it.
My observation is that these results should be disconcerting to Democrats, who want the ACA provisions to be successful – but also disconcerting to Republicans. This use of the government to incentivize good market behavior (rather than simply and nakedly subsidize the costs) is pretty key to Republican approaches to control health care inflation while maintaining the social safety net.
Jeff –
Here ya are. In the Dolan letter thread on 6-5-11 at 10:14 a.m., you ask:
“I’m wondering if Pelosi’s position passes moral muster?”
Yoo then refer us to this site: http://thepage.time.com/2011/06/05/pelosi-draws-line-on-medicare/”
I checked the site, and it is a discussion by a number of people on Face the Nation, including Pelosi. You don’t even point to anything she says that you think might not “pass moral muster”. In other words, you haven’t really made a point about her at all — you’ve just raised a doubt about her integrity. And it’s not that that was just an aside in a wider post — that’s the whole post — implying that something (we’re not told what) might not pass moral muster.
Here’s another example. In this post you gratuitously point out the moral failures by Democrats failures which have no connection WHATSOEVER with what we’re talking about on this thread.
I had asked for a some information, thinking that someone might know the answer off the top of their head. But your answer goes into some totally unrelated moral failures of some Democrats.
I had asked : “By the way, does anybody know what percentage of the Republican party is lower=middle class financially?”
Your answer: “I don’t really think you want to go here in light of Bunny Mellon and John Edwards. Or Goldman and Team Obama.”
Your only point, Preacher, is that there are some immoral Democrats. And it’s TOTALLY irrelevant to what I asked about.
Sorry, I posted that on the wrong thread.