Commentary is a magazine of strong, and sometimes unpalatable, views. It is, perhaps, most famous as a neoconservative magazine: Norman Podhoretz is Commentary's Editor-at-Large. Other prominent contributors in a conservative vein are Gabriel Schoenfeld, Joshua Muravchik, and Victor Hanson Davis. In addition to its political side, Commentary, provides criticism, book reviews, and a "Letters" department that prints the longest letters I have ever seen in a magazine. Even though I disagree with the contributors more often than not, I find Commentary fascinating because the articles are usually well thought out, well-written, and thought-provoking. On top of all that, Commentary provides insight into Jewish (and Israeli) culture and thought which is all terra incognita to this Gentile.
The tradition of commentaries is long and rich. I would imagine that most of my readers have read Machiavelli's Discourses on the First Ten Decades of Tito Livio. (If you haven't, run right out and get yourself a copy.) In the Discourses Machiavelli uses the stories in Livy's history of Rome since the founding of the city to generate and illustrate a variety of political and military lessons. Many of the essays of Montaigne are also based upon his reading in the classics.
I am not trying to establish the essays in Commentary as equal to Ab Urbe Condita. I am merely invoking the tradition of one author using the words of another as starting point for his own reflections. There are, of course, other sources upon which one may draw as an inspiration for one's essays. In any event, I plan to comment upon a number of articles from Commentary. Those who are interested in seeing the orginals are invited to visit commentarymagazine.com.
The February 2007 issue of Commentary, is rich in material. Joshua Muravchik leads off with "Our Worst Ex-President," attacking Jimmy Carter's Palestine: Peace Not Apartheid as the centerpiece in our 39th president's array of crimes of omission and commission. Two articles on Iraq: "Realists to the Rescue?" by Bret Stephens and "Is Israel the Problem?" by Amir Taheri follow. I can recommend the Taheri article, although the question posed in the title is somewhat disingenuous. It is interesting to compare Taheri to some of the articles and essays in Bernard Lewis From Babel to Dragomans, as a study in the tendency of the Arabs to displace the blame for their failures and shortcomings onto the Israelis, the British, and, naturally, the United States. Gabriel Schoenfeld weighs in with "Why Journalists Are Not Above the Law." Hillel Halkin contributes an essay about Tel Aviv: "The First Hebrew City." Terry Teachout, the regular music and art reviewer, has sent in "Hitchcock's Music Man", a nice piece for anyone who has seen North by Northwest recently enough to remember the way in which Bernard Herrmann's scoring helps to maintain the pace and tension of the film.
The books reviewed include Dangerous Nation, by Robert Kagan (a neoconservative himself); The Emperor's Children, by Claire Messud; Dean Acheson: A Life in the Cold War, by Robert L. Beisner; Resurrection and the Restoration of Israel: The Ultimate Victory of the God of Life, by Jon D. Levenson; and American Islam: The Struggle for the Soul of a Religion, by Paul M. Barrett.
The particular article I would like to discuss here is by Eric Cohen and Yuval Levin, "Health Care in Three Acts." In the interests of full disclosure, let me note that one reason - the primary reason, I enjoyed this article is that I have an analytic bent. The original meaning of "analysis" goes back to the Greek for "breaking down" or "taking apart." I don't have any problem with big, sweeping measures to solve a lot of problems, but I think they should be based upon a process in which the problems are disassembled into their constituent parts and examined severally. This is what Cohen and Levin do in "Health Care in Three Acts." The key sentence comes near the end of the first page of the article (page 46 of this issue of Commentary, for those who are following along).
"In fact, America faces three fairly distinct predicaments, affecting three fairly distinct portions of the population - the poor, the middle class, and the elderly - and each of them calls for a distinct approach."
They go on to further analyze the problem of the poor, in which they break the 46 million uninsured Americans into:
- those who have lost insurance with their jobs
- those who are not American citizens
- those who are eligible for for Medicaid and similar programs
- those ("many of them young adults under 35") who could afford insurance but don't buy it.
The problem of the middle class, on the other hand, is "the uncertainty caused in part by the rigid link between insurance and employment and in part by the vicissitudes of health itself."
Finally, the elderly face different problems based on costs and end-of-life issues.
As Cohen and Levin note, such disparate problems are not susceptible of a single solution.
Let me note at this point that the portability of health insurance, with some means-tested subsidies, would take care of many people both the "poor" (i.e., the poor and the unemployed). There is a program now, COBRA, which allows people to retain their employers health insurance coverage, if they can pay the premiums. Take off the time limits, add a subsidy for those who can't afford the premiums, and allow coverage to continue if a new employer does not offer a health care plan, or if the employee has a pre-existing condition, and you would both eliminate many of the 46 million uninsured, and ease middle-class anxiety about the prospect of losing coverage. Add to that a campaign to educate poor people about the programs for which they are already eligible, and you narrow the numbers a lot. The big remaining question is: Do we, or do we not, want to provide health care coverage for illegal immigrants?
Cohen and Levin opine, and I find them persuasive, that the biggest problem we face, the one we've done least to solve, and the one that is going to be a killer, is how to manage health care for the elderly. Again, we can break this problem down into its constituent parts, but the big problem is that we are not facing the problem at all As Cohen and Levin say:
"Neither socialized medicine nor a pure market approach is suited to America's three health-care challenges, while the bipartisan conspiracy to ignore the looming crisis of Medicare in particular will return to haunt our children." (Page 52)
Let me give you their last paragraph, as they seek to balance practicality and compassion in a complex system:
"Even as we pursue practical options for reform, however, it behooves us to remember that health itself will always remain out of our ultimate control. Medicine works at the boundaries of life, and its limits remind us of our own. While our health-care system can be improved, our unease about health can never truly be quieted. And while reform will require hard decisions, solutions that would balance the books by treating the disabled and debilitated as unworthy of care are no solutions at all. In no small measure, America's future vitality and character will depend upon our ability to rise to this challenge with the right mix of creativity and sobriety."
Glenn A Knight
In my study
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11 comments:
Glenn - I'll skip over your first few paragraphs, except to say the following:
(1) As a Jew, I can tell you that most American Jews are profoundly opposed to the Commentary viewpoint on many things.
(2) Josh Muravchik was two years ahead of me in my high school. So I followed his work for awhile, until it became clear that, while to err is human, to be wrong as often and as fundamentally as he is (like saying our best ex-president is our worst) takes a major commitment to something other than truth.
(3) I've also followed the work of Norman Podhoretz (Commentary's longtime editor and shaper) on and off for decades, and I believe the following post is entirely just: http://www.salon.com/opinion/greenwald/2007/06/21/podhoretz/ (though I'd never trust anybody with a first name like that).
On to the main event: I think Cohen and Levin on health care are profoundly wrongheaded.
Assuming (as I do) you're reporting their argument accurately, my biggest problem is that they write about being insured as though it's like being pregnant - you either are or you're not. The plight of the underinsured in America is profound, covering much of the lower, middle, and even upper class. Michael Moore's movie "Sicko" (if you haven't seen it, you really should) is entirely about the plight of the underinsured - the uninsured are touched upon only briefly. There is a vast health insurance bureaucracy dedicated to denying coverage. This simply isn't a problem in other countries.
Second, their aside about COBRA - "if they can pay the premiums" - masks a serious problem. Insurance has to be offered under COBRA, but for many people who no longer have jobs, or have jobs that don't pay as much as their former jobs, the premiums simply are not affordable.
And as far as health care for the elderly being our biggest problem, that's the one we actually have handled, with something called Medicare - a universal, single-payer program with tiny administrative costs, devoting careful attention to what it covers. Contrary to the authors' "analysis", there IS a single solution, and that's it. It just needs to be expanded to the rest of the population. - Jay
Jay:
I hope all is well with you. It's good to see your words on the screen.
Very good point about the "underinsured". I’m printing a hardcopy of the article now and won't be able to read it till later today or tomorrow but I wanted to make a quick point about your comment.
One of the things I noticed after Ken pulled the plug on the old Cafe Board is that the politeness we exercised at that time (yes, I know, it wasn't always THAT polite) is hard to find currently on the internet.
I remember you as my correspondent for the best good-faith argument I ever had about a tough and emotional subject, but your preliminary remarks here could set a tense tone. We are not discussing Muravchik and your insinuation that he is a liar is gratuitous and distracting.
Again, nice to (virtually) be around you again.
Regards,
Zabeli
It's good to hear from any and all parties. I appreciate your comments, Jay. I should make one thing clear: it was my aside, not Cohen and Levin's, about COBRA "if you can pay the premiums." I thought I covered the point that many people can't afford the premiums by supporting a system with some subsidies for those who cannot afford the premiums.
I have not yet seen "Sicko." We have it in our Netflix queue. I look forward to seeing it.
If I had not read Muravchik's article "Borat!", in the January issue of Commentary, I would agree with you that his ideology has overwhelmed his perceptual fidelity. And it may be that he is such an ideologue that the "truth" is what his ideology, rather than his eyes, tell him. But "Borat!" shows that he has a certain amount of humor (though not enough to go through with an appearance on the Ali G. Show), and I hope that would prevent him from becoming totally blind to reality.
In any event, I appreciate Agim's comment. I think it is always best to assume that your opponent (adversary) is arguing in good faith, even when that seems incredible, and critique the arguments as given. Once you get into characterizing your opponent as a liar, you might as well just drop the subject: If he is a liar, there's no point in debating him.
Glenn-- As you note, "...the portability of health insurance, with some means-tested subsidies, would take care of many people..."
That would, indeed, go a long way toward solving the problem for the majority of those who find themselves in the middle class un- and underinsured no-man's land. Extending and tweaking COBRA may be a way to do this, but the subsidies for those too poor to afford the premiums would have a significant cost.
As Jay Gold notes, Medicare is hugely successful-- and amazingly efficient-- as our solution to health care for the elderly. However, as the number of elderly grows, the demand on health care providers will increase, and right now, that demand is squeezing them severely. No one likes to admit it, but the federal government currently is keeping Medicare costs under control solely by limiting the fees that doctors and hospitals can impose for services. In many places, the limited fees literally don't cover the actual costs of the care, so the providers increase fees for those who are insured. Such a system can't be sustained indefinitely.
Glenn concludes by pointing out that "The big remaining question is: Do we, or do we not, want to provide health care coverage for illegal immigrants?"
In many parts of the country (mine for instance, in north-central Washington State), this is the 800-pound gorilla in the corner of the room. About 30% of our local population is Hispanic, and an estimated 80% of them are illegals who are here for agricultural jobs. They are putting our local health care system into severe distress, since they neither get benefits with their jobs, nor do the jobs pay enough to allow them to buy private insurance. A glance into our hospital's emergency room nearly any hour of the day or night is sobering.
It's clear that the solution to the health care problem will be a complicated one, simply because there is not a single problem; rather, as the article in Commentary suggests, there is a group of closely related problems.
I keep thinking of that old Fram oil filter slogan: Pay me now or pay me later. That's probably the position we're in regarding our health care system.
I wasn't calling Muravchik a liar, exactly, I was saying that (in Glenn's words) "his ideology has overwhelmed his perceptual fidelity." One sees the same phenomenon in spades in the Current Occupant. I haven't read Muravchik on Borat, on whom he might be quite good. Perhaps he should stick to TV criticism.
Hi, Agim. Thanks for the kind words. I learned much from you at the Cafe, and I hope to do the same here.
Lloyd raises a good point. The Medicare trust fund is in some jeopardy long-term as the population ages. Probably a solution like the fix to Social Security a quarter of a century ago, which worked like a charm, is needed. Of course, if Medicare is expanded to the entire population, as I recommend, it will need a large new infusion of tax revenue - which is apt to be palatable to those who no longer have to pay those !@#$%^&* premiums and then fight for every ounce of coverage.
I'm going back to Cohen and Levin for a comment on the future of Medicare. When I add my own comments, I'll try to distinguish them clearly from the statements of the authors of the article.
First, they see a major problem in the cost of Medicare (and, by extension) Medicaid. They say, "Costs have risen steeply in recent years, while the economic footing of the Medicare program has been steadily eroding. Nor are demographic realities likely to change for at least a generation; to the contrary, they may only worsen. So the solution must involve some form of cost containment." (Page 51)
They go on to cite a book by Arnold Kling, called Crisis of Abundance: Rethinking How We Pay for Health Care, as supporting their concerns about cost. In essence, the increasing number of specialists and very expensive new technologies have driven medical costs up. These things would not be easy to give up, because they have positive benefits.
Then they point out that Medicare is now 15% of the federal budget, and is projected to be 25% by 2030. Long-term care, which is not covered by Medicare, cost Americans $137 billion in 2000, and may cost $207 billion in 2020. Much of the cost of long-term care is landing on Medicaid.
They go on to make suggestions about changing the age of Medicare eligibility, adding cost constraints, and so on.
Let me make the following comments on these points.
First, I'm not sure that the statement that the solution must involve cost containment is really supported by their argument. I suspect that, as with many conservatives, their aversion to additional taxes (an option they don't even mention) leads them to assume that the pie cannot be enlarged.
Second, Kling's book is published by the Cato Institute, and, for those who don't know, that is a prominent Libertarian think-tank. That doesn't make his information wrong, but it may lend a certain bias to his approach, as well as indicate something about where Cohen and Levin are coming from.
Third, the problem with long-term care is real. I have read elsewhere that, while the vast majority of Medicaid clients are young single mothers and their children, some 75% of the benefits are going to elderly people in long-term care. However, I also think that there are a number of measures that could be taken to alleviate the burden on Medicaid and the states.
First let me say it's great to see some of the folks from the Cafe again. Thanks for hosting a blog Glenn, and it's nice to see Jay and Agim again. I don't think I ever met Lloyd at the cafe, but I was a short timer there compared to many.
On to the topic at hand. This one holds some real interest for me since I watch both my taxes and my healthcare premiums increase every year.
Lloyd is correct about Medicare paying very little for procedures, and the medical industry passing the cost on to those who are insured. In addition insured patients also get a bit extra added to their bill to cover uninsured people who are not covered by Medicare.
I would like to posit a question that has not yet been covered. Why are insurance companies not Non-Profit Organizations? Perhaps this is my youthful ignorance (though I'm not terribly youthful anymore) showing through, but here's my understanding of things.
An insurance company is a shared risk pool. You put in your money every month hoping that you will not need the services covered by the insurance company. (Hoping you stay healthy). Thousands of people do this, and a certain number every month draw money out of the pool to cover broken legs, CAT scans, cancer treatment, etc. The amount you pay out of pocket each month generally determines how much is covered should you need to use medical services. Lower monthly fees mean higher risk assumed by you (eg. higher deductibles, co-payments or co-insurance, max out of pocket expenses etc.) Given these assumptions, which may be wrong, it seems to me that insurance companies would be prime candidates for an NPO-like structure where the policy holders effectively own the company.
So, what would everyone think of the idea of setting up one or more NPOs to act as insurance companies similar to Credit Unions vs. banks, to offer coverage without the need to make a profit? I'm counting on you guys to shoot holes in my suggestion.
Hi all. Jay, you wrote:
>I wasn't calling Muravchik a liar, exactly, I was saying that (in Glenn's words) "his ideology has overwhelmed his perceptual fidelity."
I'm off topic here, but I wanted to chime in saying that I happened this morning upon a clip of Chris Matthews take the wind out of Muravchik's "bomb Iran now" sails.
http://www.youtube.com/watch?v=h0VQAj1347Y
-Mark Brawner
Interesting point, Doug. In fact, a lot of insurance companies were, if not exactly non-profit organizations, something very similar. You will have seen the word "mutual" in the name of many insurance companies - Liberty Mutual, Mass Mutual, etc. A "mutual" company is one in which the owners are the policyholders, and the company pays a portion of its profits out to the policyholders either as dividends, or in reduced cost of insurance, in proportion to the value (and cost) of their policies.
Unfortunately, some mutual companies have converted to stock companies, to take advantage of the financial resources of the markets, and (I think) so that their managers can get disproportionate shares of the profits through the selective issuance of stock options to themselves.
A company with which I have had policies for many years, Provident Mutual, tried to convert to a stock company. When the policyholders refused to go along, the management sold out to Northwestern Financial.
This is an interesting example of something pointed out by Daniel Burnham, Milovan Djilas, and other Trotskyites turned conservative, many years ago. Supposedly, control of a societies assets belongs to the owners. Actually, it belongs to the managers. In capitalist societies, companies are not run by their shareholders; they are run by the hired management, which pays itself huge salaries and dominates the shareholder meetings. In socialist societies, where companies are owned by the "people," they are run by the managers, usually members of the party bureaucracy, or senior officials in the parallel government bureaucracy.
Glenn,
My father had a policy with Prudential I think, which later went public and he received stock as a policy holder.
I shudder as I ask this, but would this be a valuable place for governmental intervention?
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