Mar 272012
 

I’ve been reading the transcripts of and commentary about the US Supreme Court arguments taking place this week about the constitutionality of the “individual mandate” and associated penalty contained within the provisions of the Patient Protection and Affordable Care Act (2010).

Before I get into any analysis, a seeming triviality: many of the news reports about this case are noting the fact that its opponents refer to the act as “Obamacare,” as if this were some kind of novel piece of slang. It’s not. What’s new is that, ahead of these oral arguments, the Act’s supporters have started embracing the term instead of discouraging its use, as if Barack Obama himself has delivered this manna to the unhealthy. Frankly, I don’t think Obama has even read the full text of this legislation, so I refuse to give him sole credit (or blame) for it, and will refer to it by its acronym PPACA, which is the norm when referring to legislation of the American Congress. (What, did you think PATRIOT Act was capitalised because it’s a big deal? No: it’s because it’s the Uniting (and) Strengthening America (by) Providing Appropriate Tools Required (to) Intercept (and) Obstruct Terrorism Act of 2001. American politicians are nothing if not massively cheesy.)

Now let’s address why I’m writing this blog post. This case is an extraordinarily big deal, and you will have a hard time understanding why if all you read is the news media accounts of the arguments. The American media does not want to go into any great analysis of the issue, for fear that you might draw your own conclusions, and the British media does not understand the significance. In the British media in particular, you will find reporters utterly baffled by what appears, to them, to be a sneaky, underhand challenge of the president himself under the pretext of a legal technicality.

Whether or not a law, or a part of a law, is constitutional is simply not a legal technicality. The Constitution is the basis for all federal government in the United States. The federal government simply may not make laws that contravene, or surpass, what the Constitution allows it to do. The law, or the provision within the law, cannot be imposed upon the American people if it is not constitutional. And one of the basic rights Americans have is to challenge the federal government about the constitutionality of its laws. That British journalists don’t seem (or want) to grasp this, simply because they personally think the PPACA is a good thing, makes them shitty journalists.

So. What is the issue at stake?

The challenge to the PPACA is about the provisions in section 5000A, which require Americans to be covered by health insurance (whether purchased individually or through their employer) or incur a penalty. These parts of the law are collectively referred to as the “individual mandate” or the “minimum coverage provision.”

The challengers, in this case, are a number of American states and some associated individuals. Their basic contention is that the US Constitution does not permit the federal government to compel people to purchase health insurance when they are not purchasing health care services.

In this case, you have two participants: the challengers, and the US federal government (as represented by the Solicitor General). This case has gone through the federal courts already, and the Supreme Court agreed at the back end of 2011 to hear it. This is significant: the Supreme Court can choose not to hear cases, so the fact it has chosen to hear this one means the Court believes that there is enough doubt about the matter, or enough importance about the question at hand, to make it an issue worth settling. The Court’s decision is binding and, in this case, may also be precedent-setting. (This is kind of what puzzles me about the position of many British journalists; if the high court of the US thinks it’s important enough to discuss, who are you to call it a trivial technicality?)

But enough about British journalists. Part of the reason reportage about this case is so crappy is that there are lots of different strands of argument involved, not all of which make a lot of sense if you consider them in isolation.

For example, yesterday’s arguments centred around whether or not the Court could even hear the case. Here’s the background: as the case has made its way through the lower levels of courts, the government’s position has been that the penalty for not purchasing health insurance is, effectively, a tax, and taxes do not come under the jurisdiction of any court until the complainant has paid the tax, requested administrative redress, and been refused. Then, and only then, can the complainant bring suit. (Challenges to tax are covered under a law called the Anti-Injunction Act.) The government’s argument has been that, since the mandate and penalty/tax do not come into force until 2014, the law cannot be challenged on those grounds in 2012, because nobody has yet paid the tax and therefore nobody can at this point bring suit.

Interestingly, once the Court agreed to hear the case, the government switched positions, and yesterday argued before the justices that the penalty is not a tax subject to the Anti-Injunction Act. Because the challengers were making the same argument, the Court had to appoint independent counsel (the amicus curiae) to argue that the penalty is a tax. Ultimately, yesterday, the Court appeared to accept that the penalty is not a tax subject to the Anti-Injunction Act. Nobody was surprised by this; why would the Court schedule three days of argument about the matter if it envisioned recusing itself after the first day?

So. We proceed to today’s arguments, which were about the constitutionality of the mandate itself. I have read the transcript, but I am not a lawyer, so take what I am about to describe with the understanding that I am both ignorant and naive to a certain extent. However, you can read the stuff yourself on the SCOTUS website; the arguments were very accessible to the layman.

The government argued as follows. In the Constitution, the federal government is allowed the power to regulate commerce, and issues affecting commerce, between the states (the “Commerce Clause”). There are two commercial markets at issue: one is for health care services, and one is for health insurance. All people in the US are participants in the health care market, because all people in the US will require health care at some point. Health insurance is the method by which people finance their health care in the US, and therefore all people are technically participants in the health insurance market also. Ergo, Congress has the right to regulate both, as both constitute interstate commerce, even to the point of requiring people to purchase health insurance at a given point in time, because their failure to do so is an issue that affects commerce within that market.

(There is also a whole bunch of stuff about how the penalty for not buying is a tax, but I didn’t follow that part too well, and since the government argued yesterday that it is only kind of a tax, I’m not sure how germane the point is anyway.)

What it is important to understand about the government’s position is that, in the US, even if you do not have health insurance, you cannot be refused health care. So what happens is that people without the means to pay for their health care nevertheless receive it, which drives up the cost of care, which in turn drives up premiums for those people who are insured. So the government is arguing that because some people’s failure to insure themselves affects the price of everyone’s health care and insurance, Congress has the right to interfere in the purchasing (or not) of health insurance under the justification of the Commerce Clause.

By compelling people to purchase insurance (and penalising/taxing people if they don’t), the government’s aim is to reduce the free rider problem and thus lower the cost of care and insurance premiums.

If you read the transcript, Solicitor General Verrilli does a lot of waffling about the “40 million Americans who don’t have access to care,” but the upshot of what he’s saying is this: actually, these people can get care, they just don’t pay for it. So in order to cover the cost of people who can’t pay for the care they definitely do get, everyone has to be insured. That way, the insurance companies can use the premiums paid by the healthy to subsidise the cost of the care for unhealthy people who can’t pay for it themselves. Thus, because everybody is affected by this way of ensuring poor people can still get health care, Congress can do what it chooses, including compelling purchase, to deal with the problem.

So far, so clear. The system envisioned in the PPACA is one of the healthy subsidising the unhealthy.

The challengers argument was somewhat more complicated.

First, they disputed the “everybody is a participant” claim. Many of the Americans who do not have health insurance are young, healthy people who choose to spend their money on something else, believing themselves to be at low risk of requiring health care. Thus, these people are not, at a given point in time, participants in either the health care or health insurance market. The Commerce Clause, they say, does not give the government the right to compel people to participate in these markets when they otherwise would not choose to do so.

Second, they disputed that the health care and health insurance markets are so intertwined as make eventual participation in the one the justification for forced participation in the other. There are, they said, other means of subsidising the unhealthy who cannot pay for their care than compelling the purchase of health insurance. Social Security was brought up: a general tax, linked to income, levied on everyone, which the federal government then disburses to those requiring the payments, would be constitutional in a way the mandate is not, because the Constitution does give the federal government the right to levy taxes. (This is, in fact, how Medicare and Medicaid work at the moment.) The challengers also pointed out that the problem the provision is attempting to solve is one created by the government in the first place: namely, the government forces emergency rooms to treat those who cannot pay, and it forces insurance companies to insure high-risk individuals. If it did not do those things, there would not be a free rider problem, and so there are other solutions than the mandate imposed by the PPACA.

During the arguments, the justices focused particularly keenly on two problems with these issues: (1) are the health markets unique, and if so, what specifically is the limiting principle that will stop the federal government from engaging in compulsory purchase in other markets? and (2) if the challengers concede that the federal government can force people to purchase health insurance at the point of purchasing health care itself (which, apparently, they do concede), what is the problem, precisely, with moving that point of compulsion forward in time, when it will have the most beneficial effects?

A lot of today’s commentary was along the lines of “Obamacare in danger of being struck down,” because the justices seemed particularly pointed and hostile in their questioning, but I think this is premature. The mandate may be ideologically horrific to the average American mindset, but that does not mean it is unconstitutional. And the role of the justices is to pick holes in the arguments and expose the weaknesses; that doesn’t mean those weaknesses are fatal. The most aggressive questioning came from Justice Scalia, and I admit the Solicitor General didn’t seem particularly articulate in his answers—at one point, Justice Sotomayor summed up his argument for him much better than he had done, and he didn’t seem to notice—but that doesn’t mean his points are invalid.

There were a lot of other issues and sidelines in the arguments, but there was one point that came out pretty strongly to me, and it was made by Michael Carvin for the challengers. What he argued, in effect, was that the government’s own argument is self-contradicting. At the moment, people with insurance effectively subsidise those without. Under the PPACA, people with insurance will effectively subsidise those without. There is no difference in where the cost is borne; it is always borne by the people with insurance. What the PPACA proposes to do is to increase the pool of insured people to pay the subsidy, thereby spreading the cost over a larger base. The PPACA itself, and the government, admit this is the entire purpose of the mandate: to make healthy people who do not currently purchase health care purchase insurance in order to cover the cost of those people who cannot pay for the health care they purchase.

Therefore, the government is implicitly admitting that there are some people who are outside the market, who need to be drawn into the market in order to spread the cost of subsidy around—and since that is the whole purpose of the mandate, the existence of the mandate demonstrates that not everybody is a participant in these markets, and therefore are not engaging in commerce that can be regulated in this way by Congress.

It’s a neat little argument, and I wish he’d been more explicit about how circular it is. He does call it “bootstrapping,” though, and it’s true. If everyone was a participant in these markets, which is the government’s justification for this falling within the power of the Commerce Clause, there would be no need for the mandate; but because the point of the mandate is to make everyone participate, it is itself an admission that not everyone does, and therefore it can’t be justified by the claim that everyone is already a participant, because if they were, the government wouldn’t need to mandate that they participate.

The only other interesting thing to point out is that, although everyone involved seems keen not to get into the merits of the law as a whole, with the whole, y’know, making sure people don’t bankrupt themselves in order to stay healthy, the people who are most prone to talking about the merits of the law appear to be the justices themselves. This is why I think the commentators are premature: while it’s nice to think that Supreme Court judges are impartial, they’re not. They’re perfectly capable of allowing their approval of the aim of the PPACA to bias their views on its constitutionality—and by the same token, of allowing their repugnance at the methods of the PPACA to affect their judgment of its intention.

And that’s true of a lot of people right now, I think. Health care in the United States is totally fucked up, and I don’t think it’s really possible to dispute that. However, the PPACA is not the only possible solution to the problems, and my personal view is that it’s about the worst one, in fact. But people on the right are in danger of defending a really shitty situation when they attack this law, and people on the left are in danger of defending a really shitty law when they attack the current situation.

This is why, going back to the beginning, the label “Obamacare” is so pernicious. Would people really be as blindly and tribally partisan about this law if it didn’t involve a cult of personality and were, instead, the boring old PPACA?

Read the transcript for Monday’s arguments.

Read the transcript for Tuesday’s arguments.

Feb 042012
 

In the NHS, there two main activities. One is helping sick people. The other is measuring, improving, correcting, extending, and promoting how well sick people are helped. Much energy is expended on the first activity: technical advances, new pharmaceuticals, further training for doctors and nurses in new ways to help sick people. But the more you read about the NHS, the more you get the feeling that a lot more energy is expended on the second activity.

There’s nothing particularly wrong with this; even in a business, delivering the product or service to customers is straightforward, if not always easy, and the bulk of business energy is expended on how to improve the product or service, how to measure whether or not it’s good, strategy for getting it in front of the market, selling it, and so forth. Large numbers of people are employed to do these things, and a lot of money is spent in doing them—money that is generated by the delivery side, both by delivering the goods and by finding new ways to reduce inputs and increase outputs. Greater productivity means greater profits, which can be taken home as pay or ploughed back into the rest of the business.

The difference between a business and the NHS, however, is that issue of money. Money is the simplest metric for business success: how much are we making? Allocating money in a business is also fairly simple: wages, tools, marketing, infrastructure, tax, in varying proportions, and what’s left over goes to the shareholders. And if the metric drops—we are making less money—the allocations drop too. Therefore business responds to money.

The NHS, on the other hand, doesn’t respond to money, because it doesn’t make any. You can argue whether this is an intrinsic function of what it does—healthcare—and you can even argue the ethical toss about measuring something as important as health by looking at money, but you can’t get away from the fact that the NHS has something to do with money, because helping sick people has a cost.

The NHS is sort of halfway in the market. It doesn’t directly charge its customers for its services, so it can’t respond to the “how much are we making?” money question. But it still has to answer “how do we allocate it?” and “what do we do if we have less to allocate?” Doctors and nurses don’t work for free, so it still has to think about wages. Medical supply manufacturers don’t manufacture for free—they are businesses, so they have to worry about how much money they’re making—and infrastructure has to be paid for as well. The NHS has all of the business problems of spending money, and none of the tidy business solution of earning it.

So when, in the NHS, the costs grow and/or the pool of money to spend shrinks, the sector has to find pseudo-business solutions to deal with this problem. “Pseudo” because what businesses do is frequently not an option for the NHS. For instance, a business could produce more goods or services. The NHS can’t do this, because it’s really unethical to go round trying to make people sick so that you can cure them more, but also because the NHS’s primary service—helping sick people—is actually a cost, and doesn’t make them any money. For the same reason, they can’t look for new markets like a business would, but also because the market for the NHS is already every person in Britain. Other solutions are simply odious. The NHS can borrow money, but their collateral isn’t private, so they end up mortgaging the public good. The NHS can ask patients to pay—private patients, or foreigners—but this invalidates the ideology that health shouldn’t depend on wealth. They can ask the government to raise taxes, but that’s a PR nightmare, and the existence of the NHS depends on people’s loyalty and goodwill.

So the NHS has only one option, and that is to reallocate its spending. Reduce the number of doctors and nurses treating the sick people, and thus lower the wage bill. Find cheaper suppliers, and thus lower the tools bill. Hire cheaper builders to patch up the estate, and thus lower the infrastructure bill. Use what you’ve saved to increase marketing healthy lifestyles, and hopefully the number of sick people will drop, and through all of these increases in productivity (in the NHS, it’s called “efficiency”), maybe you can break even, or even turn a profit (in the NHS, it’s called a “surplus”).

In the NHS, you can also do rain dances, make offerings, and perform collective prayer rituals that the UK economy flourishes enough for tax receipts to go up, giving the government the power to increase your budget again.

Unfortunately, all of these things make for a cumbersome and difficult-to-run healthcare system. Sacking nurses looks evil, and makes life harder for the other nurses. This, and using cheaper supplies, can literally endanger people’s lives. Infrastructure creaks as it gets older, and the population rapidly outgrows the limited space. Paying staff, suppliers, and contractors less reduces tax receipts. And public-health marketing is notoriously ineffective.

So what the hell do you do, if you’re the NHS? Do you say, “Fuck it, this half-business life is no life at all—let’s act like a real business and charge people money. Then if they pay us, we know we’re doing a decent job”? This doesn’t even have to mean that poor people die in the streets, because the government could just give them the money to buy their healthcare.

No. Instead, you bitch and moan and look for Rube-Goldberg-esque solutions to act as proxies for normal market behaviour. And then you can see why helping sick people is the least of what goes on in the NHS.

Let us consider, for example, the Health Service Journal, the premier trade journal for non-medical NHS staff. Does it have anything to do with awesome new and better ways of helping sick people? Does it fuck. It is Rube Goldberg literature for the Rube Goldberg system.

This week’s stories include:

(1) The way to improve the NHS’s effectiveness and efficiency is to set up an independent standing commission to look into the matter.

(2) Outsourcing middle management can, in ideal circumstances, reduce “overspend” (in the business world, “losses”).

(3) Medical unions are concerned that competition will lead to health “inequality.”

(4) A government quango will judge who is allowed to help sick people.

(5) The same quango prioritise patients over creditors when it puts private providers out of business by disallowing them from helping sick people.

(6) The same quango shouldn’t give NHS bodies credit ratings for borrowing purposes, because credit ratings are not an appropriate proxy for how well sick people are helped.

(7) Another government quango will measure how well sick people are helped by a series of inspections centred on 100 performance metrics.

(8) Another government quango will judge which GPs are allowed to buy healthcare from the NHS for sick people, but it will need management consultant help to do this.

(9) The GPs will also need to be helped to create a QIPP strategy. (QIPP stands for “quality, innovation, prevention, productivity.”)

(10) Publication of how well these 100 metrics are met may lead to health “inequality.”

(11) However, not publishing these data, because they are impossible to collect and monitor, is also unacceptable.

(12) PCTs can close down their competition but only if they don’t ask doctors whether or not they should do it.

(13) A commission will investigate whether imposing fines for making people sick with C. difficile will hurt hospitals.

(14) Some middle managers are unhappy about spending money, time, and energy on healthy lifestyle programmes for staff.

(15) Patients need a better way to complain about the quality of help they received when they were sick.

(16) In order to do all of this stuff, there needs to be a strategy for staff engagement.

(17) There also needs to be a strategy for adopting helpful technology.

And my personal favourite:

(18) “Salford Royal Foundation Trust’s clinical leaders development programme is part of an emerging organisational development strategy to engage senior medical staff in the business of clinical leadership and develop their talent.”

So there you have it. Because the NHS cannot measure how well it provides its service—helping sick people—by the money it makes from its customers, it has to invent Byzantine proxies, implemented and assessed with great energy and at enormous cost, none of which have anything to do with helping the sick people.

And why? Because this tremendous waste of time, money, talent, and human capital is preferred as a more humane outcome than letting sick people hand over money directly in order to get better.

Mar 132011
 

Because of what I do for a living, I have a pretty decent understanding not only of how the NHS has worked throughout the past couple of years, but also of how it is envisioned to work under the reforms now being discussed in the Commons.

And I do not see that these reforms amount to selling off the NHS piecemeal and having sick people dying in the streets.

What I see, primarily, is two things.

First, a step is being eliminated in the commissioning process with the abolition of the PCTs. This doesn’t mean that GPs themselves, with all of their other workload, will also be sending the commissioning paperwork to the secondary care providers; it means that the PCTs will be, in effect, split and absorbed into the newly-forming GP consortia. These consortia are groups of GPs who have voluntarily banded together because they share a geographical area or a particular patient demographic and thus have excellent collective knowledge of the populations whose health they deal with. These GP consortia are already consulting deeply with their PCTs and, from what I’ve heard, most plan to absorb not only the function but also many of the staff.

This restructuring, therefore, allows voluntary groups with similar knowledge to take responsibility for commissioning the healthcare appropriate to that knowledge and to those patients. This is a massive improvement on the PCTs, which are region-based and have no frontline exposure to the population and patient groups in their regions.

Second, all NHS trusts are being compelled to become, or join, foundation trusts. For those not familiar with foundation trusts, they are locally-established and locally-accountable, fiscally independent hospital or healthcare trusts. They are governed, ultimately, by a membership consisting of local people, and they are required to demonstrate the involvement of that membership in major decisions. This makes foundation trusts both more democratic and more responsive. Some of the best trusts in this country—such as Guy’s at St Thomas’s—are foundation trusts and have been since the Labour government brought in the concept.

Every other part of these reforms is incidental and, incidentally, is what seems to have the “Save the NHS” and “N4S” (Not 4 Sale) campaigners so worked up. OMG, there will no longer be a cap on private-patient income for foundation trusts! So what? FTs can’t make those kind of changes without the agreement of their membership. And if the membership wants the FT to take more private patients, who are you to stop them? OMG, care might be given by non-NHS providers! So what? GPs are not technically part of the NHS; neither are care homes, many mental health centres, many home carers, and so on. Provision doesn’t have to be done by NHS bodies, and there is no proof whatsoever that private providers will give a lower standard of care, or that NHS commissioners will choose the cheapest private providers at the expense of patient wellbeing.

In fact, lately there have been a lot of, erm, questions (let’s be nice about it) surrounding the quality of care the NHS itself provides, particularly when it comes to (a) old people and (b) hospital-acquired infections, and therefore I see no reason to cling so tightly to this idea that NHS provision is automatically a good, or better, circumstance for patients.

In the end, none of these reforms alter the vital fact that the NHS is still free at the point of use for everyone, which I believe was the object in the first place: that sick people would have access to care regardless of income. However the back-end management works, this salient fact will still be true, and there is good reason to believe that these reforms, particularly the commissioning reforms, will help to improve that care, as the people responsible for looking after these sick people will have a much better understanding of their patients’ needs, both individually and as part of a particular community, and thus be much able to direct both budget and resources where they are needed, instead of distributed evenly across the board without reference to patient and community health profiles.

Jan 202011
 

It appears that the House of Representatives has voted to repeal last year’s bloated healthcare act and has put committees together to draft new legislation to replace it—without a timetable.

As you will know, the ‘without a timetable’ aspect is something I lean toward favouring, as I criticised the act heavily, in large part for this reason:

Obama and his Congress sure did fuck it up, didn’t they? Instead of doing thorough research, either before the election or after it, and determining the best possible way to ensure universal, affordable healthcare, they cobbled together a travesty of a bill, full of unrelated pork to get various hold-out politicians onside, that when all is said and done, could serve as an exemplar of what every rent-seeker (in this case, the insurance industry) hardly dares even to dream.

But this vote is not a repeal in itself, of course. That whole ‘checks and balances’ thing means that the repeal bill will have to go before the Senate and win passage there, and then go before… the president. And, typically:

Democratic leaders in the Senate have vowed to shelve the repeal bill, and President Obama has said he would veto repeal if it ever reached his desk.

‘Shelving’ essentially means that the Senate Majority Leader, one egregious Harry Reid, can simply refuse to put the House bill onto the Senate’s legislative timetable—more or less indefinitely, if he so chooses. And even if, by some miracle of organised crime, intimidation, and sweet sweet reason, Republicans get the bill put on the Senate timetable and manage to pass it there, Obama can employ a number of veto tactics depending on when over the course of the legislative session the bill is presented to him. (Although he is required to submit his reasons for vetoing in writing; I wonder what boilerplate he’d spew on that occasion?)

The Congress can override the veto, but only with a two-thirds majority vote in both houses. So that’s pretty unlikely unless the Tea Party start getting uppity again.

I’m pleased the Republicans in the House have taken this first step, and they have a backstop in the fact that the healthcare act is being challenged in a number of cases and has already been ruled unconstitutional by a federal judge. (That ruling is under appeal, naturally.)

But they won’t get anywhere in the absence of some serious pressure from the American people, and given how the sheeple are, and how blind the Democrats are to protest and demonstration when it’s against their policies, I think the actual repeal of this hideous act will not occur. It’s more likely to be struck down by the high court, and even that’s pretty pie-in-the-sky.

Still, I wonder if the Democrats will now begin to hyperaccuse themselves of being obstructive, partisan, and resistant to the expressed will of the demos. It’s hard to imagine anything that demonstrates those qualities more than:

Democratic leaders in the Senate have vowed to shelve the repeal bill, and President Obama has said he would veto repeal if it ever reached his desk.

UPDATE: Hmm, seems I forgot about those little things called states…

Jul 212010
 

[I wanted to leave this as a comment over at John Demetriou’s original post, but his implementation of Blogger rejects comments of more than 4,096 characters.]

JD, unlike your usual rants, this post is dire. I don’t mean that to be harsh, but you’re coming at this from an angle of misunderstanding that makes your ‘I don’t understand’ claims all too believable.

For one thing, you refer to ‘Americans’ and ‘the American people’ as if there is one collective American mind, and you find its schizophrenia puzzling. Perhaps for the sake of simplicity, it might be better to think of Americans as two collective minds: those who voted for Obama, and those who didn’t. For all sorts of reasons, he is and has been a polarising figure. And so you have two poles, rather than the single mad hive-mind you say is so bizarre. It is one pole that exhibits ‘curious rage’ against Obama, not ‘the American people.’

For another thing, you massively overstate Obama’s popularity during the election and at the beginning of his term. You assert that he ‘won by a landslide’ and was the subject of ‘hero worship,’ ‘hagiography,’ and high approval ratings. In fact, he did not win by anything like a landslide. He won with 53% and 28 states.

By comparison, in 2004, George W Bush won with 51% and 31 states. In 1988, George H W Bush won with 53% and 40 states. And in 1984, Ronald Reagan won with 59% and 49 states. And that wasn’t even as impressive as the 1972 election, when Richard Nixon (Nixon, of all people!) won 49 states and 61% of the vote.

Obama has had nothing like the electoral success other presidents have managed. Your perception of hero-worship and hagiography, just like your perception of rage and hatred, comes from one pole of the American populace.

Furthermore, your understanding of the role of US president is woefully incomplete. You say that ‘Bush inherited an excellent, albeit imperfect, set of books from Clinton and very quickly wrecked it.’ As if either Clinton or Bush had anything whatsoever to do with the books or quality thereof. Congress controls the cash, and the Congress that delivered Clinton a budget surplus was, in composition, almost exactly the same Congress that fucked it all up for Bush. And the Congress Obama has been working with is, in composition, almost exactly the same Congress Bush was working with during his last two years in office. The state of the books in the US is entirely unrelated to the views and actual quality of the president.

You also say that Obama is hated ‘for having the temerity to actually carry out what he proposed to do.’ Again, the president does not ‘do’ things. He does not draft legislation, propose it, debate it, or vote on it. He merely signs it once it’s made its way through Congress. (Or not, as the case may be, but I don’t think Obama’s actually used his veto yet.)

So any carrying out during Obama’s term has been done by Congress. And what they have carried out bears little actual resemblance to the platform on which he campaigned. Sure, the health care bill, but what about everything else? What about the war, the ‘middle-class tax cuts,’ the great repeal of the Bush administration’s incursions on civil liberties? Neither he nor Congress have done any of those things, which were major selling points among Obama’s supportive node. Surely you don’t think the whole election revolved around the question of a healthcare bill?

A healthcare bill which you describe thus: ‘The timing…was perhaps ill-judged, even from a social democrat perspective, but this was one of those once-in-a-thousand-years opportunities, politically, to achieve this ambition.’ For a once-in-a-thousand-years opportunity, Obama and his Congress sure did fuck it up, didn’t they? Instead of doing thorough research, either before the election or after it, and determining the best possible way to ensure universal, affordable healthcare, they cobbled together a travesty of a bill, full of unrelated pork to get various hold-out politicians onside, that when all is said and done, could serve as an exemplar of what every rent-seeker (in this case, the insurance industry) hardly dares even to dream. That’s not even to mention the costs this bill imposes, both to individuals and to the body politic, which have been revised upward continually since the passage of the bill. And the bill fails to achieve even its basic objective, which is to ensure that the poor and low-paid have access to affordable, customised insurance and care.

Is it any wonder that a significant number of Americans are horrified and disgusted by it?

All of this is a far cry from, ‘Hey, you all voted for him, he did what he said he’d do, so what’s the big problem?’

Finally, you assert that les Americains sont fous because ‘their media and overall educational standards are so lacking in substance.’ This is, basically, not true. Unless by ‘their media’ you mean Fox News, and by ‘their overall educational standards’ you mean ‘those five schools in Kansas where they teach intelligent design.’

Or perhaps you just mean the rednecks, Tea Partiers, and Christians are poorly educated. Maybe you can confirm or deny.

What I don’t understand is why you are displaying so much contempt for a bunch of people who, for the most part, share your opinions. These are people who didn’t vote for Obama (as presumably you wouldn’t have, did you have the opportunity) and who loathe what he stands for and what he’s supported as president. Sure, some of them have authoritarian tendencies, but they’re with you on at least 50% of stuff. If you were in their position, wouldn’t you be angry? They didn’t want him, they didn’t vote for him, and his presidency is riding roughshod over their cherished conception of what the United States is.

I never expected you to take this position, I must say. That you would present Americans who disagree with their president and his Congress, and who display that disagreement with words, ideas, and peaceful legitimate protests, as ‘wild, irrational…mad and retarded’ comes as a great surprise to me.

And a serious disappointment.

UPDATE: JD rebuts here.

Nancy Pelosi: dumb

 indolence, political blunders, US-bashing  Comments Off on Nancy Pelosi: dumb
Jan 212010
 

From the Telegraph:

Republican leaders in Congress called for a reworking of the bill, which would provide near universal coverage and aimed to bring down long-term costs. But Nancy Pelosi, the Democratic House Speaker, argued that because Massachusetts already had near-universal health coverage under a state law, the vote should not be seen as a referendum on the issue.

“We don’t say a state that already has health care should determine whether the rest of the country should. We will get the job done. I’m very confident,” she said.

It’s because Massachusetts already has just such a health care system as the one Pelosi’s Democrats are proposing that the opinion of their citizens is worth more than that of any other state’s.

They know what it’s like. They know what it costs. And they know that if the Democrats get their retarded bill passed, the citizens of Massachusetts will be paying through the nose twice.

That’s one of the great things about the federal system, you see: experiments can be tried in the states that want them, and the results can be judged by the rest of the country as either worth duplicating or worth abandoning. Massachusetts has done the experiment the Democrats would like to foist on the whole country. Not only have the other states looked at Massachusetts and said, ‘Dude, that doesn’t look like it’s working out so well, maybe we’d better not try it here,’ the people of Massachusetts themselves have said, ‘This isn’t going so well for us! Don’t try it at home!’

I reckon Nancy Pelosi should take a long, hard look at what’s happened to the healthcare system in Massachusetts, if for no other reason than because costs there have skyrocketed beyond all expectation, and seriously reconsider whether she wants to push the same money-suck on the entire rest of the nation.

Unless, of course, she wants to go down in history as the Politician Who Bankrupted America. Because you can bet your sweet buttocks it won’t be Obama who gets blamed. A man who can rise to president from two years’ experience of national office and prior experience in a Democrat safe seat and in a Democrat safe state’s legislature is more than canny enough to figure out a way to let some other poor bastard take the fall.

Jan 202010
 

Scott Brown, the Republican candidate, appears to have won the special Senate election in Massachusetts.

Predictably, there is over-hype from the right (‘Healthcare reform is dead! Yay, woo, a victory against creeping socialism!’) and under-hype from the left (‘These things are vastly complicated, the rest of American still wants healthcare reform, this election is not indicative of the true feeling of blah blah blibbity blee.’)

When Scott Brown is seated, the Senate Democrats will no longer have their 60-member supermajority, which as far as I’m aware was what they were counting on to pass their obese and unwieldy healthcare bill. So yeah – maybe that bill is dead.

Unless they decide to hold their vote before Scott Brown is seated. And Harry Reid won’t agree to seat him until the Mass. Secretary of State has certified Brown as the winner. And as we all remember from Election 2000, certifying a winner can be a long and thorny process fraught with much concession and recantation and fro-ing and to-ing and suing and accusations of fraud and faulty paper ballots (paper ballots? really?) and HEY LOOK, it’s the Supreme Court, and Katherine Harris’s political career is over forever, poor woman, through no fault of her own.

So maybe that bill isn’t dead.

The only genuine effect Scott Brown’s victory has had, as far as I can tell, is that it’s been great for morale on the right, and pretty bad for morale on the left (however much they downplay it).

But it’s one Senate seat in a special election won against a dreadfully unpleasant Democrat candidate in a state where they’d had the same self-important blowhard in charge for almost 40 years. While that’s Change the people of Massachusetts Can Believe In, I’m sceptical of claims that it’s a reely reely big deel y’all, TEA PARTY REVOLUTION!

But I’ll happily eat my words if I’m wrong.

P.S. It’s getting harder and harder for me to comment on American politics without descending into silliness.

UPDATE: Lulz.

H/T Hillbuzz.

Jan 122010
 

(That’s ‘thicker’ in the American blues sense, meaning amply proportioned but shapely.)

Scientists say: big bottoms and thighs protect against cardiovascular disease and diabetes. Big bellies… don’t.

Lead researcher Dr Konstantinos Manolopoulos, of Oxford University, said: “It is shape that matters and where the fat gathers.

“Fat around the hips and thighs is good for you but around the tummy is bad.”

He said in an ideal world, the more fat around the thighs the better – as long as the tummy stays slim.

Coolness. I shall continue to cultivate the figure of a pre-agrarian fertility statue* secure in the knowledge that it is excellent for my health.

*Pub quiz question: What is the Greek-derived term for this type of female figure? (Archaeology buffs, sing it with me now…)

Jan 122010
 

Via CNN I see that President Obama has considerately taken into account the date of the season premiere of LOST in deciding when to hold the annual State of the Union address:

Fear gripped the hearts of fans when it was announced that the president wanted to push back the annual State of the Union address – typically held in late January – to February 2, which everyone should know by now is the premiere of the ABC drama’s final season.

Crazy talk! Doesn’t he know people have been dying to find out what happened to the castaways?

But White House press secretary Robert Gibbs assured viewers Friday he “doesn’t foresee a scenario in which millions of people that hope to finally get some conclusion in ‘Lost’ are preempted by the president.”

This non-news was not, I confess, particularly interesting to me, until I started reading the comments beneath it.

And boy, is America unhappy.

Remarks seem to be conforming to the following general categories:

(1) “Americans are pathetic. I can’t believe LOST is more important to some people than what the president has to say.”

(2) “Obama is pathetic. I can’t believe he’d change the date of his speech to suit a bunch of sheeple LOST fans.”

(3) “Politics and politicians of any stripe are pathetic. LOST will be more interesting and more factual than the heard-it-all-before SOTU.”

(4) “You’re all pathetic. Ever since the SOTU has been televised, presidents have taken into account conflicts with the normal viewing timetable.”

(5) “Everything is pathetic. LOST? State of the Union? Who gives a shit.”

The general malaise and negativity displayed in these 470 (yes, 470 comments) is breathtaking. In full awareness of the fact that this is anecdata, I’m still going to postulate that the Change which Obama hath wrought has been, on the whole, not so good. By far the most illuminating of the comments are the ones that express a deep and weary scepticism about why the date of this regular address is in question in the first place. The State of the Union is traditionally delivered in late January; the suggestion of postponing it until February (and thus creating a conflict with the LOST premiere) has led many people to believe that Obama wishes to be able to extol a successful healthcare reform bill therein. As far as I know, this sort of manoeuvring is rare; the whole point of the SOTU is to describe, duh, the state of the union at regular intervals. It loses much of its impact if the president gets to decide to describe the state of the union whenever he judges that state to be most positive.

Not to mention that Obama has been, not to put too fine a point on it, one of the most speechifying presidents I can remember, having addressed the nation in this way at least three times that I can think of already in his first year of office. I realise these speeches have been topical, rather than holistic, but when you put them all together, we’ve had his words on education, healthcare, and the on-going wars in the Middle East. Possibly the economy as well, though I don’t remember that specifically. I think Americans are pretty up-to-date on the state of their union.

I suspect that much of the negativity and cynicism stems from the fact that Obama has gone about his presidency in entirely back-asswards fashion. Having campaigned on a platform that consisted largely of reversing the mahoosive mistakes of the Bush administration, once in office, he immediately set out to… not reverse any of them. Patriot Act? Still there. Guantanamo? Still there. Wars? Still there. Bailouts and stimuli? Still there. Discontinuing these things, while difficult, would have been popular on both sides of the political divide, as well as with the mythical ‘independent’ voters. Obama would have been seen to be cleaning up the mess and providing himself with a fresh slate, correcting the massive loss of civil liberties and doing his best to get the country back on its economic feet.

Instead of pursuing these popular campaign policies, however, he has spent the vast majority of the last year shilling for his Congressional party members and their ridiculous healthcare reform. A task as huge as the overhaul of the nation’s health infrastructure should have been begun cautiously, slowly, and thoroughly, with cost/benefit analyses, input from providers and consumers, multiple scenarios of best practice, and above all, genuine bi-partisan contribution. What Obama has allowed to happen, however, is the creation of a massive, cobbled-together bill based on the barest minimum of research into the health market, the barest minimum of input from the industry as a whole, and containing almost innumerable lines inserted solely to get this or that special interest group onside, or this or that senator. The legislation is a gigantic fucked-up mess that appears designed, not to represent a unified vision of healthcare or emulate best practice elsewhere in the world, but to prove that the Democrats in Congress have done something, dammit, and it looks plausible if you stand back from it and squint a bit.

And Americans are not impressed. Yes, healthcare needed reform. Yes, Obama promised to do it. But did it have to be done so quickly, and in so slipshod a fashion, and at the expense of so much good he also promised?

Few presidents have had as unsuccessful a first year as Obama; even fewer have been almost the sole authors of their own failure. I do not envy the man, but I do not pity him, either. If Americans are unhappy, it is because Obama misjudged them; it is because he believed his initial popularity meant he didn’t have to conform. Ultimately, I think, Americans do not want a cult of personality. They want what they have always liked best: a competent, steady leader, with a sure hand on the helm and an appropriate sense of solemnity for the huge responsibility he bears. Obama has lurched from crisis to panic to embarrassment, and while he’s handled it with fairly good grace, he may at last be discovering that, to Americans, only Mr President deserves respect and confidence. Barack Obama will receive the same when he remembers that they come, not in response to his personal charms, but by grace of the office he holds.

Jan 052010
 

From the TaxPayers’ Alliance comes the news that the Tories are planning… to be absolutely no different from Labour:

Well, it’s the second day of the unofficial 2010 election campaign and already it appears that the Conservatives have pledged to create a new quango. In a speech today to the Oxford Farming Conference, Shadow Environment Secretary Nick Herbert is pledging to create a “Supermarket Ombudsman”. Sigh. So much for a “bonfire of the quangos”.

Yes, that’s right: the Conservatives have pledged to create government oversight of the retail food supply. This is in addition to the NHS policy announced earlier this week, in which they pledged to create more government oversight of health allocation:

But then…

To make sure the NHS is funded on the basis of clinical need, not political expediency, we will create an independent NHS board to allocate resources to different parts of the country and make access to the NHS more equal. (Page 8)

Eh?

So we have another new quango, explicitly designed to remove the people’s control of how the biggest budget in British Government is spent. Of course, when you want to make democracy sound like a bad thing you call it “political expediency”, rather than “accountability” as it was termed earlier in the very same document.

It seems that despite all the speechifying about the post-bureaucratic age, the Conservatives are yet to shake the temptation to slam everything into a quango and then wash their hands of responsibility. Not exactly change we can believe in.

Too right. ‘Change we can believe in’, British-style, appears to be the same as it was Obama-style: more of the same, really, but dressed up in attractive language.

Meanwhile, the discerning voter begins to feel rather like Sally from Dr Seuss’s The Cat in the Hat: weary of the identical Thing One and Thing Two, and desperate to rein in their nonsense before they destroy the whole house.

UPDATE: And hey look, I agree with Sunny Hundal at Liberal Conspiracy!

But let’s assume we want these decisions to be more accountable. A good idea in theory right? But what’s this?

With less political interference in the NHS, we will turn the Department of Health into a Department of Public Health so that the prevention of illness gets the attention from government it needs.

Less political interference? But I thought that was more ‘accountable’ surely?

Can we file this under the Steve Hilton award for ‘Progressive Gobbledegook’?

Truly, Camerhoon is a uniter, not a divider.