Defending Conservatism, Part 4: The Benefits of Social Harmony and Apolitical Spaces

In Part 3, I defended the need for decentralization and a robust civil society. Building on that point is the need for apolitical spaces, so that we can work together with people of different ideological persuasions in doing good.

This is, of course, a fairly rich perspective, coming as part of an eight-part series on politics and political orientations. But there is much more to life than political views.

There is a frequent debate (often by proxy) between two perspectives on how life and politics should interact. One view states that it is best to keep politics and other parts of life separate.The other postulates that the personal is inevitably political, and that those who seek to keep politics and life separate merely oversee that their own political preferences are *implicit* in the areas they seek to “protect.”

This second view is compelling, but in a world we do not understand, the advocates of separate spheres have the stronger argument.

First is the more prosaic one: in a world we don’t understand, we are likely to be wrong, periodically. Keeping contact with and listening to people who have differing views is one way to insure ourselves against error. We can learn things, or be persuaded that our approach on a given issue is more likely to be mistaken.

But there is a deeper rationale. If we accept that life is improved by the connections that we make, it doesn’t really make sense to preclude personal attachments and socialization with people who don’t agree with us on politics. What an impoverished view of the depths of human contact! There are so many dimensions of human contact in the real world: physical chemistry, sports, hobbies, conversational styles, religion, philosophy, scientific inquiry, and musical interests, among thousands of others. Why eliminate possible gains across those dimensions because of a disaffinity on a single dimension, politics, particularly when those politics may be misguided anyway?

This is not merely about rejecting gains; it’s also about assistance in the tough times. Human societies are full of sadness, loss, hardship, and loneliness. The connections we make can help us through those difficult emotions and can allow us the ability to bond with a greater number of people. When politics produce outcomes that depress us, when we lose our loved ones, when our long-term significant other terminates our relationship, when our favorite sports team loses in crushing fashion--all of these experiences produce varying degrees of despair. Having a broad array of connections and people to share our interests and hobbies with makes those times easier.

This is an easy, consequence-free position to have as a white male. To use the academic jargon: I am privileged enough to have the opportunity to set aside politics, because it doesn’t directly affect me. But for those who do feel that politics bombards them because of their choices or their “invisible backpack,” to what end does living in a perpetually-political world lead? Does it make you happier? Does it increase the odds of politics turning out the way you want them to, of the outcomes turning in your favor? I contend, simply, that it does not. Privilege is a fact of life, and one that it makes sense to recognize in our political lives. But allowing it to consume the rest of things does not necessarily result in sustainable change. If anything, it generates a backlash from those who are accused of “privilege” but don’t feel it in their daily lives. A 45-year old white man in rural Indiana is “privileged” under the hierarchies of privilege theory, but if he’s divorced with two drug-addicted teenage kids and has been in and out of part time jobs for 15 years, he probably doesn’t see it that way. And if 2016 proved anything, it’s that backlash is toxic.

There is a third rationale that is equally important: the politicization of everyday life leads almost inexorably to the desire for government involvement in everyday life. Politics is a long-term discussion about what government should do. But government is force, first and foremost. It’s a blunt instrument that has a monopoly of violence over a given area. Any law that is passed compelling someone to do something is ultimately backed by the force of arms, and could be enforced by a man or woman in a uniform with a gun.

All of this leads to where we should be headed: a bias towards tolerance and toleration rather than uniformity and acceptance. As a society, we should encourage acceptance of difference, but the force of government should insist on a society where people of difference tolerate one another. Moving in the direction of acceptance is a rejection of this sort of difference and the liberty interest of folks who reject someone else’s choices, and it ultimately results in the politicization of non-political spheres. Resentment, not harmony, is the byproduct, and force, not persuasion, is the tool.

A final point: Part of the problem here is the cultural ubiquity of the president. He is everywhere, and anywhere the president is involved, politics (almost) inevitably follows. A president who actively shunned the spotlight, and remained in political spheres, would help depoliticize more of society.

In Part 5, I will defend the rule of law.

Defending Conservatism, Part 3: In Favor of Decentralization and Subsidiarity

For the sake of argument (see Part 2), we’re accepting that we don’t fully understand the world around us. One very straightforward implication is that we should prefer the local to the national. A single solution at the national level may well be wrong because of our knowledge problems and our issues understanding policy reality. Getting policy wrong at a national level affects us all, and often locks us into bad outcomes. Preferring local policies is better: some of those will likely work better than others, and states and localities can gravitate, over time, to models that prove more effective. Moreover, the calamities are more contained, and there are ready-made solutions to consider in response, with actual data and a track record worth evaluating.

Let’s take health care policy as an example. Three fictitious states are trying to figure out how best to provide health insurance in their states:

• Columbia: Columbia adopts a “three-legged stool” model and provides subsidies for the purchase of private insurance: all individuals must have a policy, either through their employer or via purchase on an individual market. Insurance companies cannot deny coverage for any reason, and cannot charge sicker people larger premiums or deductibles.
• New Eagle: New Eagle opts for a market-oriented “Health Savings Account” model, providing tax credits to all of its citizens for spending on routine services, and insurance coverage for more unpredictable expenses. The state sets up a “reinsurance” system for catastrophic expenses, where insurance companies can have the state government partially cover patient expenses above a certain amount.
• Cascadia: Cascadia goes for a “single-payer” model. Insurance companies exist only for their administrative expertise, but ultimately, all reimbursements come from the state government.

I have my suspicions about which state model would work best. But the reality is that we’re just guessing until we try the models out. And even if we do get data, no two states are exactly alike. If New Eagle’s program succeeds, that does not necessarily suggest that it is the best approach; there may have been confounding factors that were more relevant. It is merely a data point in favor of one position.

The alternative is that the federal government steps in, makes its decision about which model is most effective--or decides to “solve” the issue by hammering out perverse compromises through a challenging political environment--and locks us into whatever solution results. If the federal government chooses poorly, or if the political dealings result in less-than-ideal outcomes, we are stuck with a bad model, complete with the backing of well-funded, entrenched stakeholders.

Decentralization, in contrast, gives us the opportunity for policy experimentation. This is vital in complex domains, because otherwise, we are essentially hoping that the one answer to the policy question we come up with happens to be the best of all possible worlds. The odds of this are not great in a complex domain. At the government level, decentralization points towards federalism; let individual states have discretion to try new things. But more broadly, decentralization suggests that we should look towards markets for new models and new approaches to complex problems. Thousands of decentralized actors will likely create better models for the 21st century than the wisest government bureaucrats; they have many more opportunities to fail, and will recognize their failures quickly. Bureaucracy is much slower.

The only situations where we should prefer a national solution are ones where there are dramatic risks of externalities. In those situations the risk of broad errors and contagion are surpassed by the inability of a local solution to remain a local solution. This is typically a question of prudential balance: one can make an attenuated externalities argument about most issues. For example, education: if students in New Eagle are worse than students in Cascadia, then we all suffer due to the loss of potential human capital. There is certainly a claim worth considering here, but we should not compare our “bad New Eagle” example against a beau ideal; we need to compare it against the reality of what we can and cannot do.

Environmental regulations are one such area where externalities are relevant and immediate. (If New Eagle wants strict air quality standards, and Columbia doesn’t, then New Eagle will not actually be able to implement their policies because of the prevailing winds.) Likewise with climate change: New Eagle dramatically reducing its emissions is practically meaningless, in the overall scheme of things, if other states and countries do not. In other areas, though, like transportation, education, and health care policy, externalities are much less relevant, and as such we should be open to broad and bold experimentation at the local level.

Moving towards a locality-driven approach means that we should become more comfortable with regional differences in our country: they’re not necessarily failures; they’re learning experiences, and opportunities to grow.

Decentralization need not be entirely limited to the states, though. In general, subsidiarity is the way to go: drive the decision-making to as low a level of government or organization as it can go. Encourage people to get involved in their own communities, rather than focusing exclusively on the activities of the federal government. The more people are involved, the more they can take ownership of their lives and society, rather than feeling voiceless when pitted against a cold bureaucracy. Most critically, mistakes are less contagious mistakes this way.

One final point here: not all of this needs to be “the government.” Republican Senator Ben Sasse often cites “Rotary Clubs” as the foundation for American civil society. I’ve never lived in a place with an active Rotary Club that had a real visible presence in a community, but I envy that.

People tend to be more charitable when dealing with the local than with the national or international. Having nongovernmental organizations that can step in and provide stability for struggling kids, and public meals for low-income families, and toy drives, and all of the other things that benefit the less fortunate is a must. These are intrinsic goods, and they help us achieve meaning in ways that simply sending a few extra bucks a year in taxes to Washington DC will ever do. On top of that, we shouldn't reject a state-sponsored safety net, but we should steer it towards the local when and where we can.

Defending Conservatism, Part 2: The Problem of Modernity

A proposition, to begin: there is a true reality about the world around us. We may not always know it, but the truth exists. We attempt to use our cognitive faculties to ascertain what the truth is.

It is possible to disagree with that assertion, or to argue that not being able to comprehend the truth is functionally equivalent to there being no truth at all. But for the purposes of this series, I am going to assume that truth is real.

But instead of delving into this from the perspective of politics and government, a better place to start is from a seemingly-more complicated domain: particle physics.

I never quite understood even the hints at particle physics in my high school classes, and I so feared studying a STEM subject in college that I majored in history and took a class on diseases as a way to fulfill my general science request. I was probably right to avoid it, for what it’s worth; it’s incredibly complex, so much so that it took a $10 billion investment in a gigantic particle accelerator to do the necessary research on it. We’ve learned a fair bit about the way that the universe functions, thanks to the Large Hadron Collider. Among other things (courtesy of Wikipedia):

• The “Standard Model Higgs boson, if it exists, is most likely to have a mass constrained to the range 115–130 gigaelectronvolts.”
• There exist two previously-undiscovered subatomic particles. They are “baryons that are composed of one bottom, one down, and one strange quark.”

My friends who majored in hard sciences often expressed envy for those of us who chose the humanities, or business, as our fields of study. After all, they were doing complex math and experiments, and we were writing papers on subjects of our choice, essentially. Particle physics may be the most complicated thing we study, but students of the “hard sciences” deal with higher levels of complexity than do students of the “liberal arts.” Organic chemistry requires more esoteric knowledge than political science; microbiology requires more esoteric knowledge than economics; astrophysics requires more esoteric knowledge than history.

But we draw the wrong conclusions from this. Intuition suggests that because something is harder to study, it is actually harder to comprehend the “truth” in that subject. But this is precisely backwards. It is, in fact, the opposite: the truth underlying politics, policy, and economics is much more complex than the truth underlying physics and chemistry. But because our tools to measure the truth in those areas are so (comparatively) ineffective, there is a lot more wiggle room for debate, disagreement, and competing interpretations. You cannot build a Large Hadron Collider for studying economics. You can do some rudimentary experiments, which helps, but those experiments cannot be fully regulated, in the sense of having complete control over your dependent variables and constants. Conclusions are always tentative, and always subject to change. Paradigms are more fragile, with less consensus.

Note, too, that it’s much harder to “fake” your way through the hard sciences. In contrast, it’s very easy to fake your way through politics and policy: you can make bold assertions with selective evidence, and at best, the response will be debatable. (In a field where the truth is more opaque, “faking it” works a lot more effectively.) Try doing the same in a physics lab. They will laugh you out of the room, or, if they’re feeling polite, ask you to leave.

All of this makes sense, if we think about humans in a material sense: humans, after all, are the synthesis of billions upon billions of those very same scientific processes, acting through their own logic. What we study in economics, political science, and history is merely the effect of the outcomes of those particles, not those particles themselves and how they affect actions and decisions. It’s infinitely more complex, because we are not merely studying the particles themselves, but how the particles combine to form a consciousness, and how the consciousness interacts with its surrounding environment. Everything we study there is a mere approximation of reality, not reality itself.

This very same pathology--that we study approximations, not realities--infects all fields. But it is worse in fields that are associated with the “social sciences”--a misnomer if there ever were one--and the humanities. But this leads us to the key point: we live and breathe in the world of the liberal arts, not the world of the hard sciences; politics and economics, not physics and chemistry, are the levers we use to change the world, when discussing public policy. With apologies to Nassim Nicholas Taleb, the problem of modernity is thus: we live in a world that we do not fully understand.

Unfortunately, we see the effects of this all the time when we study and review politics and policy: we treat the knowlege of those fields as if they were as solid as the knowledge that we learn in the hard sciences. A few examples:

• The “Great Moderation” of monetary policy in the 1990s and 2000s--where we thought that we had learned to control the business cycle through the wise stewardship of the Federal Reserve--was merely an exercise in hiding risk, rather than eliminating risk. Brilliant people like Alan Greenspan underestimated the risks of a calamity (though Greenspan personally gets more blame for this than he should).
• It turns out that democracies are much more prone to war than was assumed by the pervasive “Golden Arches” theory (popularized by Thomas Friedman) of the late 1990s.
• It turns out that party structures have less control over the outcomes of presidential nominating processes than was argued in the leading book on the issue, The Party Decides.

F.A. Hayek nailed this in his 1974 Nobel Prize address, and it remains correct today:

Unlike the position that exists in the physical sciences, in economics and other disciplines that deal with essentially complex phenomena, the aspects of the events to be accounted for about which we can get quantitative data are necessarily limited and may not include the important ones. While in the physical sciences it is generally assumed, probably with good reason, that any important factor which determines the observed events will itself be directly observable and measurable, in the study of such complex phenomena as the market, which depend on the actions of many individuals, all the circumstances which will determine the outcome of a process... will hardly ever be fully known or measurable. And while in the physical sciences the investigator will be able to measure what, on the basis of a prima facie theory, he thinks important, in the social sciences often that is treated as important which happens to be accessible to measurement. This is sometimes carried to the point where it is demanded that our theories must be formulated in such terms that they refer only to measurable magnitudes.

The more important piece is this: not only do we not really understand the world, we aren’t particularly likely to “understand” it anytime soon. We’ve been making mistakes for centuries, and we should expect that it will continue. The pretension that we do understand the world leads us towards grave errors.

It is both terrifying and liberating to accept that we live in a world that we cannot and do not fully understand. It’s terrifying, in that we have invented or discovered thousands of things that can kill us, from bacteria to nuclear weapons, and we don’t fully understand the space in which we interact with those doomsday devices. But it is also liberating, in that admitting that we have a problem is the first step towards figuring out an approach to solving it.

The remainder of this series is going to focus on how we deal with a world that we don’t understand. Below will follow five suggestions, each of which will get its own writeup this week. In a world we don’t understand:

1. Decentralization is better than centralization.
2. Social harmony is an intrinsic good, and apolitical spaces are an important way to foster it.
3. We should strive for a system built on predictable rules, rather than reliance on individuals.
4. Tradition and the “old ways of doing things” deserve some deference, though we should not slavishly adhere to them.
5. We should be wary of demagoguery and populism, though not reflexively dismissive.

Finally, I will attempt a synthesis, and I'll recommend some (better) writers.

Defending Conservatism, Part 1: An Introduction

Much of this was put together in a fit of excess energy after a particularly busy few weeks at work, so it’s a scattered brain dump. But I found myself writing a defense of conservatism, and it kept going on and on and on. I did some aggressive cut and paste and reorganization, and this is what emerged. I originally was just going to post to Facebook, but it makes sense to post here as well.

These are dark days for those of us with a conservative outlook on things: the so-called “conservative” party has taken power in ways almost unimaginable eight years ago, but conservatism itself is beset on multiple fronts. The principled conservatives in Congress are mostly backbenchers acting in exile, or tiptoeing around the emergent new nationalism. The president professes himself a conservative, but he has spent his whole life in a deeply liberal enclave and has no real philosophical grounding. A growing “white nationalist” movement with a keen understanding of social media is attempting to take the reins by appealing to the desire of conservatives to oppose a common enemy; an ally of theirs is the president’s chief strategist. Meanwhile, the Left has grown increasingly strident and certain of its positions; if the president’s approval rating is where it is now in three years, nominating someone on the Far Left will be awfully tempting for the Democrats. If these are victories for conservatives, I should hate to imagine what defeat would look like.

However, dark days lead to opportunities, and this is an opportunity to start fresh, and to make a public case for a different understanding of conservatism. Why here, why now?

Some context: I grew up on the east coast and currently live on the west coast, so most of my friends  and associates are quite liberal/progressive. Judging by my Facebook feed, many are rapidly becoming moreso in the age of Donald Trump. I intend this in part as a dissent, but more as an opportunity to present some ideas that don’t usually kick around in academia. Academia is deeply focused on privilege, power structures, and the role of race, class, and gender in societies. When you start from this position, your conclusions drift in a progressive direction. Indeed, as someone who has studied those areas as an undergraduate and graduate student, I agree that the evidence is clear that race, class, and gender do matter, that differences in these areas have been the foundation for oppression, that progress has been made on these issues thanks to increasing awareness and action, and that there is much work still to do. But there are other starting points for thinking about organizing a “good society,” ones that don’t usually get much traction or focus in an academic setting.

In the absence of this sort of exchange of ideas, conservatism is represented by the hucksterism of folks like Sean Hannity, or Bill O’Reilly, or Rush Limbaugh, or Joe Scarborough, or Tucker Carlson, or any of the other vapid entertainers that have claimed the mantle of conservatism over the past few decades. Bill Buckley, they are not. But they become the faces and voices of a venerable philosophy. It’s disheartening.

Thus, with Donald Trump and his allies as standard-bearers for conservatism, I’m basically a guy without a home politically. I am deeply concerned that “conservatism” and “Trumpism” will become one in the same by the end of his first term. I intend to fight that with every (available) fiber in my being that is not otherwise occupied by family, social, and professional commitments. (So, probably not with all too much effort, I guess. But I can at least put pen to paper. Or fingers to keys, as it were.) If Trump is conservative, than what I propose here is not conservative, but it’s worth saying anyway.

A couple of disclaimers, before I begin. First, I am Catholic, and much of what I believe is informed by my Catholicism. I intend for the arguments I make here to stand alone, apart from any particular faith tradition, but it would be dishonest to suggest that my political views and my religious views are unrelated; on the contrary, religion very much informs my politics. Second, I have been a self-professed conservative since I was 15 years old, and I wouldn’t have defended my views this way back then. It’s possible that this is all an elaborate post hoc rationalization. So please take everything I have to say with a grain of salt (or three or four).

Lastly, the framing I work with is my own, but the ideas are not; I am merely trying to publicize them, using my (admittedly) small platform. Any errors, of course, are mine and mine alone.

For the next seven days, I will post an article here, making the case for an alternative to progressivism and Trumpism. If you’re interested, follow along! If not, more power to you. Use your time for good.

Part 2 - The Problem of Modernity
Part 3 - In Favor of Decentralization and Subsidiarity
Part 4 - The Benefits of Social Harmony and Apolitical Spaces
Part 5 - The Imperative of Predictable Laws and Regulations
Part 6 - The Legitimacy of Tradition
Part 7 - The Virtues and Vices of Populism
Part 8 - The Way Forward and Additional (Better) Reading

A Quick Postmortem on the Election

I posted this on Facebook after becoming someone I didn't want to be over the last couple of months: a guy who shares a lot of links and articles on Facebook. Social media politics spamming is for Twitter, after all.

I'll probably stop Facebook posts on politics after tonight; it's a bit too depressing, and I think that it's best to avoid tilting at windmills. But my position, 18 hours after the deluge, is as follows:

1. I've been a Republican since I first registered to vote back in 2005. But I cannot abide being a member of a Republican Party founded on "Trumpism." To the extent that there is a coherent ideology of Trumpism, it is a belief in the power of centralization, "strength," intentions, and wise dealmaking. My views are much the opposite: government must be about interests, limits, subsidiarity, and dealing with human weaknesses. The GOP was closer to me on those issues for much of my life as a voter. That might no longer be the case.
2. It is not clear what the GOP will look like at this time next year, or in two years, or in three years. It makes sense to wait and see, and to resist, resist, resist, as firmly as I can, wherever and whenever the GOP abandons the principles I respect. If the GOP appears too far gone--if Trumpism infects it thoroughly--I will leave. But after some thoughts on this following Trump's nomination, I decided that I'd rather not throw away my (small) voice to steer it toward better outcomes, at least not until it is clearly a lost cause.
3. There are lots of Republican elected officials across the country who have built their careers on a more inclusive, deliberative politics while retaining skepticism of progressive social programs. For starters, I admire Ben Sasse, Rob Portman, Nikki Haley, Susana Martinez, Tim Scott, and Mike Lee. (Much to Ohio's credit, Portman ran well ahead of Trump.) I will monitor those elected officials closely over the next few months to see how they respond to Trump.
4. There is much wisdom, I think, in focusing on the local and the community, rather than on the federal leviathan. I will try to do this in my daily life more: to be a participant in good standing of various levels of civil society. If the federal government is going to hell in a handbasket, we should at least make our communities and churches strong and welcoming.
5. Lastly, a personal failing that I will attempt to address: in any future encounters with the GOP, I will call out examples of bigotry I see. By accident of birth and upbringing, I've been lucky enough to see very little of them in person. But they're obviously more central in American society than I'd hoped or believed, and I expect to see an uptick of examples in the aftermath of Trump's victory. The reports I've seen already are heartbreaking and troubling.

I hope that in my year or so of sharing #NeverTrump stuff and telling everyone I could about the dangers of Trump, I made a small difference: I wanted to communicate to my conservative friends that Trump is dangerous, and to my liberal friends that some conservatives they knew recognized the danger. If I didn't--if I just polluted your feed with things that wasted your time--I apologize for that.

In the meantime, there's work to do, and interesting times ahead.

Brain Dump: Steven Brill's *America's Bitter Pill*

I had a million things racing through my head while reading Steven Brill's America's Bitter Pill, a well-reported deep dive into the flaws in America's health care system and the passage and implementation of the Affordable Care Act. (I like "PPACA" as the acronym, rather than "Obamacare," which is tendentious, or the "A-C-A," which sounds less like a bill than an interest group.)

I recommend reading the book. It's really three stories in one: one about legislative maneuvering, one about executive branch execution (my area of interest), and one about Brill's thoughts on justices and injustices in the health care marketplace.

None of them quite warrant a full article, but I wanted to clean out my brain and get my initial thoughts on paper somewhere. Some of these are comments on the book, others are comments on the events themselves. So, without further ado: a brain dump.

At its core, theirs was a plan any Republican or chamber of commerce lobbyist would likely love: The government would create tens of millions of new customers for all those profiting from the current system--insurers, drug companies, hospitals, and makers of all varieties of high-margin medical equipment, from CT scans to defibrillators. - Chapter 2 

I found this description to be tendentious, depicting the average Republican as a sort of vulgar plutocrat focused only on business profits. It seemed to me that Brill was trying to set up a narrative where Republican opposition to PPACA was entirely founded on a desire to oppose President Obama, rather than over real concerns with the policy.

Ultimately, if the private sector continues to make a ton of money in health care, that's fine. But if government distortions of the marketplace result in higher prices than that which a freer market would bear, then Republicans would (and should) oppose. The ideology is not "What's good for doctors is good for America."

Grassley and Baucus were good friends and had worked together to produce numerous Finance Committee legislative initiative. The Democratic and Republican staffs also got along. "I remember going to one of the Finance meetings on health," recalled one [Ted] Kennedy staffer, "and you couldn't tell the Democrats from the Republicans." Their summit, organized by the staff to include participation in marathon panel sessions by everyone who was anyone in healthcare policy, was going to be a big deal. - Chapter 3

This was one of those "Aha!" moments in reading a book. This kind of buddy-buddy politics is part of what ignited the Tea Party: the idea that their representatives became captured by the Washington system. Frankly, Republicans and Democrats should sound different on health care.

... then Obama broke in. "If I become president, I'm going to try to do healthcare fast. And I can't do it fast if I don't talk about it in the campaign. So we have to talk about it." 

As they left the meeting, Obama took a relieved [Neera] Tanden aside and casually said something that left her wondering whether to laugh or cry. "You know," Obama said. "I think maybe Hillary was right about the mandate.... I'm not going to talk about it in the campaign, but we may need it." - Chapter 5

This alludes to then-candidate Obama's famous opposition of the individual mandate in the Democratic primary campaign. "Flip-flops" don't really bother me, if politicians are forthright about why they changed their minds. But this sort of political nihilism bothers me. It just does. I know it's par for the course, but why should we tolerate it without calling it out when we see it?

Meanwhile, while Obama was dodging on the mandate, his VP was calling John McCain's sensible plan to detach employment from insurance the biggest middle class tax hike in history.

One potentially devastating cut involved a reform long proposed by Democrats and resisted by Republicans that would allow Medicare to negotiate the prices it paid for prescription drugs. In what had become an enduring monument to the lobbying power of the drug companies, in 2003 Congress had prohibited Medicare, the world's largest drug buyer, from negotiating prices the way insurance companies were allowed to. Instead the government had to pay 106 percent of what the drugmakers reported to them was their "average wholesale price," a straitjacket that cost taxpayers $40 billion a year. PhRMA's highest priority, according to [lobbyist Billy] Tauzin, was preserving that law, even if it meant giving back some money to the federal government through discounts related to other Medicare and Medicaid payments. - Chapter 8, p. 97

Brill was extremely skeptical of all arguments about pharmaceutical innovation, slamming pharmaceutical companies for excess profits. But I think he has an overly-mechanistic view of the way that corporate profit margins work, and completely ignores survivor bias in markets; Megan McArdle offers the necessary corrective.

Also, $40 billion a year for decentralized pharmaceutical innovation that benefits the entire world isn't a bad use of government funds.

During their negotiations with the Baucus staff, the PhRMA people had talked vaguely about helping to get their $80 billion deal done by supporting a political action fund that would buy television ads supporting senators who favored reform and attacking those who didn't or were wavering. Messina and Selib, aided by political consultant Nicholas Baldick, were now calling in that promise. They outlined a plan for PhRMA to become the main financier of two political action committees that would buy those ads, by which, under law, would not have to reveal their donors. The funds had the kind of innocuous-sounding names that Obama had made fun of on the campaign trail when attacking special-interest money polluting politics: Health Economy Now and Americans for Stable Quality Care. 

PhRMA ultimately contributed $70 million to the two funds, while the unions and other left-of-center groups chipped in relatively token amounts. The Service Employees International Union's Michelle Newar, who attended the April 15 [2009] meeting, explained the lopsided funding this way in an email to her colleagues, including SEIU boss Andy Stern: "They plan to hit up the 'bad guys' for most of the $. ... They want us to put in just enugh to be able to put our names on it--@ 100k." - Chapter 8, p. 100

Something something laws and sausages.

[The insurance companies'] tight profit margins were dwarfed by those of the drug companies, the device makers, and even the purportedly nonprofit hospitals. 

This was because even in noncompetitive markets, insurers had to buy products from suppliers--hospitals, device makers, drug companies--that had been able in the past two decades to raise their prices with abandon. 

That's not to say that the big insurers are managed well or that they haven't reacted to the corner they have been forced into by taking it out on their consumers. But it does mean they are the only industry players who, however unsympathetic, are on the consumer and taxpayer side of the divide. Like us, they buy healthcare. Yet the White House healthcare reform policy team thought they should be the only players to have their profits capped. They were the bad guys. - Chapter 9, p. 122

This was a good observation from Brill; I think it often gets missed in health care stories. This is, of course, part and parcel of our inflation of health care and health insurance. But Brill sees it.

Sixty people from the White House and the Department of Health and Human Services attended a July 15, 2009, "innovation" meeting that Summers's and Orszag's people considered a bust, because it was mostly taken up with the HHS and Medicare people explaining why they couldn't make better use of data and didn't have the computer systems that could implement bundled payments. - Chapter 9, p. 138

Just an amusing anecdote about the way the bureaucracy works and the way political appointees work. They are often conflated, but this is appropriate. The former has more power on issues they choose to emphasize, but the latter has more power on net.

[Pollster David] Simas was right. Bureaucrats were regarded as evil. But if [self-styled Republican message guru Frank] Luntz had his way, Obama was going to become the "evil" bureaucrat in chief. This label would stick despite the fact that, from the Democratic perspective, Obama's plan was the opposite of a government "takeover" of healthcare. Rather, it was all about the government, through premium subsidies, giving everyone money to buy healthcare from the same private insurers who would pay the same high prices to the same private drug companies, doctors, device makers, and "non-profit" but profitable hospitals to provide it. - Chapter 9, p. 143

I initially flagged this because I missed the "Democratic perspective" piece; I thought Brill was adding in some sort of facile on-the-spot fact check. And frankly, we see this sort of thing in fact-checks all the time: the underlying Democratic assumptions are equivalent to the ones that the fact-checkers use, and the veracity of a given assertion is graded more favorably than it would be under different assumptions. This would be one of those cases. Considering PPACA to be a "government takeover" is not an unreasonable position: the insurers are essentially converted into highly-regulated utilities that have to provide specific services, responsive to the whims of government.

[Health policy adviser Jeanne] Lambrew wanted no insurance policies to be grandfathered at all once the exchanges were launched. She hated the insurance companies, she told one meeting, and especially hated the insurers who sold those skimpy, often useless policies. Consumers needed to be protected. Period. - Chapter 9, p. 146

It must have been very difficult for people like Ms. Lambrew to deal with PPACA, because it was so much a giveaway to private business.

... on September 2, with Obamacare in such trouble, the Baucus people and [Nancy] DeParle's White House team had agreed that they would leave the doc fix out of the bill. Why? Because the Congressional Budget Office had scored its cost at $200 billion over ten years. Jettisoning it would instantly bring healthcare reform $200 billion closer to the deficit neutrality they had promised. They would tell the doctors they would do a permanent fix in a separate bill, something Washington had failed to do for more than fifteen years. Sure, the CBO would still score that separate bill at $200 billion if and when such a bill was drafted, but that wouldn't count against Obamacare. - Chapter 10, p. 154

Among the many things about PPACA that drove me crazy was the flagrant, ridiculous gaming of the CBO process. These budget shenanigans are just so fundamentally dishonest; they wanted to create a brand new entitlement, but refused to own the implications.

The most important drafting mistake seemed to say that insurance bought on the exchanges run by the federal government and not by the states (if a state decided not to set up its own exchange) would not qualify for subsidies at all, although elsewhere the language did, as was clearly intended, including the exchanges run from Washington. - Chapter 13, p. 194

I found this passage (and the surrounding paragraphs) frustrating, mostly because of an error of omission: Brill never mentions the Gruber "speak-o" about the potential for subsidies to states to be used as a cudgel. But there are a couple of reasons to think it could have been. One is that the statute uses a similar threat against subsidies for noncompliance over the Medicaid funding structure. The other, though, I think is more critical: if you simply think about the way the bill was put together, it is likely that different drafters had different opinions over different sections. The bill was moved quickly and covers a ton of ground; we don't really know what was intended, and there was surely more than one drafter. I would bet that someone involved thought that the rationale of punishing states that didn't participate was a solid one. But it didn't get hashed out.

At the very least, it's not unambiguous, as Brill claims.

Brill, as he tends to do, gives the Democrats the benefit of the doubt on these questions, but there are reasons to problematize that. (Incidentally, this is how media bias actually works: it's about assumptions and the benefit of the doubt. Of course the Democrats meant for subsidies to be available for everybody.)

Also, in general, if you can't take a massive bill to a conference committee, it shouldn't pass.

The night of the House vote, Obama gathered his staff on the Truman Balcony for a champagne celebration. Obama toasted his team, although he noted that "now we all have to get to work." 

One member of the group, while sharing everyone else's near delirium, later recalled that there was something slightly troubling about what Obama said next. The president seemed more focused on the work ahead involving getting people to sign up on the exchanges, rather than on executing all the steps that had to be completed--the regulations, the software, the rules for the insurance companies--to get people to the stage where they could sign up. "Assumption that passage  = execution, which is worrisome," is how this healthcare staffer shorthanded it that night in a journal that this person kept. - Chapter 13, p. 192-193

I found this anecdote unsurprising. Obama obviously cares a great deal about policy, and he's wonderful at politics. But he has never seemed particularly animated by the nitty-gritty of governance, choosing instead to believe in the capabilities of the professional bureaucracy while he focused on other areas. Scandals in his administration--such as they have existed--have been due to incompetent or corrupt governance throughout the broad executive branch, not in specific actions within his White House.

This is an issue that animates me, and frankly should animate more of my friends on the Left: if government is incompetent, the best-laid policy proposals will fail, citizens will suffer, and people will resent government.

"[Obama] had never run anything before," added another former close adviser who was in the White House at the time. "And I think he was finding his way about how much detail to get into, how much attention he should pay to this stuff. It was always, 'You guys figure it out.'" - Chapter 14, p. 204

Another point in favor of electing people with some sort of experience.

When I looked at [a] list of salaries for the Time article, I discovered that compared with their peers at equally venerable nonprofits, these executives were comfortably ensconced in a medical ecosystem that was in a world of its own. For example, Sloan Kettering had two development office executives, or fund-raisers, making $1,483,000 and $844,000. Another New York nonprofit that mines the same field for donors--the Metropolitan Museum of Art--paid its top development officer $345,000. Harvard paid its chief fund-raiser $392,000. - Chapter 15, p. 233

Brill's focus on salaries for executives was disproportionate. Sure, they're high, and perhaps a bit of an outrage. But they're a rounding error on costs. Personnel costs are driven by the salaries of the line-workers: doctors, nurses, technicians, etc.

Through the Republican primary contests of 2012, the former Massachusetts governor had been put on the defensive by opponents who charged that the reviled Obamacare was the offspring of Romneycare. Tim Pawlenty, the Minnesota governor who had ordered every agency in his state to have nothing to do with the new law, had taken to calling Obamacare O'Romneycare. - Chapter 16, p. 248

Pawlenty called it "Obamneycare," a far cleverer portmanteau.

On the 2012 campaign trail he promised to repeal Obamacare on the first day of his presidency. What he had done in one state, he asserted, did not justify Obama's "one-size-fits-all" for all states, and he attacked a federally imposed mandate as an assault on liberty that would not work. 

Jonathan Gruber, the MIT economist who had helped Romney create Romneycare and then worked on Obamacare, had sat out the 2008 election. Now, he happily allowed himself to be interviewed at every opportunity confirming that Obamacare was modeled exactly from Romneycare and, like Romneycare, was going to work fine. - Chapter 16, p. 248

Brill takes pains throughout the book to compare the similarities between Romneycare and PPACA, suggesting that Republican opposition to it was disingenuous or a product of motivated reasoning. But there were good reasons--and remain good reasons--to be OK with Romneycare and to dislike PPACA. Ramesh Ponnuru and Yuval Levin wrote the most relevant piece on this back in 2012. Romneycare was a decent solution within the confines of a badly-designed federal context. A federal solution should have moved away from those issues to repair the federal problems, rather than entrenching them further. It did not.

Also worth noting is this excellent piece from Reihan Salam, who discusses the origins of the individual mandate. The staffer who created the mandate originally is now an aid to mainstream Democrat Richard Blumenthal, which says something about the way that the parties have shifted over the last 20 years, and, more trenchantly, about how little Republican policy people focused on health care prior to PPACA.

... with the Court having cleared away what looked to be the final external hurdle for the law to go forward, the insurers and the rest of the healthcare industry assumed they would start seeing the necessary regulations and other preparations flowing out from Washington with fire-hose velocity. 

However, through the summer of 2012, nothing happened. There was a presidential election looming, and the Obama political team didn't want to pollute the news cycles with anything that  cold prompt an Obamacare story. Someone was bound to criticize anything they issued. "We literally fell a year behind," a senior CMS official told me. "We were told by the White House to do nothing, not even circulate drafts of regs, because they might leak out if lobbyists got ahold of them." - Chapter 16, p. 259

The Obama administration has consistently put politics ahead of governance, period, end of story.

So we had agreed that through the summer I would make multiple trips to Washington to look in on how this massive program and its core e-commerce website was being built. I even told my editors that based on the efficient, dedicated people I had seen at the CMS campus in Baltimore while reporting on the vetting and processing of Alana A.'s Medicare bills for the first article, this was likely to be an uplifting saga of unsung heroes. Whatever the political dysfunction in Washington, Obama's managers and these civil servants were going to prove that big government could work. - Chapter 18, p. 289

I admire Brill for laying his biases out so clearly here: he was expecting a big government success story and had trouble imagining bureaucratic disaster. Left-leaning folks, in general, have more confidence in government than it warrants.

Lucky for him, Brill found the Kentucky success story and focused on it as a contrast to the federal debacle.

One additional point: there is a connection between governance dysfunction and political dysfunction.

White House chief of staff Denis McDonough had a friend who had been pestering him with calls in September. The friend warned the chief of staff that his insurance industry contacts thought the exchange wasn't even close to being ready. One had even told McDonough's friend that his company was thinking of pulling out to avoid being involved in what was going to be a fiasco. "My people say he's overreacting to some last-minute problems," McDonough had assured his friend. 

Now, on the evening of September 30, just hours before the launch, McDonough called the same friend. "Based on the reports I'm getting I think we're gonna knock your socks off tomorrow," he promised. - Chapter 19, p. 322

It's interesting to me that private sector folks had a better idea of what was going on than public sector folks.

There were some additional points in this book about how the disaster unfolded, and how the administration repaired it with a "tech surge" of talented young programmers liberated from most government contracting restrictions (which worked out better, frankly, than I anticipated).

A couple of things that I thought warranted more coverage in the book:

1. A discussion of how broadly the Obama administration defined basic services, and how vigorously they pushed things like birth control as a requirement. (see: Little Sisters of the Poor, Hobby Lobby, etc). This is part of why even the bronze plans are expensive.
2. The Obama administration's essential function as an ad hoc conference committee, smoothing out drafting errors with an incredibly broad interpretation of executive discretion.

In the end, though, what we see is President Obama's desperate desire for a legacy, to catch the great whale of American politics and to go down in the history books as bringing about universal care. I suspect historians will give him what he wants. But the plan could have been a lot better, a lot less controversial, and/or a lot less disruptive. (I would have preferred for Obama to use his legislative majorities to go after the structural issues in American health care first. And once Scott Brown won, I thought that Obama should have scaled back a bit, opting for a straightforward expansion of Medicaid. I bet that would've passed without issue.)

A Quick Post on Voting Third Party

I posted this on my Facebook wall this morning, in response to an article in the National Journal. I figure that I have a handful of friends in this group, and I'd like to try to at least flip a vote or two.

A quick rant for this morning, reading the below article. My apologies in advance.

• If you voted for McCain and/or Romney, and you can't vote for Clinton, I can respect that.
• If you voted for Obama twice but have soured on his tenure and think he did a bad job, and you can't vote for Clinton, I can respect that.
• If you voted for Obama once or twice, and you think he's done a *good* job, and you're NOT voting for Clinton, please, *please* reconsider. I know this is a real phenomenon based on polling data: there are many people who like Obama who can't or won't pull the trigger for Clinton and are opting for Johnson or Stein. I suspect most of them are in their 20s and early 30s.

You don't have to convince me that Clinton is deeply flawed. The transfer of classified information over an unsecured email server--and the unconvincing efforts of her allies to downplay it--drives me insane. Her penchant for secrecy is downright destructive. She and her husband have used the halo of the presidency to enrich themselves far beyond what is appropriate; overpaid corporate tycoons run companies that at least add something to society. Clinton made money by giving speeches at $250,000 a pop.

But she's essentially running for Obama's third term, a continuation of what we've seen. If you're happy with Obama, you'll probably be decently happy with Clinton.

And she is not Trump, who knows nothing about anything other than what he watches on cable news; who is utterly self-obsessed; who acts out of personal pique *all the time*; who exploited birtherism to get a political profile; who barely knows the structure of government; who admires governmental exhibits of strength, even when it results in the deaths of thousands of innocent people (see: Tiananmen Square); who represents a genuine risk to global safety and stability; and who, at minimum, tolerates affiliation with this generation's white supremacist movement, and, at maximum, genuinely sympathizes with its evil worldview.

A vote is not an exercise in self-actualization; it's an exercise of genuine political power, however small. Entertaining the idea of voting third party was reasonable through the summer; after all, it was plausible that someone could catch fire, like Perot in 1992, and have a legitimate chance. But that's simply not the case; polls are clear that 80% of people are voting for Clinton or Trump.

Many of my co-partisans tried to stop this nightmare, and we failed. You don't have to do the same. If you wake up on November 9, and Trump won, what are you going to say if you voted for Johnson or Stein?