Glenn Greenwald: Blame the all-powerful left! Buried deep in this is the point I made a couple of days ago. I think it bears repeating (and repeating and repeating):

All that said, and as horrible as the Democrats have been all year, the most amazing -- and depressing -- aspect of all of this is how Americans have so quickly forgotten how thoroughly the Republicans, during their eight-year reign, destroyed the country. Whatever the source of our national woes are, re-empowering that faction cannot possibly be the answer to anything.

The main point of the article is the repeated charges, especially by right-wing Democrats like Evan Bayh, that Obama's problem is that he's fallen under the spell of "the furthest left elements" of the Democratic Party. As Greenwald documents, this is based on "exactly nothing" -- other than the idiot repetition of a line that strains credulity even when mouthed by Republicans.

Paul Krugman: Do the Right Thing: At last reckoning, the Democrats still had a majority in the House of Representatives. A majority -- less than the official party majority, but still a majority -- have even voted for a health care bill at least somewhat to the left of the one the Senate voted for 60-39. That bill was in fact so "moderate" that it was approved by Lieberman, Nelson, Bayh, and others who repeatedly held it up. One had hoped that reconciling the two bills would have resulted in one slightly better than the Senate bill, if not as much better as the House bill. But now that the Senate Republicans are free to wreck any bill, that option no longer works. But what would work would be for the House to pass the Senate bill as is, avoiding the need to reconcile versions. All we need for that is for the same Democratic majority to approve the weaker Senate bill as approved the stronger House bill. Do that, and Obama will have something significant to show for all his mealy compromises and uninspired leadership. Do that and the Democrats can claim to have delivered the one thing their base wants more than anything else. Don't do that and all the House Democrats will have to show their base is that they don't have any principles, and America that they don't have any guts. I wouldn't bother lobbying any Republicans on this: all they've shown is that they'd rather break America than let the Democrats get credit for facing up to a major problem. But go after the Democrats with everything you got. Any Democrat who refuses to stand up for this bill doesn't deserve the party's ticket. Or the party doesn't deserve its supporters.

Krugman adds this on his blog:

Maybe they'll come to their senses over the next few days. It would be really helpful, of course, if Democrats actually had a party leader -- you know, the president or someone.

One more point: although I'd be happy to see the Senate bill passed by the House and signed by Obama -- if served up on a silver platter, he'd at least do that much, wouldn't he? -- it's not at all clear that Obama's habitual rejection of leftist proposals has done him any good. Maybe it's politically determined by the intransigence of the Republicans and the clout of established interests -- the health care industry accounts for about 18% of US GDP, and the finance industry for a bit more, and if you give extra weight for profits over the last 10-20 years you can add to those figures. But genuinely leftist proposals would in many cases have more resonance with more people than those who identify themselves as leftists: they build on a sense of justice and fairness, they hold established interests responsible for their transgressions; they are simpler, they make more sense, and they are more likely to actually work.

To take one example, Obama's hands-off approach to Big Pharma deprived him of using one of biggest, most obvious villains in the health care costs death spiral. (Instead, Billy Tauzin came back at the last minute demanding even more patent extensions, threatening to withdraw his lobby's hitherto useless support.) But there are plenty of more examples: get tougher on the banks, deflect the deficit projection gibberish by raising taxes on the rich, get out of Afghanistan, and scale back the incredible waste that is the US Department of Defense.

Funny thing is that if he actually moved left it wouldn't change the Republicans line one iota. But it would give him something to stand up for.

I, for one, am pleased that the Senate passed any kind of health care reform bill. Without the reforms it is virtually impossible for me to buy functional insurance at virtually any price. I wish the bill covered more people more affordably. I wish the bill did a much more aggressive job of tackling the critical problem in the system here, which is profit-seeking by virtually everyone involved. This has led to fragmentation and unnecessary complexity, to obfuscation and propagandizing. This leads patients to not understand when they do or do not need treatment, making critical decisions based on all sorts of things that should be secondary or irrelevant. This tempts doctors to give more or less or just different treatment than the patient actually needs. This leads drug companies to mislead us on medications, including covering up major harm. This has led to all sorts of things that have very little to do with promoting public health. Most impressively of late this system has done everything within its considerable power to corrupt political discourse. That anything positive has come out of it is remarkable.

I've been thinking about the health care system for a long time now. I have some pretty straightforward ideas about how to fix most of the problems, and they led me to favor different solutions from the one that Congress settled on. Everyone likes their pet ideas, and I'm no different in that respect, but T.R. Reid's recent book is helpful in showing that there are actually many variations on health care system that all work much better than the one we have, both in terms of lower costs and better outcomes. In theory, I'm inclined to favor a "Beveridge Model" system like the UK has (or like the US provides through the Veterans Administration), where all services are government run. But the UK system tends to be underfunded, resulting in longer delays and fewer options than we are used to (assuming you have reasonably good insurance here in the US). Especially in terms of availability and flexibilty, it looks like the best health care systems in the world are in France and Japan, which use private insurance and providers, but regulate them severely, in effect squeezing the profit motive out of the system. This has led to great cost efficiencies in the systems: for example, an MRI that costs over $1000 in the US costs $100 in Japan -- a situation which allows Japanese doctors to order more MRIs and still save money. But the various systems aren't exclusionary: it's easy to imagine a UK-type system pursuing upstream supplier costs like the Japanese do. It's easy to imagine a Canadian system with adequate funding for specialists: in fact, that's what the US Medicare system does.

Reid offers good and bad news on prospects for change in the US. He shows two examples of systems that were similar to ours (profit-seeking, out-of-pocket) up to 1994 but were then changed successfully: Switzerland and Taiwan. In the Swiss case, the main change was to require private insurance companies to refund any profits. Before the change, Switzerland had the second most expensive health care system in the world at 11% of GDP, just 1% behind the US. Fifteen years later, Switzerland is still second, still at 11%, while the US GDP cut has boomed to 17% and is still headed up. Taiwan did a bit more, and got better results: they adopted a Canadian-style single payer scheme. The good news here is that such change is possible. The bad news is that in both Switzerland and Taiwan the changes were pushed through by conservative political parties, preferring to compete with the left-liberal parties by adopting progressive change on their own terms. In both cases, the decision was arrived at not just politically but morally: in both cases, even conservatives agreed that equal access to health care should be a right for all people, not just for those who can afford it. Of course, that's not bad news for Switzerland and Taiwan; it's bad news for us, where even the Democrats have trouble articulating health care as a fundamental right, and where Republicans are nothing short of shameless. Not a single Republican voted for health care reform this year, despite the numerous deals that Obama negotiated with the AMA, the pharmaceutical industry, and other lobbyists, despite the fact that insurance company stock prices rose on passage. The Republicans have moved past their usual stance of sucking up to industry; on health care they're into pure ideological malevolence. So the near term prospects for conservatives doing anything responsible are close to nil.

For a taste of Reid's book, look here.

Matthew Yglesias: Mitch McConnell's Proud Unipartisanship. Quotes the Republican Senate Minority Leader:

This fight isn't over. It's going to be a multi-cycle campaign issue. Many Democrats will be defeated over this. The landscape is shifting. We have an excellent chance of having the cavalry arrive next year. The Democrats will be more skittish. A substantial number of them will want to change the subject as rapidly as possible. [Health care] is a huge political loser for them.

And they say generals always prepare to re-fight the last war. Republicans remember how their intransigent opposition to Clinton's 1993 health care reform effort was followed by Republican wins in the 1994 congressional election, so they figure what worked then will work now. That strikes me as monumentally stupid, both as a political strategy and as a reading of history. The single biggest difference is that Obama passed his bill whereas Clinton failed to get his bill out of committee. Clinton's failure looked incompetent, then when he walked away from the bill like some embarrassing road kill, he gave Democrats little reason to expect more from him. On the other hand, Obama persevered, against tough odds, and he comes out of this with something to defend.

At most, the defeat of health care contributed some moment to the Republicans in 1994. Their big issue was the corruption of Congress under long-term Democratic rule, and it was largely H. Ross Perot who turned the tide in their favor. After that they used every trick of incumbency to hang onto narrow margins until 2006 when their own corruption finally sunk them. During the 15 years between Clinton's failure and Obama's success, Republican intransigence and blindness has allowed a predatory health care industry to increase its share of GDP from 12% to 17%, during which time more and more people were unable to buy or afford insurance, bankruptcies proliferated, and the US sunk further and further on most international metrics of health. Those are costs that fall not just on the poor and working families; they cut into business profits and burden manufacturers, who in turn cut real wages and/or export jobs. Against these trends, the Republicans have done nothing, turning a blind eye to greed and a cold heart to suffering and fear. They've made a lot of noise, and worked themselves up into a frenzy, but it's all been negative, paranoid, surreal. Aside from their fanatic base, will anyone else believe them? Why would anyone else trust them?

I'm not saying the Democrats have no problems. They have all of our problems: continuing pointless wars, economic rot, solutions that don't go far enough. But they can point back to the wreckage of Republican rule, which is all the more credible given that the best the Republicans can claim is that Bush screwed up because he was a big spending big government closet case. And they can point to their own pragmatic moderation, which gets real (but modest) results without upsetting the Establishment. The Democrats would have it made if the Establishment showed them equal respect, but even so, the Republicans seem determined to make sanity the issue the next couple of election cycles turn on. The last time they exposed their conservatism so nakedly was Goldwater.

Paul Krugman: Simulating Single-Payer. A little economic analysis arguing that Hackerish health care plans, like the one in Massachusetts and the one the Senate just passed, approximately simulate single-payer plans: "just imperfect, somewhat inefficient ways of simulating the results of a single-payer system." This is basically the same thing as we get out of Reid, who shows time and again how universal coverage ("community rated") private insurance systems approximate the behavior of single-payer systems. You can take this as reason not to get too disappointed that Obama and the Democratic leadership didn't stick their necks out for a real single-payer system. On the other hand, the inefficiency is likely to be more than "somewhat," and the imperfections glaring. It all depends on how strictly regulated the insurance companies are, and how efficiently the market can be made to work. Up to now the key to profits has been inefficient markets: opaqueness at every stage, lack of standardization in billing, uncertainty in payments, complexity everywhere, monopoly rents nearly everywhere. There is a lot of room here for savings without sacrificing one iota of service, but I expect the interests to fight efficiency as doggedly as they've fought equality. Single-payer may not in principle be any more efficient than a well-managed private system like in Japan. But single-payer would be much simpler, and would show political will to make it work. And while it may not have been politically practical, the main reason is that leaders who know better didn't have the guts to go for it.

Some other books that I've noted in my book prospecting notes but (generally) haven't explored further. Listed alphabetically by author. A couple go beyond the politics of health care to get into the practice, but I usually drew the line short of there. Some deal with suspicious public health issues, and some of those are suspicious in their own right. Some push right-wing or status quo-ist agendas, some ideologically (e.g., Cato Institute) but most with a financial stake in their scheme. A small number of more general political books are listed where they seem to be especially relevant (e.g., Rahm Emanuel's The Plan), but not many. I've skipped over most books published before 2001, except when they seem to have historical value. There were a rash of books that appeared during 1992-94 that are presumed hopelessly dated. There was a slight uptick around 2004, and again from 2006 on when it started to look like a Democrat might be elected president in 2008 -- although more than a few of those books were meant to ward off Republican agendas like HSAs and CDHC.

I've added notes to some where I thought helpful, but have let most explain themselves through their titles. Several books have book page links. I've eliminated all of the superfluous titles (mostly MD) on author names.

• Henry J Aaron/Leonard E Berman, eds: Using Taxes to Reform Health Insurance: Pitfalls and Promises (paperback, 2008, Brookings Institution Press)
• John Abramson: Overdosed America: The Broken Promise of American Medicine (2007; paperback, 2008, Harper Perennial): Drug industry expose; there are several of these.
• Carl F Ameringer: The Health Care Revolution: From Medical Monopoly to Market Competition (2008, University of California Press)
• Marcia Angell: The Truth About the Drug Companies: How They Deceive Us and What to Do About It (paperback, 2005, Random House): Especially this one.
• Tom Baker: The Medical Malpractice Myth (2005; paperback, 2007, University of Chicago Press)
• Charles Barber: Comfortably Numb: How Psychiatry Is Medicating a Nation (2008, Knopf)
• Dan Beauchamp: Health Care Reform and the Battle for the Body Politic (paperback, 1996, Temple University Press)
• Donald M Berwick: Escape Fire: Designs for the Future of Health Care (2004, Wiley)
• RE Biedermann: Health Care Cure! (paperback, 2002, Wheatmark): As far as I can tell, his cure is positive thinking.
• David Blumenthal/James Morone: The Heart of Power: Health and Politics in the Oval Office (2009, University of California Press): New history of the politics of health care policy.
• Bill Bradley: The New American Story (2007, Random House): Favors single-payer "Medicare for all," then offers a voucher-based alternative.
• Howard Brody, Hooked: How Medicine's Dependence on the Pharmaceutical Industry Undermines Professional Ethics (Rowman & Littlefield)
• Shannon Brownlee: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (2007, Bloomsbury): On my shelf; the idea that you can not only save money but also improve quality by eliminating unnecessary treatments is attractive but may prove to be hard to attain.
• Grace Budrys: Our Unsystematic Health Care System (2nd edition, 2005, Rowman & Littlefield)
• Lawton R Burns: The Health Care Value Chain: Producers, Purchasers, and Providers (2002, Jossey-Bass)
• Lawton Robert Burns, ed: The Business of Healthcare Innovation (paperback, 2005, Cambridge University Press)
• Michael F Cannon/Michael D Tanner: Healthy Competition: What's Holding Back Health Care and How to Free It (paperback, 2005, Cato Institute): Nothing wrong here consumer choice in a free market can't fix.
• Clayton M Christensen/Jerome H Grossman/Jason Hwang: The Innovator's Prescription: A Disruptive Solution for Health Care (2008, McGraw-Hill)
• Larry R Churchill: Self-Interest and Universal Health Care: Why Well-Insured Americans Should Support Coverage for Everyone (1998, Harvard University Press)
• John F Cogan/R Glenn Hubbard/Daniel P Kessler: Healthy, Wealthy, and Wise: Five Steps To A Better Health Care System (2005, American Enterprise Institute for Public Policy Research): Calls for patient empowerment (i.e., CDHC).
• Jay S Cohen: Over Dose: The Case Against the Drug Companies: Prescription Drugs, Side Effects, and Your Health (2001, Tarcher)
• Jonathan Cohn: Sick: The Untold Story of America's Health Care Crisis -- and the People Who Pay the Price (2007; paperback, 2008, Harper Perennial): personal case reporting.
• Gregoire Coombs: The Rise and Fall of the HMO Movement: An American Health Care Revolution (2005, University of Wisconsin Press)
• Greg Critser: Generation Rx: How Prescription Drugs Are Altering American Lives, Minds, and Bodies (2004; paperback, 2007, Mariner Books)
• David M Cutler: Your Money or Your Life: Strong Medicine for America's Health Care System (paperback, 2005, Oxford University Press)
• Norman Daniels: Just Health Care (1985, Cambridge University Press)
• Tom Daschle: Critical: What We Can Do About the Health-Care Crisis (2008, Thomas Dunne; paperback, 2009, St Martin's Griffin): not much when you have lobbyists like Daschle cutting insider deals.
• Gregory Dattilo/David Racer: Your Health Matters: What You Need to Know About US Health Care (2006, Alethos): From an insurance exec.
• Mike Davis: The Monster at Our Door: The Global Threat of the Avian Flu (2005; paperback, 2006, Holt)
• Howard Dean: Howard Dean's Prescription for Real Healthcare Reform: How We Can Achieve Affordable Medical Care for Every American and Make Our Jobs Safer (paperback, 2009, Chelsea Green): Or, why Obama didn't offer the most visible Democratic MD in the country a job.
• Richard DeGrandpre: The Cult of Pharmacology: How America Became the World's Most Troubled Drug Culture (2006, Duke University Press)
• Alan Derickson: Health Security for All: Dreams of Universal Health Care in America (2005, Johns Hopkins University Press)
• Adam F Dorin: Jihad and American Medicine: Thinking Like a Terrorist to Anticipate Attacks Via Our Health System (2007, Greenwood): Lots of bad things that could happen; no reason to link them to Jihad.
• David Dranove: Code Red: An Economist Explains How to Revive the Healthcare System Without Destroying It (2008, Princeton University Press)
• Carl Elliott: Better Than Well: American Medicine Meets the American Dream (paperback, 2004, WW Norton)
• Rahm Emanuel/Bruce Reed: The Plan: Big Ideas for Change in America (2006; paperback, 2009, Public Affairs)
• Madelon Lubin Finkel: Truth, Lies, and Public Health: How We Are Affected When Science and Politics Collide (2007, Greenwood): AIDS, contraception, stem cell research, marijuana as medicine, breast implants, obesity, vaccination, etc.
• Leonard M Fleck: Just Caring: Health Care Rationing and Democracy (2009, Oxford University Press): If you have to ration (and to some extent you do), how do you do it ethically?
• Sherman Folland/Allen Goodman/Miron Stano: The Economics of Health and Health Care (6th Edition, 2009, Prentice-Hall): At $168, priced like its subject matter.
• Meredith Fort/Mary Ann Mercer/Oscar Gish, eds: Sickness and Wealth: The Corporate Assault on Global Health (paperback, 2004, South End Press)
• Philip J Funigiello: Chronic Politics: Health Care Security from FDR to George W Bush (2005, University Press of Kansas)
• Laurie Garrett: Betrayal of Trust: The Collapse of Global Public Health (2000; paperback, 2001, Hyperion)
• Arthur Garson/Carolyn L Engelhard: Health Care Half Truths: Too Many Myths, Not Enough Reality (2007, Rowman & Littlefield)
• Atul Gawande: Complications: A Surgeon's Notes on an Imperfect Science (2002; paperback, 2003, Picador): Notes on the practice of surgery; has a useful discussion of malpractice issues.
• Atul Gawande: Better: A Surgeon's Notes on Performance (2007; paperback, 2008, Picador)
• John Geyman: Falling Through the Safety Net: Americans Without Health Insurance (paperback, 2003, Common Courage Press)
• John P Geyman: The Corporate Transformation of Health Care: Can the Public Interest Still Be Served? (paperback, 2004, Springer)
• John Geyman: Shredding the Social Contract: The Privatization of Medicare (paperback, 2006, Common Courage Press)
• John Geyman/Marcia Angell: The Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy? (paperback, 2007, Common Courage Press)
• John Geyman: Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It (paperback, 2009, Common Courage Press)
• Susan Giaimo: Markets and Medicine: The Politics of Health Care Reform in Britain, Germany, and the United States (2002, University of Michigan Press)
• Julio Gonzalez: Health Care Reform: The Truth (2009, Aragon): Anti "Democrat agenda"; hint: only right-wingers label their books "The Truth."
• John C Goodman/Gerald L Musgrave/Devon M Herrick: Lives at Risk (paperback, 2004, Rowman & Littlefield): Anti-single-payer hysteria.
• Merrill Goozner: The $800 Million Pill: The Truth Behind the Cost of New Drugs (2004; paperback, 2005, University of California Press)
• Colin Gordon: Dead on Arrival: The Politics of Health Care in Twentieth-Century America (2003, Princeton University Press)
• Peter Gosselin: High Wire: The Precarious Financial Lives of American Families (2008; paperback, 2009, Basic Books): Needless to say, health insurance (or lack thereof) plays a big role.
• David Gratzer, The Cure: How Capitalism Can Save American Health Care (paperback, 2008, Encounter Books): Also has a book on how to wreck Canada's health care system.
• Katharine Greider: The Big Fix: How The Pharmaceutical Industry Rips Off American Consumers (paperback, 2003, Public Affairs)
• Jerome Groopman, How Doctors Think (2007; paperback, 2008, Houghton Mifflin)
• Robert Gumbiner: Curing Our Sick Health Care System: A Solution to America's Health Care Crisis (paperback, 2006, Author House): Looks like "Medicare for all."
• Jacob S Hacker: The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (1998; paperback, 1999, Princeton University Press): One of the main books on the Clinton fiasco.
• Jacob S Hacker, The Great Risk Shift: The Assault on American Jobs, Families, Health Care, and Retirement and How You Can Fight Back (2007; paperback, 2008, Oxford University Press): a general book where, again, health care costs loom large.
• Jacob S Hacker, ed: Health at Risk: America's Ailing Health System -- and How to Heal It (paperback, 2008, Columbia University Press)
• Nortin M Hadler: The Last Well Person: How to Stay Well Despite the Health-Care System (2004, McGill-Queen's University Press)
• Nortin M Hadler: Worried Sick: A Prescription for Health in an Overtreated America (2008, University of North Carolina Press)
• George C Halvorson/George J Isham: Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care (2003, Wiley)
• George C Halvorson: Health Care Reform Now!: A Prescription for Change (2007, Jossey-Bass)
• George C Halvorson: Health Care Will Not Reform Itself: A User's Guide to Refocusing and Reforming American Health Care (2009, Productivity Press): Kaiser Permanente CEO.
• Mark J Hanson/Daniel Callahan: The Goals of Medicine: The Forgotten Issues in Health Care Reform (paperback, 2001, Georgetown University Press)
• Fran Hawthorne: Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat (2005, Wiley)
• David Healy: Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression (paperback, 2006, NYU Press)
• David Hemenway: Private Guns, Public Health (paperback, 2006, University of Michigan Press)
• Regina Herzlinger: Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America's Largest Service Industry (paperback, 1999, Basic Books): Harvard Business School prof, sees insurance as the problem for distorting prices; uses eyewear as an example of how an effective market-driven system would work.
• Regina Herzlinger, Who Killed Health Care? America's $2 Trillion Medical Problem -- and the Consumer-Driven Cure (2007, McGraw-Hill)
• Philip J Hilts: Protecting America's Health: The FDA, Business, and One Hundred Years of Regulation (2002; paperback, 2004, University of North Carolina Press)
• David Himmelstein/Steffie Woolhandler: Bleeding the Patient: The Consequences of Corporate Health Care (paperback, 2001, Common Courage Press)
• Stephen SS Hyde: Cured! The Insider's Handbook for Health Care Reform (paperback, 2009, HobNob): Perfect markets can fix anything.
• Icon Group International: Health Care Reform: Webster's Timeline History, 1945-2007 (paperback, 2009, Icon Group)
• Haynes Johnson/David S Broder: The System: The American Way of Politics at the Breaking Point (1996, Little Brown; paperback, 1997, Back Bay Books): History of Clinton's health care fiasco.
• Timothy Stoltzfus Jost: Health Care at Risk: A Critique of the Consumer-Driven Movement (paperback, 2007, Duke University Press): Abbreviated CDHC, not that any actual consumers are driving it.
• Martin Kantor: Uncle Sam's Shame: Inside Our Broken Veterans Administration (2008, Greenwood): Don't know how this squares with other reports that the VA system is actually pretty good.
• Jerome P Kassirer: On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health (paperback, 2005, Oxford University Press)
• Joel M Kauffman: Malignant Medical Myths: Why Medical Treatment Causes 200,000 Deaths in the USA Each Year, and How to Protect Yourself (paperback, 2006, Infinity)
• Sharon R Kaufman: And a Time to Die: How American Hospitals Shape the End of Life (2005, Scribner)
• Ichiro Kawachi/Bruce P Kennedy: The Health of Nations: Why Inequality is Harmful to Your Health (paperback, 2006, New Press)
• JD Kleinke: Oxymorons: The Myth of a US Health Care System (2001, Wiley): Another CDHC scheme, based on eliminating employer groups.
• Arnold Kling: Crisis of Abundance: Rethinking How We Pay for Health Care (paperback, 2006, Cato Institute)
• Laurence J Kotlikoff: Healthcare Fix: Universal Insurance for All Americans (2007, MIT Press): Mandatory private insurance with vouchers.
• Richard D Lamm: The Brave New World of Health Care (paperback, 2003, Fulcrum): Former Colorado governor; if I recall correctly, big into rationing and death panels.
• Richard D Lamm/Robert H Blank: Condition Critical: A New Moral Vision for Health Care (paperback, 2007, Fulcrum)
• Marie L Lassey/William R Lassey/Martin J Jinks: Health Care Systems Around the World: Characteristics, Issues, Reforms (paperback, 1996, Prentice Hall)
• Jacky Law: Big Pharma: Exposing the Global Healthcare Agenda (paperback, 2006, Basic Books)
• Evan S Levine: What Your Doctor Won't (or Can't) Tell You: The Failures of American Medicine -- and How to Avoid Becoming a Statistic (paperback, 2005, Berkley Trade)
• Robert Arthur Levine: Shock Therapy for the American Health Care System: Why Comprehensive Reform Is Needed (2009, Praeger)
• Harold S Luft: Total Cure: The Antidote to the Health Care Crisis (2008, Harvard University Press): Pushes something called "SecureChoice," which looks like single-payer for big ticket items (e.g., hospital stays) with CDHC for small change and a cut for the insurance companies for processing checks.
• Joanne Lynn: Sick To Death and Not Going to Take It Anymore!: Reforming Health Care for the Last Years of Life (2004, University of California Press)
• Maggie Mahar: Money-Driven Medicine: The Real Reason Health Care Costs So Much (2006, Collins): Looks like one of the more systematic analyses; on my shelf.
• Theodore R Marmor: The Politics Of Medicare (2nd edition, paperback, 2000, Transaction)
• TR Marmor: Fads, Fallacies and Foolishness in Medical Care Management and Policy (2007, World Scientific)
• Rick Mayes: Universal Coverage: The Elusive Quest for National Health Insurance (paperback, 2005, University of Michigan Press)
• David Mechanic, ed: Policy Challenges in Modern Health Care (paperback, 2005, Rutgers University Press)
• Ivan J Miller: Balanced Choice: A Common Sense Cure for the US Health Care Systems (paperback, 2006, Author House): sort of a single-payer base with wildly diverging copays depending on provider choices.
• Matthew Miller: The 2% Solution: Fixing America's Problems in Ways Liberals and Conservatives Can Love (paperback, 2005, Perseus)
• James A Morone/Lawrence R Jacobs, eds: Healthy, Wealthy, & Fair: Health Care and the Good Society (2005, Oxford University Press)
• Ray Moynihan/Alan Cassels: Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients (paperbck, 2006, Nation Books)
• Ray Moynihan/Melissa Sweet: How Patients Should Think: 10 Questions on How to Make Better Decisions about Drugs, Tests, and Treatment (paperback, 2009, Pegasus)
• Rudolph Mueller: As Sick As It Gets: The Shocking Reality of America's Healthcare, A Diagnosis and Treatment Plan (2001, Olin Frederick)
• David B Nash/Neil L Goldfarb, eds: Quality Solution: The Stakeholder's Guide to Improving Health Care (paperback, 2006, Jones & Bartlett)
• Vicente Navarro: The Politics of Health Policy: The US Reforms, 1980-1994 (1994, Wiley): Reagan, Bush, Clinton, if you can call them reformers.
• Barack Obama: The Plan: Barack Obama's Promise to America and His Plan for the Economy, Iraq, Healthcare, and More (paperback, 2009, Pacific)
• Mary O'Brien/Martha Livingston, eds: 10 Excellent Reasons for National Health Care (paperback, 2008, New Press)
• Robert Ohsfeldt/John E Schneider: The Business of Health (paperback, 2006, American Enterprise Institute for Public Policy Research)
• Lawrence J O'Brien: Bad Medicine: How the American Medical Establishment Is Ruining Our Healthcare System (1999, Prometheus): Focuses on physician mindsets.
• Oliver S Owen: Doctors, Dollars and Death: Bad Medicine in America (1994, Warren H Green)
• Kant Patel/Mark Rushefsky: Health Care Politics and Policy in America (3rd edition, paperback, 2006, ME Sharpe)
• Kant Patel/Mark E Rushefsky: Health Care in America: Separate and Unequal (paperback, 2008, ME Sharpe)
• Melody Petersen: Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs (2008; paperback, 2009, Picador)
• Michael E Porter/Elizabeth Olmsted Teisberg: Redefining Health Care: Creating Value-Based Competition on Results (2006, Harvard Business Press)
• R Lee Prescott: Barack Obama's Plan to Socialize America and Destroy Capitalism (paperback, 2009, Madrona Books)
• TR Reid: The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2009, Penguin Press): Compares US health care to other systems all around the world.
• Marc Roberts/William Hsiao/Peter Berman/Michael Reich: Getting Health Reform Right: A Guide to Improving Performance and Equity (paperback, 2008, Oxford University Press)
• J Patrick Rooney/Dan Perrin: America's Health Care Crisis Solved: Money-Saving Solutions, Coverage for Everyone (2008, Wiley): HSA pushers; you didn't actually think they had a solution, now did you?
• Peter Rost: The Whistleblower: Confessions of a Healthcare Hitman (paperback, 2006, Soft Skull Press)
• David J Rothman/Sheila M Rothman, Trust Is Not Enough: Bringing Human Rights to Medicine (2006, New York Review Books)
• Mark E Rushefsky/Kant Patel: Politics, Power and Policy Making: The Case of Health Care Reform in the 1990s (paperback, 1998, ME Sharpe)
• Jessica Snyder Sachs: Good Germs, Bad Germs: Health and Survival in a Bacterial World (paperback, 2008, Hill & Wang)
• Lisa Sanders: Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis (2009, Broadway)
• Len Saputo/Byron Belitsos: A Return to Healing: Radical Health Care Reform and the Future of Medicine (2009, Origin Press): Pushes something called "Health Medicine" which doesn't sound like medicine at all.
• Stuart O Schweitzer: Pharmaceutical Economics and Policy (2006, Oxford University Press)
• Karen Seccombe/Kim A Hoffman: Just Don't Get Sick: Access to Health Care in the Aftermath of Welfare Reform (paperback, 2007, Rutgers University Press)
• Saul William Seidman: Trillion Dollar Scam: Exploding Health Care Fraud (paperback, 2008, Universal)
• Virginia A Sharpe, ed: Accountability: Patient Safety and Policy Reform (2004, Georgetown University Press): Figures 98,000 Americans die each year due to medical error; wonders why.
• George P Shultz/John B Shoven: Putting Our House in Order: A Guide to Social Security and Health Care Reform (2008, WW Norton): Another GOP complaint about poor people living too long.
• Theda Skocpol: Boomerang: Health Care Reform and the Turn Against Government (2nd edition, paperback, 1997, WW Norton): The sinking of Clinton's health care agenda.
• Don Sloan: Practicing Medicine Without a License! The Corporate Takeover of Healthcare in America (paperback, 2006, White Cloud Press): Single-payer, universal care, damn the corporations.
• Susan Smith: Sick and Tired of Being Sick and Tired: Black Women's Health Activism in America, 1890-1950 (paperback, 1995, University of Pennsylvania Press)
• Barbara J Sowada: Call to Be Whole: The Fundamentals of Health Care Reform (2003, Greenwood)
• Paul Starr: The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (1983; paperback, 1984, Basic Books): Pulitzer Prize-winning history of medical profession in US; although old, its conclusion about the profit-driven corruption of the profession has only become more true; I have a copy on the shelf.
• Rosemary A Stevens/Charles E Rosenberg/Lawton R Burns, eds: History and Health Policy in the United States: Putting the Past Back In (paperback, 2006, Rutgers University Press)
• Kip Sullivan: The Health Care Mess: How We Got Into It and How We'll Get Out of It (paperback, 2006, Author House)
• Cass R Sunstein: The Second Bill of Rights: FDR's Unfinished Revolution -- and Why We Need It More Than Ever (2004; paperback, 2006, Basic Books): On legal issues surrounding a right to universal health care.
• Keith Syrett: Law, Legitimacy and the Rationing of Health Care: A Contextual and Comparative Perspective (paperback, 2007, Cambridge University Press)
• Ken Terry: Rx for Health Care Reform (paperback, 2007, Vanderbilt University Press): Single-payer, PGPs, pretty much seconds Relman.
• Richard H Thaler/Cass R Sunstein: Nudge: Improving Decisions About Health, Wealth, and Happiness (2008; Yale University Press; paperback, 2009, Penguin Press): Makes a science of manipulating people by architecting options; both authors are prominent Obama advisers.

• Werner Troesken, The Great Lead Water Pipe Disaster (MIT Press)
• Neil Vidmar: Medical Malpractice and the American Jury: Confronting the Myths About Jury Incompetence, Deep Pockets, and Outrageous Damage Awards (paperback, 1997, University of Michigan Press)
• Howard Waitzkin: At the Front Lines of Medicine: How the Health Care System Alienates Doctors and Mistreats Patients . . . and What We Can Do About It (2001, Rowman & Littlefield)
• Andrew Weil: Why Our Health Matters: A Vision of Medicine That Can Transform Our Future (2009, Penguin)
• Joel S Weissman/Arnold M Epstein: Falling Through the Safety Net: Insurance Status and Access to Health Care (paperback, 2004, Beard Books)
• Susan Wicklund: This Common Secret: My Journey as an Abortion Doctor (2007, Public Affairs)
• Richard Wilkinson: The Impact of Inequality: How to Make Sick Societies Healthier (paperback, 2006, New Press): Broader than just health care.
• Richard Wilkinson/Kate Pickett: The Spirit Level: Why Greater Equality Makes Societies Stronger (2009, Bloomsbury) [Dec. 22]

The more I look, the more such books I find, although many of them seem outside the bounds of good taste or immediate relevance. Selecting a short reading list is impossible. I have only read 3 of these (the Bradley and Hacker links, and the first Atul Gawande), plus 7 of the 9 books I reported on yesterday (1 link was based on a review, one more on an excerpt). And I have a few more books on hand if/when I get time for them: Brownlee, Mahar, Starr, the second Gawande, Groopman; and I have Kawachi/Kennedy and the first Wilkinson on order. Reid's new book looks promising, and Rothman is a historian I've long admired tackling an important subject. Hardly makes me an expert, but it does suffice to cover much of the story. It also helps that I've read quite a bit of the background history and theory; also that I have more personal experience that I really want to think about. I've been thinking that health care would make a good subject for a case analysis in my book on how to think about public policy. The exercise of dredging up all these books makes me realize that there's an even bigger gap here for a book that can triangulate between the practice of health care, the business and politics around it, the social and philosophical concerns of patients, and the technology. Will have to think more about that.

I overheard most of Obama's health care speech the other night. I usually duck political speeches, but it came on during a break in the music, and I wasn't much enjoying the music. Seems like he made the basic case clearly, although he didn't go very deep, in large part because he's not trying to fix very much. I heard one peculiar round of boos, but didn't catch what occasioned it -- maybe that Rep. Joe Wilson flap. And I heard three or four more boos, clearly coming from Laura in the TV room. I agree with her that the only way to actually fix the system is to wring the profit incentives out of it and to restore a professional ethic of care giving, and that the first step should be to institute single-payer insurance. Obama's credentials as a progressive and for that matter his reputation as someone with a grip on reality were tarnished by his eagerness to make light of single-payer. He also came up short on two other key points: one is whether government can run programs that serve the people, which is really a key article of faith for anyone who professes belief in democracy; the other is deficits question, where the right answer is: we'll spend what we need to spend to provide everyone with quality health care, and if that's more than is in the current budget we'll raise taxes to cover it. But then, as I said, Obama wasn't trying to fix very much. And if he manages to make it possible for someone like me who can afford to buy health insurance but can't find any insurance company willing to sell me a policy, I at least will be pleased. On the other hand, lots of other people will remain disappointed. One thing for sure is that Obama won't be the last president to attempt to reform the health care system. Even if he delivers what he's promised, he'll leave plenty more to be done.

Over the last few weeks, I read three health care books I found at the library. I've read more over the last few years, and have more on tap. The books are:

• Ezekiel J Emanuel: Healthcare, Guaranteed: A Simple, Secure Solution for America (paperback, 2008, Public Affairs): The perscription here is for a regulated private insurance system, allegedly because people want choices, but then goes on to expect big changes in the provider segment -- a much higher bar to reform than simply dropping private insurers no one likes anyway. Emanuel is Rahm Emanuel's brother, which may be one reason Obama leans in this direction, but even Emanuel sees bigger problems and goes further to fix them than Obama does.
• Jill Quadagno: One Nation Uninsured: Why the US Has No National Health Insurance (2005, Oxford University Press). This is a good full range history of political efforts to reform health insurance going back to the progressive era before World War I. One consistent thread is how business interests have played decisive roles each step along the way -- even Medicare was slanted in favor of special interests, and did much to vastly increase growth in spending and costs. The reform section at the end is weak, but the historical survey is essential.
• Arnold S Relman: A Second Opinion: Rescuing America's Health Care (2007, Public Affairs). Probably the best policy book I've seen. At least Relman gets the essential contradiction between profit-seeking and quality care. He favors both single-payer financing and a major reorganization of medical care in favor of large, non-profit PGP groups. The latter may seem like a radical idea, but there are several good examples already established (e.g., Kaiser-Permanente) and they have superior results for lower costs. One weakness is that he doesn't get into pharmaceutical and technology companies.

Some older books that I read and commented on earlier:

• Donald L Barlett/James B Steele: Critical Condition: How Health Care in America Became Big Business -- and Bad Medicine (2004, Doubleday): Long on case histories, a/k/a horror stories. My note has more about Bush's "ownership society" plots.
• Robert H LeBow: Health Care Meltdown: Confronting the Myths and Fixing Our Failing System (2003, Alan C Hood): More convincing stories of failure; more sensible but cautious steps to help out.
• Phillip Longman: Best Care Anywhere: Why VA Health Care Is Better Than Yours (paperback, 2007, Polipoint Press): A report on the VA system, the closest thing the US has to a fully socialized government run system, also a remarkably effective one.
• David Mechanic: The Truth About Health Care: Why Reform Is Not Working in America (2006, Rutgers University Press): Another useful survey of the manifest problems with cautious recommendations.
• Julius B Richmond/Rashi Fein: The Health Care Mess: How We Got Into It and What It Will Take to Get Out (2005, Harvard University Press): Jimmy Carter's Surgeon General surveys the current situation, registers his opinion that single-payer insurance would be the right fix, then offers an alternative that closely matches Kerry's 2004 campaign platform.
• Susan Sered/Rushika Fernandopulle: Uninsured in America: Life and Death in the Land of Opportunity (paperback, 2006, University of California Press): My book note here mostly derives from a Malcolm Gladwell review that takes off from the book to provide a superb summary of the issue (see quote below).

Malcolm Gladwell: The Moral-Hazard Myth. An article published in 2005, in part a review of the Uninsured in America book cited above. When I originally posted a quote from the article, I didn't bother tracking down the URL, but now I've found the piece online. Part of the quote deserves reiteration (the only thing that has dated it is that the costs are even more outrageous now):

One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century -- during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years -- efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world's median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average. Infant-mortality rates are in the nineteenth percentile of industrialized nations. Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland have more MRI machines per capita. Nor is our system more efficient. The United States spends more than a thousand dollars per capita per year -- or close to four hundred billion dollars -- on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita. And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy -- a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper -- has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.

I started assembling a list of miscellaneous books related to health care policy issues, starting with my previous book prospecting blogs. Wound up with a pretty long list, which probably needs a few more notes, so I decided to hold it back. Tomorrow, maybe.

George Lakoff: The PolicySpeak Disaster for Health Care. Useful and somewhat insightful critique of how Obama and most of those who more or less support him speak about the health care issues -- not that I'm not annoyed with the insinuation that it's all a matter of framing. The masses may only respond to political issues in emotional terms, but there's still something to be said for rationally figuring out the policy details. Of course, the left is at a disadvantage here, as in virtually all policy debates, both because we have some good faith in democracy and because we actually intend to accomplish something worthwhile. The right, with no interest in either, is free to kick our asses, but they've hardly been geniuses in this shouting match: they repeatedly come off as ignorant, hysterical, and mean, and in some ways we're best off just to let them destroy themselves. Lakoff has a knack for finding an important point then losing it on his first stab at reframing:

Eighth, it was a mistake to put cost ahead of morality. Health care is a moral issue, and the right-wing understands that and is using it. That's why the "death panels" and "government takeover" language resonates with those who have a conservative moral perspective and have effectively used terms like "pro-life." Health care is a life and death issue, which is as moral as anything could be. The insurance companies have been on the side of death, and that needs to be said overtly.

Morality isn't the right word here, but he's close. The basic fact is that if you can put a price on surviving an illness or injury vs. dying, that price would gladly be met by anyone able to meet it. It's easy enough to see that we value our own lives and most likely the lives of the people we love most more than money. Focus on cost runs against this instinct. (A curious turnaround, actually, since it is usually the moneygrubbing right that lectures us on how little we can afford to pay even for the most basic necessities of those most desperately in need.) That's why we should focus first on quality care and keep that from slipping regardless of cost, only secondarily looking at cost as an aid to being able to do more thing better. On the other hand, following Lakoff's suggestion and decrying insurance companies as deathmongers isn't even true -- at most you can say they are indifferent to deaths because their fiduciary responsibility is focused on profits.

So, sure, we can do a better job of talking in this campaign, but what would help more than better branding and wordsmithing would be a better solution to the problem. In fact, a good start would be to actually understand the problem, which quite simply derives from the commercialization of health care. That part is simple enough, but the industry is so huge and varied that no one realistically wants to try to wring out all of the commercialization. The single-payer advocates are only going after the insurance companies, which is a big and pernicious target and one that could most easily be dispensed with, but that leaves the actual providers, who have plenty of their own problems. Arnold S. Relman, in A Second Opinion, wants to go further and reorganize the providers into non-profit PGPs, which also makes sense, but is a much bigger task, is very likely to be disruptive, and still leaves the drug and tech companies free to scheme. I'd go after them too, and I got a few more things on my list too, like information architecture, training more professionals, and educating people to make smarter health decisions. But more than all that, you need to get people to recognize that professional virtues are more important than acquiring money. The essential reform of the system is to get to the point where your doctor values your health more than his own pocketbook. That's not impossible, but it's pretty hard to do in America these days.

Matt Yglesias: The Psychology of Health Reform. Back to reality, this quotes an article by James Suroweicki on the psychology of loss aversion, then adds a couple of points that are probably more important. I'll add that a key part of why the "public option" is so critical to those of us who think reform is not just a good idea but a dire necessity is that -- exactly contrary to so many folks on the other side of the divide -- we can't stand the idea of ever again being subject to a corporate bureaucracy where our health and welfare is treated as a zero-sum game. We at least know that even mediocre government bureaucracies in theory work for us. We can at least appeal to them, and it helps knowing that the coverage we need isn't coming out of their pockets -- it's actually coming out of our own, but cushioned by the fact that in a public insurance scenario everyone helps everyone out.

Ironically, the other side is equally convinced that it is the government that is arbitrary and capricious, attributes which they may or may not also recognize in the companies. (Some may hold to the fantasy that a free market forces companies to respond to the demands of customers, but there is no free market for health insurance -- nothing even remotely resembling one.) This is one reason why the real debate isn't over health care: it's over democracy. One side insists that the government can never be trusted with anything so important as health care. The other takes a similarly jaundiced view of companies, except insofar as they are regulated by laws enforced by government. Moreover, it sees government as the only agency that can represent the interests of the broad public in a society that is otherwise dominated by business. The Republicans have tied themselves to the mast of Ronald Reagan's dumb joke about the scariest words in the English language being "I'm from the government, and I'm here to help." The fact of the matter is that whenever anything goes seriously wrong -- a hurricane, an earthquake, a terrorist attack, a bunch of bankers swindling themselves into a drunken tizzy -- even Republicans descend on Washington looking for a bailout. There actually isn't anything wrong with that: many problems, especially really big ones, are by far best handled by government. Health care is one of those problems, but if the Republicans admit it they'll lose their whole shtick. So they stick to their guns and suffer, their only comfort being that others suffer worse.

Paul Krugman: Obama's Trust Problem: The news today (i.e., 5 days after this column appeared) is that Obama will renominate Ben Bernanke for a second term as Fed Reserve Chairman. Bernanke hasn't been as bad as a lot of Bush appointees, but part of that was circumstance -- he was nominated as a hawk against inflation, but he spent most of his term in a deflationary recession where his instincts were unneeded and could do little harm. On the other hand, past Fed chairmen have repeatedly been able to hold the economy in a death grip. If you're a president who is committed to trying to stimulate enough growth to actually improve the welfare of the people who voted for you, you'd think you'd want a Fed chairman who'd see eye-to-eye with you on that. Obama could in theory appoint anyone he wants, so why not come up with someone more in line with his programs and ambitions? I don't know what the thinking is here, but it sounds like Obama did this to reassure the banks and investors. That's what his team has done consistently ever since they took office, which is why we've had bailouts without any meaningful reform. Same thing has happened all across the board. Obama was elected as antiwar but he's presdided over business as usual in Iraq, an escalation in Afghanistan, and budget increases for the defense industry. The only other issue as important to his voters is a massive overhaul of the health care racket, and there he's made a series of inside deals with the AMA and PHARMA to cut back on any meaningful reform while the Republicans have had a field day with their unanswered hysterical nonsense. Obama's offer to drop the public option in favor of non-profit co-ops is one more example of his willingness to knuckle under. Krugman notes:

And let's be clear: the supposed alternative, nonprofit co-ops, is a sham. That's not just my opinion; it's what the market says: stocks of health insurance companies soared on news that the Gang of Six senators trying to negotiate a bipartisan approach to health reform were dropping the public plan. Clearly, investors believe that co-ops would offer little real competition to private insurers.

What's left of Obama's plan is a set of private insurance company regulations that would be better than the present situation but will almost instantly translate into significantly higher insurance prices, which will make universal care all that harder to achieve, and leave us in pretty much the same mess we've been entrapped in for several decades now. That may eventually turn into a make-work program for future Democrats, given that the Republicans have no ideas and no desire to actually address any real problems. But with 60 Senators and a big majority in the House you'd think now would be the time to do something. It's not happening, and a big part of the reason is that it doesn't look like Obama's fighting to make things happen or stand up for things he certainly knew before the election were right. Krugman again:

But there's a point at which realism shades over into weakness, and progressives increasingly feel that the administration is on the wrong side of that line. It seems as if there is nothing Republicans can do that will draw an administration rebuke: Senator Charles E. Grassley feeds the death panel smear, warning that reform will "pull the plug on grandma," and two days later the White House declares that it's still committed to working with him.

Time: Top 10 Health-Care-Reform Players: Just a list, but gives you a sense of the obstacle course.

1. Max Baucus: Montana senator, safely in the industry's pocket
2. Nancy-Ann DeParle: White House "health czar"; the insider most responsible for cutting industry deals
3. Douglas Elmendorf: CBO director, projects costs to be surmounted by any plan
4. Rahm Emanuel: White House chief of staff, Obama's gatekeeper
5. Charles Grassley: Iowa senator, the Great White Hope for a bipartisan deal that will never happen, even if it doesn't matter
6. Karen Ignagni: top insurance company lobbyist
7. Peter Orszag: OMB director
8. Nancy Pelosi and Harry Reid: House speaker and Senate majority leader, presumably responsible for pushing the bills through Congress
9. Olympia Snowe: Maine senator, what passes for the left-wing of the Republican party these days
10. Henry Waxman: House Energy and Commerce Committee chairman

Two things from the Wichita Eagle worth pointing out. The first is Richard Crowson's editorial cartoon:

Crowson was retired last year when the Eagle decided they didn't need original editorial cartoons, then finally brought back on a very infrequent basis. For more, see Crowson's blog.

Also:

Bill Roy: Health care rationed based on ability to pay: One of the best opinion pieces I've seen on the health care town halls. Lynn Jenkins defeated Democrat Nancy Boyda in the 2008 election, running as a "moderate" Republican (versus a rather uninspiring one-term Blue Dog Democrat), but since she got in her record has been indistinguishable from the other Kansas Republicans: conservative Jerry Moran and rabid fascist Todd Tiahrt (both running for Sam Brownback's senate seat). Roy is a retired MD who served two terms in the House, then lost two very narrow statewide Senate races against Bob Dole. I'm tempted to quote the entire piece, but here's just the start:

I attended a death panel in Holton last week. Rep. Lynn Jenkins, R-Topeka, was the convener and presided.

I don't think anyone went there expecting to participate in a death panel, and even afterward, most don't realize they did. But any group that meets with the specific purpose of denying other people necessary medical care fully qualifies as a death panel. By its action, people die.

Small-town people should have a good idea that people without insurance or money often -- not always -- can't get care. If for no other reason, they should remember the bake sales they have had to raise money to help a neighbor get care for a family member who would die without it.

On the other hand, no one would expect them to have read the 2004 report by the Institute of Medicine of the National Academy of Sciences that estimated 18,000 uninsured people die each year because they don't get timely medical care.

Americans ration health care on ability to pay. If people did not know that before the congresswoman's meeting, they should have when they left, because a neighbor told them how it happens.

A local businessman said he has 15 employees, and only one has health insurance. He cannot afford to buy health insurance for his employees, who earn $12 to $15 an hour, and they cannot afford to buy their own health insurance.

The consequence: "One of our workers died of cancer last year, because he didn't see the doctor until it was too late." There was a short pause. Then those in the crowd, which was heavy with Medicare recipients, went back to expressing fears about what would happen to them if other people had health insurance, too.

Read the whole thing.

By the way, I've started Arnold S. Relman's A Second Opinion: Rescuing America's Health Care. Thus far, it is one of the best books I've seen on the subject. More on that later.

Matthew Yglesias: Republicans Calling for Super-Majority for Health Care. I take it the political winds are changing. Maybe some of the insane opposition is blowing back. Maybe some of Obama's deals with the powers that be are bearing fruit. A while back Jim DeMint was saying that failing to deliver on health care would be Obama's Waterloo. Now he's saying that if he passes a bill without broad Republian support, the Democrats will never win an election again. Here we see Enzi and Grassley, who seem like rather arbitrary picks as the party's designated negotiators, pleading for a bill which only the 20-25 most hopeless Republicans will oppose. I think it's clear now that the Republican Party from top to bottom will say and do anything to derail any kind of reform -- a point made clear in Yglesias's last paragraph:

I note that if the people who wrote that story, Lori Montgomery and Perry Bacon Jr., were interested in producing a well-informed audience they might have noted that the House bill Grassley opposes meets both of his criteria for supporting a bill. They might have noted that the Senate HELP bill Grassley opposes meets both of his criteria for supporting a bill. They might even have speculated that Grassley is just lying when he says he wants to vote for a bill, noting that his nominal desires are contra[di]cted by his actual actions. But we don't live in a world where Washington Post articles can be reliably expected to be informative.

From TPM: Throw Mama from the Train:

That's about where Congressional Republicans are on the escalating health care debate. Rep. Paul Broun (R-GA) just sent out a letter that tells voters, among other things, that "When mama falls and breaks her hip, she'll just lie in her bed in pain until she dies with pneumonia because her needed surgery is not cost efficient."

Broun is getting ahead of himself here. Not only it he assuming that the government's going to health care at such a detailed level that they'll routinely overrule doctors, he's assuming that the Republicans are going to be running the government.

Republican vehemence over health care seems to be coming from a deeper point in their reptilian brains than their usual desire to help rich businesses fleece poor customers. They seem to recognize that if government is ever trusted to run anything as critically important to voters as health care, they'll never win another election.

One thing that is certain is that Broun's concern has nothing to do with mama. Preserving the status quo leaves these life or death situations in the hands of the private, profit-maximizing insurance companies. In fact, if health insurance reform fails, the private companies will be all that much emboldened in their search for profits.

Fred Mann: Tiahrt gets warm response at area town halls. Similar reports on Reps. Jerry Moran and Lynn Jenkins. On the other hand, the sole Kansas Democrat in the House, Dennis Moore, called off his town hall meetings after receiving death threats. (Scott Roeder, the guy who assassinated Dr. George Tiller, resided until his arrest in Moore's district.) Tiahrt is the worst of the worst. People urge us to write to him, call, go to his events, but he's so far gone it's pointless trying to reason with him. I've seen him do his town hall thing, and it's a complete waste of time -- one reason he hears so little reason. Still, there is something relatively new here: his crowd is getting out in front of him, pulling even harder to the right:

Speakers were in sync with Tiahrt's opposition to the Obama health care reform plan.

But he didn't escape criticism. The first speaker he called upon said Tiahrt and his party were part of the system that grew federal spending.

Tiahrt cited efforts he made to limit the growth of government, gave a history of how it grew, and drew applause when he said, "If we want to grow the economy, we need to grow it from the ground up, not the government down."

But the next speaker, Jim Hughes of Mulvane, accused him of answering in platitudes rather than saying what he was going to do about government spending.

Hughes then moved on to a series of issues that made him angry, including health care reform. He said he didn't want government in his health care plan.

In some sense this doesn't matter, because Tiahrt is already bought and paid for. But it's starting to look like Obama's has lost not just the fight but his political courage. It's hard to sell a bill full of compromises and loopholes designed to undo the benefits originally promised. It's hard to sell a bill when you yourself admit that something else -- single-payer -- would do the job better.

Robert Reich: How the White House's deal with Big Pharma undermines democracy. As bad as the private sector health insurance companies are, it's not obvious to me that they are the biggest problem, either in terms of health care quality or excessive cost. Big Pharma is way up there, and the megacorp profit-oriented health care providers may even be further up there. The main reason I see for focusing on insurance first is that it not only solves a couple of major problems -- lack of coverage for people who have inadequate insurance and no coverage at all for large numbers of people excluded from the present system -- but that beyond solving those problems it provides purchasing power leverage on the rest of the system. The other nice thing about the insurance companies is that we don't need them at all, so cleaning up that problem should be relatively simple. On the other hand, the health care providers are needed -- the workers, anyhow, if not all the financiers -- which makes it harder to sort out. Drug companies are in between, but the problems can easily be separated out. For starters, rewrite patent law to eliminate monopolies and to regulate drug prices. More importantly, publicly fund research and development, and make all of the planning, procedures, and testing transparent, so you can put an end to drug companies spinning test results and covering up problems (cf. Vioxx). And put some strict regulations on drug industry marketing; better still provide transparent public forums for disseminating information about drug performance. One goal here is to make all drugs generic, reducing the industry to manufacturing. And make this system international, so that research, development, and manufacturing anywhere in the world is available anywhere in the world. Even with new investment in R&D, these few simple changes should result in savings of 50-75% of what is currently spent on pharmaceuticals. That in itself would be a big chunk of cost savings which would help out everywhere else.

The same sort of thing can be done with any other medical technology. One big thing that drives up the cost of health care is that nearly all of the new technologies and procedures are monopoly-priced under patent protection. Which is to say that every new whizzbang development gets to ask the question: how much is your life worth? Most are marketed with ridiculous gross margins, the most successful ones becoming huge bonanzas. Public funding of research and development would if anything outproduce the current private system. For one thing, it would encourage competing groups to build on each other's work. Public testing would make it possible for anyone to spot a problem and come up with a better solution. One of the big hidden costs of the current system is liability: what it costs when a product does unexpected damage. That costs would get wrung out of the system real fast.

Admittedly, private insurance has some easy cost targets too: they currently spent something like 30% of their gross on marketing and administration, whereas a single-payer system like Medicare only spends 3%. The difference could easily pay for universal coverage. But that sort of change is more than Obama will allow himself to consider. Instead, he's pushing a set of regulations on private health insurance which will make it less unpalatable but also more expensive. Then he's shackling those reforms with a requirement that they be deficit-neutral, which opens his whole program to charges that he'll inflict some combination of higher taxes and service restrictions. Cutting this deal with Big Pharma just digs himself a deeper hole.

Personally, I would prefer an approach where we started talking about how the system fails qualitatively, then figure out how to improve on that, introducing savings only once we ensure that no quality will be lost. This means educating people pretty much from scratch about how it all works, and how it currently malfunctions. At some level Obama must understand this, but instead of tackling the problem head on, he keeps trying to skirt past problems by making deals with established interests. That's why he keeps losing. That's why it feels like we wound up with the Clinton administration we voted against.

Phillip Longman: The Best Care Anywhere. This is actually an article from 2005, back in the dark (Bush) ages when nobody even considered the possibility of trying to do something to reform our mess of a health care system, but it's worth taking another look at now. It's about how a government agency carved off a single-payer population and provided them with a health care system with virtually no private sector participation. Free from the influence of private interests, the government only had to balance costs and benefits off. The result is the best quality, lowest cost health care system in America. That's what the Veterans Administration did. Longman went on to expand this article into a book, Best Care Anywhere: Why VA Health Care Is Better Than Yours (paperback, 2007, Polipoint Press).

The story of how and why the VHA became the benchmark for quality medicine in the United States suggests that much of what we think we know about health care and medical economics is just wrong. It's natural to believe that more competition and consumer choice in health care would lead to greater quality and lower costs, because in almost every other realm, it does. [ . . . ]

But when it comes to health care, it's a government bureaucracy that's setting the standard for maintaining best practices while reducing costs, and it's the private sector that's lagging in quality. That unexpected reality needs examining if we're to have any hope of understanding what's wrong with America's health-care system and how to fix it. It turns out that precisely because the VHA is a big, government-run system that has nearly a lifetime relationship with its patients, it has incentives for investing in quality and keeping its patients well--incentives that are lacking in for-profit medicine.

This came about basically because of two moves by Bill Clinton: in 1994 he appointed Kenneth W. Kizer VHA undersecretary of health, and in 1996 he signed a bill to expand eligibility to all veterans, not just combat casualties.

A physician trained in emergency medicine and public health, Kizer was an outsider who immediately started upending the VHA's entrenched bureaucracy. He oversaw a radical downsizing and decentralization of management power, implemented pay-for-performance contracts with top executives, and won the right to fire incompetent doctors. He and his team also began to transform the VHA from an acute care, hospital-based system into one that put far more resources into primary care and outpatient services for the growing number of aging veterans beset by chronic conditions. [ . . . ]

Yet the most dramatic transformation of the VHA didn't just involve such trendy, 1990s ideas as downsizing and reengineering. It also involved an obsession with systematically improving quality and safety that to this day is still largely lacking throughout the rest of the private health-care system.

A lot of details follow on just how this works, but much of it shouldn't be surprising. Most problems are easier (less expensive and more successful) to deal with when you catch them early, which became a focus. And health care is a team activity, so having one set of common electronic records both eliminates extra work and errors and lets everyone work on the same plan. They also took a look at evidence, identifying problems and checking what worked and what didn't. This is almost common sense when you're trying to provide quality health care, but it isn't always followed in the private health care system, where there's an overriding concern for profits.

For example, there is little controversy over the best way to treat diabetes; it starts with keeping close track of a patient's blood sugar levels. Yet if you have diabetes, your chances are only one-out-four that your health care system will actually monitor your blood sugar levels or teach you how to do it. According to a recent RAND Corp. study, this oversight causes an estimated 2,600 diabetics to go blind every year, and anther 29,000 to experience kidney failure.

All told, according to the same RAND study, Americans receive appropriate care from their doctors only about half of the time. The results are deadly. On top of the 98,000 killed by medical errors, another 126,000 die from their doctor's failure to observe evidence-based protocols for just four common conditions: hypertension, heart attacks, pneumonia, and colorectal cancer.

Doctors write their orders into the electronic records system, and nurses check off every time they administer a drug or procedure. The system, by checking the patient ID and the drug/procedure, has virtually eliminated routine mistakes.

Conclusion:

As the health-care crisis worsens, and as more become aware of how dangerous and unscientific most of the U.S. health-care system is, maybe we will find a way to get our minds around these strange truths. Many Americans still believe that the U.S. health-care system is the best in the world, and that its only major problems are that it costs too much and leaves too many people uninsured. But the fact remains that Americans live shorter lives, with more disabilities, than people in countries that spend barely half as much per person on health care. Pouring more money into the current system won't change that. Nor will making the current system even more fragmented and driven by short-term profit motives. But learning from the lesson offered by the veterans health system could point the way to an all-American solution.

Of course, you don't automatically get superior health care by turning it over to the government. It also takes management skill, professional dedication, adequate funding, enough time to review cases and refine and improve methods. You could duplicate many of these methods with private health care providers, especially if you can develop a portable system of records and a system of reviews and accountability that can be shared everywhere. You also need to do as much as you can to isolate medical decisions from the profit machinations that inevitably come with private sector companies. (No one denies that profits are powerful motivators, but nothing is clearer than the fact that optimal health outcomes and optimal profit outcomes have nothing in common.) Public financing of as much shared infrastructure as possible would help -- indeed, would be essential -- with private providers. Open source software is one key element here: it makes adoption practically free, while keeping all of the technology transparent so it can be critiqued and improved by users all over the world. Freely published academic research is another. A single-payer insurance system would also help to push best practices throughout a private provider system.

Lots of lessons here, but the most important one is that the pursuit of best practices and quality outcomes also works best as a cost containment system. In fact, it's the only cost containment methodology that doesn't sacrifice quality. Moreover, by focusing on quality first, we have an answer to everyone worried more that reform will diminish quality, as well as an answer to the bean counters.

Dan Eggen: Industry is generous to influential bloc. Uh, what was it I was saying about the Blue Dog Democrats and health industry money?

Andrew Leonard: The worst healcare reform option: Doing nothing: Links to Ezra Klein on Bill Kristol, Jonathon Chait on Martin Feldstein, and a Bloomberg article by Matthew Benjamin and Brian Faler, which among other things cites an estimate that unreformed and unchecked health care expenses will hit 20% of GDP by 2018. (Again, think of the whole national economy being strangled and swallowed by a giant boa constrictor.) Conclusion:

After reading the Bloomberg piece, it's difficult to see Republican and Blue Dog Democratic resistance to significant healthcare reform as anything other than ruinously irresponsible.

Paul Krugman: Why markets can't cure healthcare. A brief primer starting with Kenneth Arrow's classic paper, "Uncertainty and the welfare economics of health care. This has been discussed many times before -- Robert Kuttner wrote a whole book on it, Everything for Sale: The Virtues and Limits of Markets. The bottom line is that there is no theoretical and no historical/empirical basis for thinking that the present problems of the US health care system can be remedied by any sort of free market approach. You'd have to be stupid and/or blindsided by money to think otherwise.

Krugman has had a lot of good health care blog entries lately, as well as several columns, especially this one:

Paul Krugman: Health care realities. Krugman has been a steady voice on this issue, and this column hits many of the basics: at least as regards insurance and the government, as good a place to start as any. Read it. If I started quoting, I'd quote it all.

Nate Silver: Yes, the GOP's still out of touch. Quotes GOP Rep. Tom Price (R-GA) on how "nothing has had a greater negative effect on the delivery of health care than the federal government's intrusion into medicine through Medicare." Then does some polling, showing: 60 percent of people participating in Medicare rate it 9 or 10 on a 10-point scale (84 percent 7 or better) vs. 36-40 percent approval of private insurance plans; that 77 percent would like to see Medicare expanded to people aged 55 and older; that 58 percent would support Medicare-for-all (i.e., single-payer). That you can't find similar percentages in Congress is solely attributable to the influence of money there.

Matt Yglesias: Health insurance industry's strategic bribery. Good chart here, showing how the health insurance industry has spread its money around. Sure, the rich have a general Republican bias, but every year most of the money went to the majority party in Congress. The majority party is, after all, the one able to make or break the legislation that all that money rides on. Second point is that the totals have been going up and up, expanding even faster than the industry's take of the GDP. No breakdown here between liberals and Blue Dogs.

David Barstow: An Abortion Battle, Fought to the Death. Long New York Times piece on Dr. George Tiller and his struggles to keep his women's clinic open. Well on its way to book length. Barstow likes to characterize Tiller as a battler, one who fought back as much as he got. That's not really true. Tiller never killed anyone. Tiller didn't go around harrassing other people and their businesses. Moreover, Tiller didn't just provide abortions. He was a doctor who cared for his patients, even when carring called for performing an abortion. For the rest of us, he stood up for rights that in theory we have but that in practice are under constant assault. We make a big deal when soldiers die for our rights in some far away country. Tiller died for us, defending us against a much more real threat.

It occurs to me that the problem with the Blue Dog Democrats is, in principle at least, pretty simple. All politicians need voters to get elected, but they also need financial contributors, and in some circumstances the money is much more important. The Blue Dogs almost always run in districts that could more than conceivably be won not just by a Republican but by a really nasty one. That saves the Blue Dog from any real chance of a challenge from the left, no matter how lukewarm or wishy-washy the candidate is. That also means the Blue Dogs have a big Democratic loyalist vote locked in -- maybe less than 50% but close enough to build on. So base voters aren't much of an issue for Blue Dogs. What really matters to them is that the Republicans don't run real strong candidates against them, and what deters opposition candidates more than anything is a big war chest of money. One thing I think you'll find that Blue Dogs are real good at sniffing out is a lot of money. There are two basic political things about health care reform: one is that it's an issue that voters, especially in the Democratic base, really care a lot about; the other is that there is an incredible amount of money riding on the outcome (16% of GDP is one dollar out of every six in the whole economy). The Blue Dogs are taking positions that make no logical sense except for their determination to pay back their sponsors -- e.g., they worry about the costs of things they don't want, while rejecting taxes on the rich to pay for those costs, and promoting higher payments and profits to the industry. They don't worry about pissing off their voter base because they know that if they raise enough money they'll be unbeatable.

Equations like this are one of the dominant features of US politics. It's always safe to be a Republican because the rich take care to support their partisans. The Democrats have had a tougher time with this, especially where labor unions have lost their grip. One result is that Democrats habitually look for candidates who can support their own campaigns. Another is that most rank and file Democrats and lots of non-partisans would put campaign finance reform at the head of any list of things to do when and if we ever get the chance. You'd think that with Obama in the White House and big Democratic majorities in both houses of Congress now would be that time, but I've yet to see them make any effort made in that direction. The top dogs in the Democratic party are there because they're top money raisers, and they get that money because they're good for business. In some cases that's not such a bad thing, but in health care it's deadly. There are lots of problems in health care, but the big one is that the industry has a boa constrictor grip on the economy, slowly, steadily devouring it -- 10% of GDP, 12%, 14%, 16%, any crystal ball into the future only shows larger numbers until the whole thing keels over and dies. If ever we needed to contain the interests of a select few to do something that practically everybody desperately needs it is in health care today.

Matt Yglesias: Poverty Will Always Be With Us Until We Do Something About It: Check out the chart, "Poverty Rate, 1959-2007": not only the big drop from 1959-69 coinciding with Michael Harrington's The Other America and a spate of Democratic programs trying to do something about poverty, but the roller coaster afterwards.

Aside from Nixon, who's a somewhat anomalous Republican in this regard, note poverty rises with the coming of the Ford, Reagan, Bush, and Bush administrations, and drops with Carter and Clinton. There is a secondary effect having to do with overall performance, which is why the latter half of Reagan's reign sees a slight drop. It's also likely that Bush II's bump has more to do with the economy than with administration policy. The chart is baselined at 11% because no one has gone lower. The drop from 11% to 0% would be more difficult than going from 22% to 11%, but the assumption that it's not doable says more about the mental blinders conservatives work under than anything else.

I imagine there's a similar chart somewhere for the 1930s, a time when government -- at least after FDR took over -- was exceptionally proactive at fighting poverty. The conservative predeliction for inaction leads to all sorts of rationalizations, but the only proof they have to offer is their conviction, which looks pretty pathetic compared to what people who care and try manage to accomplish.

Andrew Leonard: How to Upgrade Human Values. Comments on a paper by John E. Roemer, Changing Social Ethos Is the Key. I was especially struck by this, which is a line of thought I've been moving toward:

Roemer believes that in a capitalist society individuals will always figure out ways to break or twist the rules. So he proposes what he calls "a less ambitious aim": Changing people. "If we follow a path leading to a society whose individuals are more solidaristic, then I believe it is much easier to design rules that will guarantee good outcomes."

Conservatives will blow a gasket at this notion, but people change all the time. On the other hand, greed (for instance) causes so many problems it's easy to see how casting it into disfavor (as had long been done) is a simpler solution than trying to rejigger the incentives to make greed less destructive.

Of course, with conservatives it all depends on who's getting helped. It's hard to find conservatives who objected to deficits used to fund tax cuts, imperial wars, and plain old patronage when Bush was in the White House. They may be convinced that government can't help the poor, but they work themselves into a frenzy every time the rich need government action to boost their bottom line.

Andrew Leonard: Joe Stiglitz's Last Minute White House Party Invite. A different set of issues, but wanted to keep this link. Leonard quotes Michael Hirsh reporting on Stiglitz:

The subprime scandal was all about people who knew a lot -- like mortgage lenders and Wall Street derivatives traders -- exploiting people who had less information, like global investors who bought up subprime-mortgage-backed securities. As Stiglitz puts it: "Globalization opened up opportunities to find new people to exploit their ignorance. And we found them."

Haven't felt up to blogging since I got back from my "vacation" -- wouldn't have had much time anyway. One thing I have been doing is reading about the Great Depression and Roosevelt's 100 Days -- Adam Cohen's Nothing to Fear on the latter, following Timothy Egan's The Worst Hard Time -- and thinking a bit on what's similar and what isn't. Started to write a note on Paul Krugman's Boiling the Frog column and his somewhat wonkier blog post on how Deficits Saved the World. One thing the latter shows is that the speculative bubble that caused our recession was as large and its collapse was as powerful as the one that caused the Great Depression. That we don't seem to be as bad off this time is because absorbed much of the shock, partly because the Reagan-Bush Republicans never managed to destroy all of the New Deal-Great Society safety net -- e.g., they never even contemplated getting rid of deposit insurance -- but also because the sheer size of the public sector dampened the disaster. As Krugman put it:

What Hatzius is saying is that the initial shock -- the surge in desired private surplus -- was if anything larger this time than it was in the 1930s. This says that absent the absorbing role of budget deficits, we would have had a full Great Depression experience. What we're actually having is awful, but not that awful -- and it's all because of the rise in deficits. Deficits, in other words, saved the world.

One downside of all this is that we're not as desperate for reform as we were in 1933 when Roosevelt became president. Exactly why is rather complicated -- Krugman's sense of our insensitivity to slowly mounting catastrophes is one part of the reason -- but one difference is that the reform president's hecklers this time are not just moaning. They're circling for the kill. Josh Marshall, at TPM, reports:

Sen. Jim DeMint (R-SC) on the stakes in delaying a health care vote past August: "If we're able to stop Obama on this it will be his Waterloo. It will break him."

That may be true, but it seems perverse to entertain that thought, much less gloat over it. Health care is one of those frog boilers: in 1992 it was already scandalous that it consumed 14% of US GDP, but since then it has continued to gobble up the economy, now up to 16% of GDP. (What was it when Truman's first attempt was thwarted? 5-6%, I guess.) Absent significant reform, it only stands to keep growing, devouring more and more of the economy. At what level this becomes intolerable is hard to say. Evidently, the opponents of reform don't think the feel the water's heat yet, or are so preoccupied with the politics they don't care about the issues. Those who stand to profit from the status quo are one thing. For DeMint all that matters is making Obama look bad. The irony here is that the reason Obama would look so bad if he fails is precisely because the issue is so crucial. Reasonable people will blame opponents like DeMint if that happens, and give Obama another chance -- especially if he comes back with a stronger program (like single-payer) and takes it to the people.

Matthew Yglesias: The Next Tax Revolt: Had this stuck in a window for a week now, and didn't want to lose it, even though I don't have time to dig into it. Interesting point:

The United States already does about as much as any other country to curb inequality through the tax code. Where we fall short is in fighting inequality through government spending -- we just don't spend very much. If you care about inequality, in other words, the thing to focus on is not soaking the rich through the tax code but rather ensuring that there's enough tax revenue to finance generous public services. Broad social-insurance schemes like Social Security and unemployment insurance, as well as government operations more generally, are strongly progressive in their impact.

The most important issue is whether or not the government has the revenue needed to finance generous spending on social services. The Scandinavian model of a cradle-to-grave welfare state financed largely through regressive taxation is not regarded as punitive to the poor. By contrast, the pre-New Deal United States had an extremely progressive tax structure -- a simple income tax levied only on the wealthy -- but it resulted in meager revenue and financed no noteworthy social-insurance system or public services.

One thing that seems to be a general rule of US tax policy is to make taxation as visible, and therefore as painful, as possible. This actually runs counter to one of the basic (and oft-repeated) considerations in taxation: the belief that taxes disincentivize behavior. This is even considered a selling point for sin taxes. But if taxes are such a drag on the economy, it would make much more sense to make them less visible, as well as to focus them on cases where disincentives are trivial or non-existent -- e.g., taxing dead people. For the living, the least painful time to tax is whenever a transaction occurs: when you buy and sell something, or when you pay someone a wage or other remuneration. With few (if any) exceptions, the robust tax base countries Yglesias favors raise most of their taxes through a VAT, which (unlike American sales taxes) is generally buried within the cost of the purchase. VATs raise prices, which has some negative effect on demand, but they don't hit you out of the blue like property taxes do. It also helps if the burden of tax collection is placed primarily on business, which used to be the case in the US but is less so now: it is both less visible to most people and it fits in with accounting procedures that businesses need to do anyway.

I can't vouch for Yglesias's assertion that the US tax code is relatively progressive compared to other countries. One thing that is certain is that it is much less progressive than it used to be. There are a lot of ways that progressivism could be used that aren't now. In particular, I would make both corporate income and VAT taxes mildly progressive based on company size: a break for small and especially new competitors and a brake against WalMart-sized monopolies. I also think that unearned income -- interest, dividends, capital gains, gifts, estates -- should be taxed progressively according to total lifetime gains: a break for anyone starting to build a nest egg, and a brake on excessive accumulation.

Of course, there's no point raising taxes unless you plan on spending the revenues on something useful. I can come up with a long list there, too -- subjects for many future posts.

Getting ready to take a vacation of sorts. A long road trip, anyhow. Some interesting articles that I had kept open with some vague notion of writing something about them, but now will have to pack up:

• Tony Judt: Fictions on the Ground: On Israel's settlement occupation.
• Tony Karon: Iran's Crisis: The Opposition Weighs Its Options: Realistically, it's a long shot to bet against the house.
• Ezra Klein: Wealth-Care Reform: Yes, it's more about money than medicine, which is the reason health care reform is such a struggle: a lot of money is at stake, for uncertain medical outcomes.
• Paul Krugman: Not Enough Audacity. On health care: "The point is that if you're making big policy changes, the final form of the policy has to be good enough to do the job. You might think that half a loaf is always better than none -- but it isn't if the failure of half-measures ends up discrediting your whole policy approach." Also: "Indeed, the prospects for such savings are precisely what have the opponents of a public plan so terrified."
• Kathleen Parker: Runaway Goveror: The Sequel: On Gov. Sanford, more or less, before all the facts were in, which is why she had time/space to survey the rest of the GOP. Don't miss the Newt bit at the end.

By the way, Iraq is getting bloody again, with over 200 civilian deaths this past week. I've just slogged through Thomas Ricks's Surge-celebratory The Gamble, and it's worth noting that the intelligent people behind the strategem -- a group excluding politicians like McCain and Lieberman, pundits like Kristol, and self-appointed experts like Fred Kagan -- never saw as anything more than a beachhead that would depend on significant political reconciliation to secure. The latter didn't happen for a lot of reasons, and now it's closing. Of course some people, including Ricks in his prognosticating epilogue, will attribute this to the imminent US withdrawals, implying that we can fix the problem by launching Surge II. But the fact is that there will always be a day of reckoning when US forces leave, and putting that off tries the patience of everyone in Iraq who wants to get this war settled. The idea that Iraq is a "forever war" is stuck in the heads of a few American hawks who invested heavily in it, but it's plainly absurd to most Americans, who sooner or later will manage to pull the plug. When that happens, Iraq will sink or swim. I've always felt that Iraq's odds would be better if the country is not tied to the dead weight of American imperialism. Nothing that has happened, including the adjustments Petraeus and Odierno made, has changed that.