Ezra Klein

Which Way to Universal Health Care?

The numbers have never been this grim. Almost 50 million Americans are uninsured. The average annual premium for a family is nearing $13,000, and racing upward at rates that wages can't hope to match. If nothing changes, by 2050, government health care spending will consume 37 percent of the gross domestic product, and private health spending will be far more. There will be little left for education or wages or leisure.

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Comprehensive Health Care Reform Is the Key to Our Economic Future

"The history of health reform," explains Sen. Ron Wyden of Oregon, "is congressmen sending health legislation off to the Congressional Budget Office to die." That's not the history you often hear. Budget analyses do not make for gripping headlines. Editors want heroes and villains, narrative arcs and telling anecdotes. They do not want numbers. They do not want bureaucracies. But numbers, and the bureaucrats who decide them, can be quietly decisive in whether major policy reform lives or dies.

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Will This Man Fix American Health Care?

It started with a rocket ship (which is something we health care reporters rarely get to write). Monday morning, in the Mumford Room of the James Madison Memorial Building, Sen. Max Baucus, D-Mont., grinned broadly as the projector behind him showed the Apollo 11 blasting into space. "I think that video captures the essence of what we're trying to do today," said Baucus proudly, "which is prepare for the launch of health reform."

Whether anyone is actually more prepared today than they were two days ago is debatable. The various sessions of the Senate Finance Committee's "Prepare for Launch" Health Summit were informative enough but offered nothing the senators hadn't heard in previous testimony or read in memos from staff. No legislation was proposed, and no votes were taken. None of the senators set forth their reform plans or laid out the considerations that would drive their decisions.

Even so, it was arguably the most promising day for health reformers in a decade. The Finance Committee asserted its jurisdiction over crafting and passing a health reform bill. And Baucus, the committee's centrist chair, asserted his commitment to the effort. If health reform is to pass, both of those things will need to be more than assertions; they will need to be proven true.

The choke point for health care reform is the U.S. Senate, where major legislation tends to require 60 votes for passage. Getting 60 senators to agree on breakfast or wallpaper swatches would be a challenge. Getting them to agree on restructuring America's health care system is more a cosmic test conceived by the Gods of Gridlock.

But before any bill can get to the Senate at large, it must first be written. Legislatively, there are arguably three institutions that could shoulder the bulk of that task. The first is the executive branch. In 1994, the Clinton administration tried this tactic, attempting to bypass Congress almost entirely and simply present it with a near-final bill for ratification. In retrospect, this is considered by most to have been a terrible error, one of the crucial mistakes of the 1994 effort (for a longer explanation of why, see this article). The second is the Senate Committee for Health, Education, Labor, and Pensions. Led by Ted Kennedy, the HELP Committee is decidedly liberal and wants nothing more than to be given health reform and told to run with it. Members could pass an expansive, progressive bill out of committee with relative ease. The problem is, they lack the authority to fund such a bill.

Principal jurisdiction lies with the Finance Committee, as the rules of the Senate give it control over "health programs under the Social Security Act and health programs financed by a specific tax or trust fund." In other words, health care reform plans that require revenues require the Finance Committee's involvement. And health care reform will require revenues.

So health care reform requires a Finance Committee -- and a Finance Committee chairman -- interested and invested in passing a bill. In 1993, there was no such chairman. Many think that the original sin of the Clinton health reform effort was Clinton's decision to choose Lloyd Bentsen, the canny chair of the Finance Committee, as his secretary of the Treasury, thus depriving the committee of his leadership. In his place came the mercurial, touchy Daniel Patrick Moynihan. Moynihan had many virtues, but he did not like the Clintons and was not interested in working on health reform. His intransigence and general lack of enthusiasm were crucial to emboldening the opposition and killing the bill. When Moynihan appeared on "Meet the Press" on Sept. 19, 1993, three days before Clinton was to give his speech calling for universal health care, and flatly stated that "there is no health care crisis" and Clinton was using "fantasy numbers," it was an early sign that the effort was doomed.

That Baucus is the current chairman of the Finance Committee is not the sort of news that necessarily cheers liberals. Baucus has been, at best, an unreliable ally. In 1994, he folded before pressure from the National Federation of Independent Business and voted against Clinton's employer mandate when it came up in the Finance Committee. He was a crucial Bush ally on the tax cuts and on Medicare Part D. The Nation has called him "K Street's favorite Democrat." The New Republic grew so frustrated with him that it wrote an editorial suggesting that Democrats strip him of his chairmanship.

This time around, however, Baucus has given health reformers reason for optimism. He has staffed up, hiring Liz Fowler, a well-regarded health policy staffer with immense Hill experience. He's held a series of hearings on the need to reform the system, inviting experts to testify on everything from the explosion in costs to the failures of the insurance market. More importantly, his statements at these hearings have been invariably action-oriented. He opened a recent session by saying, "Today let us talk again about health care reform. Let us hear from the experts about how to do it right. And let us plan, next year, to actually do something about it."

Monday's "prepare for the launch" event was his initiative and served as another opportunity for him to signal that he wanted to pass health reform through his committee. "Congress must prepare for the work of reforming the health care system," he said in his opening statement. "We must develop common understandings of our system, the good and the bad, so we're ready to work toward reform." Questioning Federal Reserve Chairman Ben Bernanke after Bernanke's bloodless presentation, Baucus asked him to "drill down" on what would happen if the Senate didn't get health costs under control, prompting Bernanke to offer a dark vision of fiscal meltdown. Whereas most of the panel sessions featured two senators presiding over a panel of experts, Baucus hosted a viewing of the PBS Frontline documentary "Sick," which looks at other nations' health care systems and declares, "When it comes to providing health care for people, our nation is a fourth-rate power." Introducing the film, Baucus mused, "We Americans can be a bit smug. We figure we can't learn from everyone else because we're the biggest and the best. But I think the time has come for America to learn a bit from these other countries."

The final event of the day was a roundtable discussion among the members that was, by turns, hopeful, tetchy and constructive. The content, however, was secondary to the optics. This was the whole of the relevant committee, sitting in a single room, talking through health reform. It was a photo op, yes, but a promising one. By publicly asserting jurisdiction on health reform, the Finance Committee is also taking responsibility for it. If the effort fails, it will be on its head. And none will receive more blame then Baucus. Summing it up, Baucus said, "I don't know of anything more daunting than trying to solve health care. But hey, we're masochists! It's why we signed up for this job."

We'll see. But if his words turn out to be prophecy rather than posturing, we'll be able to say it all started with a rocket ship.

Reprinted with permission from Ezra Klein, "Will This Man Fix American Health Care?," The American Prospect Online: June 18, 2008. www.prospect.org. The American Prospect, 2000 L Street NW, Suite 717, Washington, DC 20036. All rights reserved.

Is Congress the Problem with Health Care?

The first thing you notice when you sit down with Tom Daschle is that he's got some really funky glasses. Like, surprisingly funky. Fire-engine red with odd edges and varied trim, the sort of eyeglasses you'd see perched on the nose of an art dealer, not a former Senate majority leader.

But despite the incongruent accessorizing, Daschle is a former Senate majority leader, through and through. After losing his South Dakota Senate seat to John Thune in 2004, he halfheartedly attempted to return to private life, joining a law firm and taking some teaching gigs. But soon enough, he was pulled back into public policy by the Center for American Progress, which convinced him to become a senior fellow. Soon after that, he began working with well-regarded health-policy researchers Scott Greenberger and Jeanne Lambrew on a book about the health-care system.

Critical: What We Can Do About the Health-Care Crisis, is now out, and most of it is fairly familiar. Costs are up, and coverage is down. Taxes are up, and quality is down. Anxiety is up, and access is down. We're paying more than we can afford for a system no moral person could countenance and no disinterested researcher could praise. As Daschle and his co-authors conclude, "Health-care is a complex topic, but we have to face a simple truth: We're paying top dollar for mediocre results."

If the analysis is standard, however, the solution is considerably more surprising. As a longtime veteran of Congress, Daschle has watched the proverbial sausage being made, and concluded that complicated health-care decisions shouldn't be left up to butchers. "We have to look harder at the exceptional nature of the health-care problem," he writes, "and reconsider the political process we've followed in trying to solve it. The stakes are extraordinarily high in health-care -- literally life and death -- and the issue is incredibly complex. The number of stakeholders and special interests involved is extraordinarily large, and their influence is immense ... perhaps it isn't surprising that the traditional legislative process has failed to deliver."

Daschle's solution is something he calls a Federal Health Board. I sat down with him recently to talk about his proposal and his vision of the future of health-care.

Ezra Klein: So, to begin, the Federal Health Board. Why is it needed and what does it do?

Tom Daschle: I ask audiences frequently, what would have happened if the Congress had been the ones responsible for trying to figure out what to do with the Bear-Stearns crisis, the sub-prime crisis? Or what would happen if Congress were asked to raise or lower interest rates once a month? That's why we have a Federal Reserve. We need an insulated, accountable and credible decision-making board to take that responsibility.

The Federal Health Board would have some of the same roles as the Federal Reserve board, in that it would create a management infrastructure to integrate our public and private health-care systems. About 45 percent of the people in our country get their health-care from public sources, 55 percent from private sources, but there's no integration, either among the public programs or between the public and private sectors. Somebody has to do that. We need a board -- just as we have needed commissions in the past for base closing or Social Security -- to focus and to create the kind of decision-making process that allows us to make the tough decisions. That's why we have these commissions, and that's why we need the Federal Health Board. It also has a secondary purpose, which is that as we pass the legislation, it precludes the need for Congress to get too far into the weeds and be getting so mired in the minutia of details that would never really get to the larger questions. It allows us to stay out of the details. We delegate that detail to the board.

EK: But when you have a history, like you did in 1993, when people had bumper stickers saying, "If you like the DMV, you'll love government health-care," how do you sell both the politicians and the public on the idea that what we're going to do is turn health-care decisions over to a government-appointed, semi-accountable, vaguely shadowy institution? How do you make them comfortable with that?

TD: Well, first of all, that's not what we're doing. And so if we've not gotten our message better out, we will have failed. I don't think we have a government-run banking system. Most people believe we have a private banking system. But somebody -- the Federal Reserve -- is there to help set the guidelines within which this private banking system functions. Banks are free to do almost anything on banking practices if they want, just as long as it fits within those guidelines. And so it would be with the Federal Health Board. We would try to streamline the tremendous bureaucracy that exists today in our federal government when it comes to health-care. So this would really mean far less bureaucracy, not more. And I would simply ask the question, if you think our banking system today is reasonably regulated, why not try the same type of model for our health-care system?

EK: You mention in your book a couple of other examples where Congress has ceded authority on politically troublesome issues to commissions in order to pave the way for better decisions to be made. Can you talk a little bit about them?

TD: Well I think that probably the best example is the, in some respects, besides the Federal Reserve, which I think was the best model, is the FAA. You know, we don't make decisions on flight safety, the FAA does. We've designated the responsibility to create an infrastructure that I would say works pretty well. I knock on wood as I say that, we've gone a long time without an accident, in the FAA system. But you know, we lose the equivalent of one 747 everyday every two and a half days in our health -care system. Every two and a half days, the equivalent number of people, somewhere around 450 people, die because of medical mistakes in our health-care system, and we don't even hear about it.

That would never happen in our aviation system. Well we need the same thing with our health-care system. There's also the base closing commission, probably less consequential, but that one worked as well. There've been so many, I would even say the Social Security commission back in the '80s that took on the responsibility of making the tough choices in order to save the Social Security system.

EK: The base closing commission is an interesting example because it's a more direct example of politicians giving up something they often saw as in their interests to protect -- the bases in their home state or district -- because they recognized that if everyone was going to do that, the entire system of base-closing would devolve to utter gridlock.

TD: That's exactly right. This was also Congress recognizing its limits, recognizing its capacity for making tough decisions in a timely way. The same is exactly true on health-care. These are tough decisions, and there are limits on what Congress is able to do on a routine basis as they deal with these issues. So in the case of base closing, Congress was actually prepared to turn over some of that responsibility to the commission, knowing that there was a sort of a safety hatch they could revert back to if they had to, they could override. And obviously with health-care, Congress always ought to have the opportunity to override as well. That would be the safety hatch here.

EK: But health-care is so personal. Inflation, though it has globalized effects, is really a macro phenomenon. And base closings hit much smaller numbers of constituents. Health-care feels very visceral to people. And they won't be used to this sort of model. How do you convince them of its legitimacy?

TD: Well, I would say three things. First, the Federal Reserve board maybe doesn't get some of the credit it deserves for dealing with some of these issues that are very personal. You know, whether a homeowner pays 5 and a half or 8 and a half percent interest is a big deal. That's very personal. Now, whether or not you gain or lose $100,000 on the market because of what we did in the subprime system in bailing out Bear Stearns is a big deal, that's very personal. So I do think that these decisions are very personal. This does have a very real presence in the lives of most Americans. Secondly, I think it's important to say who's going to be on the board. I would like to have people who reflect the common, daily concerns of average working Americans on that board, making sure those consumer voices are heard. This shouldn't be made up solely of insurance executives, retired congressmen, or surgeons that never leave the operating room. This ought to be a combination reflecting the eclectic mix of health-care participants we see today. That's very important. The third is also important, and that's what I said before. It is always the prerogative of Congress on some of these things to overturn these decisions that are not in keeping with the expectations of the law. And that would always be the right of Congress in this case as well.

EK: Many of these ideas, some similar, some not, have fallen by the wayside, when they stepped into the political realm. Why would this get to 60 when so many others have failed?

TD: This would only succeed if we learn lessons from the past. And there are so many lessons to learn. You know, one of the lessons of the past that we should learn is we've got to broaden the coalition as much as possible. I think our potential for broadening the coalition this time is really great. I think there's a lot more interest in it. Secondly, I think we've got to realize that there are not one but three categories of health problems: access, quality and cost. All three have to be dealt with, and all three have different constituencies. And so we have to address the constituencies where the political problems lie. With the doctors, it's going to be malpractice. With patients, it should be quality and cost. With businesses, it's going to be cost. So we've got to go right to the heart of what is the core concern for these core constituencies and try to address it. Third, we've got to have a lot more transparency. We have to break the myth, we have to put opponents of change on the defensive. In the past, it's been proponents of change who've been on the defensive. We have to turn the tables.

Reprinted with permission from Ezra Klein, "Is Congress the Problem with Health Care?," The American Prospect Online: May 14, 2008. www.prospect.org. The American Prospect, 2000 L Street NW, Suite 717, Washington, DC 20036. All rights reserved.

More Americans Fear Losing Their Health Insurance Than Being in a Terrorist Attack

If health insurance were cheap, we could all buy it. If universal health care could get 60 votes in the Senate, we'd all have it. But these two imperatives -- the need to control costs and the need to attract the 60 Senate votes required to overcome a filibuster -- point in opposite directions. This is the central paradox of health reform.

The most intractable policy problem is not, fundamentally, the 47 million uninsured or the fact that insurers have a business model right out of Dickens. It's cost. In 2006, the average family policy cost $13,600. This is why one out of six Americans are uninsured; they can't afford the premiums. An October 2007 Kaiser Family Foundation poll found that more Americans were "very worried" about being priced out of their health insurance than feared losing their job, their house, or being in a terrorist attack. And with good reason: Premiums have gone up 98 percent since 2000. Wages have not.

Corporate America's outlook is similarly grim. Better Health Care Together, a health-reform coalition that includes Intel, Wal-Mart, and General Mills, recently issued a report, Health-Cost Crossroad: Why American Businesses Urgently Need Health Care Reform. The paper warns that "health care cost growth threatens businesses, workers, and the overall health of the American economy," and frets that "if trends continue, health benefit costs will exceed profits in Fortune 500 companies in 2008."

Likewise government. Absent reform, government health spending would be 37 percent of gross domestic product by 2050. (The entire federal government now consumes about 20 percent of GDP.) David Walker, the U.S comptroller general, warns that "we have been diagnosed with fiscal cancer, and we need to start treating it." At the Congressional Budget Office, the normally staid Peter Orszag gives an Al Gore-esque slideshow on the looming threat of health costs that risk bankrupting government finances.

The question, then, is how to limit heath-care costs while still surviving the legislative process. A single-payer system would increase efficiencies, but critics fear that it would control costs excessively, limiting care. Politically, single-payer would mean restructuring about 17 percent of our economy and eliminating multibillion-dollar industries that provide tens of thousands of jobs. It would have to be legislated over the fierce objections of the Republican Party and all conservative Democrats. Conversely, many Republicans, John McCain included, advocate a radical shift of costs onto individuals, controlling spending by pricing care out of reach for tens of millions. Few Democrats or moderate Republicans -- or voters -- favor this course.

Kids First?

Looking at this blockage, many observers instinctively grope toward a political stopgap -- starting with kids, a very attractive and cheap-to-insure part of the population. Coverage for all kids, they theorize, could make it through the Senate. Once accomplished, the rest of the country would view that success and green-light full reform of the health-care system. The logic of this strategy fails on two counts. First, as George W. Bush's obstinance on the State Children's Health Insurance Program (S-CHIP) has shown, many Republicans view health-care expansions the way the National Rifle Association looks at gun control -- there's no such thing as a little bit. Second, both the Republicans and the Democrats who see S-CHIP as the road to socialism are wrong. Medicare, despite its popularity, hasn't advanced the single-payer movement. It just took seniors out of the constituency for reform. And S-CHIP hasn't even led to its own successful expansion, much less that of the whole health system.

Moreover, covering kids is just covering kids; it does nothing to reform the system. Universal coverage of children, grafted onto the existing system, could actually exacerbate problems of inefficiency and cost. Worse, politicians could posture as if they had made major progress on the health-care crisis, while in fact they would be letting it deteriorate.

Single-Payer by Stealth

Another strategy would incrementally move toward single-payer, alert to the electorate's fear of change. That's one lesson many reformers learned from 1994 -- know your audience. Among those reformers was Yale political scientist Jacob Hacker, whose book on the failure of the Clinton proposal, The Road to Nowhere, concludes that President Clinton had built a plan for wonks, not voters. Cost containment was front-loaded (global budgets, managed care) and required total restructuring of the system. Clinton's plan scared people, introducing unfamiliar and untested concepts like "managed competition" and changing current health arrangements. "They couldn't defend it in simple terms," Hacker says, "because it actually meant a complex set of changes for most Americans."

Following his book, Hacker devised a plan to avoid these pitfalls. His final proposal was embraced last year by the Economic Policy Institute and the Campaign for America's Future, the latter of which worked hard to push it to the candidates. The final plans from Clinton, Obama, and Edwards all looked a lot like the Hacker plan, with some crucial and perhaps fatal political compromises thrown in. More on that in a moment.

Hacker's plan works on a few basic principles. First, no one loses what they already have. You like your current insurance? Keep it, unless your employer kicks you off. Second, a new group market is created (the Health Care for America market, henceforth HCA), where insurers can compete for the business of individuals and employers (who can buy their employees in for 6 percent of payroll). Third, the group market contains a strong public insurer modeled on Medicare, creating competition between private insurance companies and the public offering. The hope is that the public insurer, which will not need to turn a profit and will be free of some of the perversities of private insurance, will prove the most cost-effective and attractive option, leading individuals and businesses alike to gravitate toward it. Over time, it would evolve into something approaching a single-payer system.

The Lewin Group, currently the gold standard in health-care consulting, has analyzed the Hacker plan and estimated that it will save about $1.04 trillion over 10 years. Some of these savings will come through basic efficiencies, both administrative and technological. But the savings depend heavily on the quiet cost controls built into the HCA. There, spending per enrollee will only be allowed to increase at a fixed rate of that year's GDP growth plus a half percent. Basically, the government mandates spending growth at a far slower rate than that of the private marketplace.

If it works, this has two effects: First, it saves money by mandating that a portion of the system -- the HCA -- spends less money. This, in effect, is the same way single-payer saves money. It simply caps spending and induces providers to use available funds more cost-effectively. But it also makes the most cost-effective HCA a progressively better deal for businesses to buy into, thus expanding it. Over time, more Americans end up within the cost-controlled structure. According to Lewin's estimates, the HCA would have an initial enrollment of 128.6 million enrollees (mostly individuals and small businesses), while 122 million Americans would remain in private, mostly employer-provided insurance. By 2017, the HCA would have 177.4 million members, while private insurance would be down to 93.5 million. Under these assumptions, the slower spending in the HCA alone would result in $1 trillion in savings.

Can It Work?

But therein lies the danger for the plan. The HCA is created to compete with the traditional private market. With its more attractive terms, the hope is that the HCA will largely overwhelm the private market, becoming a sort of de facto single-payer plan. Indeed, the Lewin analysis factors in this competition, and the brutal effect it will have on the private market, explicitly. "The combined effect of increased market share and a constrained rate of growth in Health Care for America spending would result in pressure on providers to shift costs to the private insurance market," Lewin says, "which will increase private insurance premiums and generate an even larger difference in premiums between HCA and the private insurance market."

But it isn't a single-payer plan. There's still a large private market to contend with, one that won't appreciate being knocked around this way. Private insurers outside the HCA will presumably compete in kind, only in the opposite direction. They'll attempt to cost-shift onto the HCA by insuring healthy, young firms that still offer private insurance at advantageous prices, and pressuring sicker, older companies and individuals into the government options. If they succeed, the risk pool in the HCA will grow expensive, the premiums will grow inordinately pricey, and cost savings won't be realized without cutting care, no matter what the government mandates.

Politically, a robust version of the Hacker plan remains a huge reach. Democrats weren't even able to attract 60 votes to allow Medicare Part D to bargain down drug prices, much less set them centrally. Even with a Democratic president embracing some version of Hacker, and a pickup of several Senate seats, many Democrats remain skeptical of price controls by government diktat.

While there are differences between the health-care plans of Hillary Clinton and Barack Obama -- notably, the much discussed individual mandate -- they are both based on structure similar to Hacker's. However, while both include his new, "Medicare-like" group market, neither uses the group market to set cost controls. Given that this is the prime source of $1 trillion of Hacker's $1.1 trillion in savings, it's hard to see how the Obama or Clinton plans will adequately control costs. They will see some savings from administrative efficiencies and more cost-effective care, but these will be comparatively minor. Nor are Obama or Clinton clear about what employers would have to pay. So they have basically embraced the politically savvy part of Hacker's plan while leaving out the cost controls -- and that's before the insurance industry and Congress get into the act. We could be left with a system very much like the current one, just with more subsidies for coverage and more clearly structured insurance choices, but with relentless cost increases that translate into reduced actual care.

Bipartisan Reform?

Hacker, it should be said, is not the only game in town. While versions of his plan are getting the most attention at the presidential level, in Congress, the action is around the Healthy Americans Act sponsored by Sen. Ron Wyden of Oregon. Along with Sen. Robert Bennett of Utah, Wyden has attracted 12 more colleagues, six Democrats and six Republicans, as co-sponsors. Given that any health-care bill will likely need Republican Senate votes, it's the closest thing to a viable legislative process currently in existence.

Wyden's plan differs from Hacker's in two key ways. First, it lacks a public insurer, meaning that there won't be public-private competition. But it compensates for that absence with much more radical system integration. Hacker's plan creates a new group market with about 44 percent of the population, leaving the existing private market with 41 percent or so and most of the remainder in Medicare. The success or failure of the plan will depend on which market can most effectively undercut the other. Wyden's plan, by contrast, does away with employer health coverage almost entirely. Rather than encouraging employers to transition to a single group market, as Hacker's does, Wyden's forces them to redirect all the money they were spending on employee insurance into paychecks. At the same time, it creates "Health Help Agencies," one in each state, which act much like Hacker's group market -- they're regulated structures where various insurers compete for business. No cherry-picking, no high premiums or denials of coverage for pre-existing conditions. Everyone pays the same price, but everyone has to buy insurance that's at least as comprehensive as the current Blue Cross-Blue Shield Standard Plan. There are subsidies for those with low incomes, and penalties for those who don't buy in. Medicare still exists for the elderly.

The Lewin Group also evaluated Wyden's proposal, and they see the possibility for even more drastic savings: $1.48 trillion over 10 years. In Wyden's case, the savings don't come from explicit spending caps in the group market, but because consumers who now see exactly how much they're spending on health care (before, their costs were obscured because employers paid most of the bill) will become more price-sensitive and choose cheaper options. Namely, HMOs. In other words, rather than asking the government to cap spending, as Hacker's plan does, Wyden's plan pushes individuals to do it. Lewin estimates that under Wyden's plan, HMO enrollment will jump from 30 percent to 70 percent, which will bring large cost savings, as HMO enrollment did in the mid-1990s.

As a contingency, Wyden sets up future cost controls if needed. Currently, it's impossible to impose targeted cost reforms because there's no system to impose reforms on. We have a health sector, composed of thousands of self-contained private insurers routed through myriad employers, not a health system. If the system is entirely under one roof, as it is in Wyden's plan, and as it comes closer to being in Hacker's plan, implementing cost controls becomes much easier. A public insurer could be the benchmark, and there could be better incentives to adopt best practices, with smart forms of cost sharing and incentives to only offer cost-effective treatments.

Overcoming the Blockage

But where the basics of Hacker's structure have a reformist political logic, Wyden's risks running into the same fears that detonated the efforts in 1994. By blowing up the employer-based system, Wyden's risks triggering the natural status quo bias of voters and insurers. In Hacker's plan, the majority of the country sees no change unless they volunteer for it. With Wyden's, the majority needs to buy new insurance. The question is whether Wyden's plan can compensate for that political risk by attracting more support from stakeholders -- employers who no longer want to run health-care businesses on the side and insured individuals worried about losing what they have. Also, to realize cost containment, Wyden's state agencies would need to define, which is to say, regulate, qualified plans -- a sensible policy that led the insurance industry to oppose a similar idea under a different name when Clinton proposed managed competition in 1993.

Moreover, both of these plans are in their idealized forms. Neither has been through the legislative process, or vetted by a White House, or larded up by special interests, or subjected to attack ads. Hacker's plan would face serious trouble attracting Republican votes. Wyden's plan would require a Democratic president's strong support to attract liberals, and it would have to persuade voters to let go of their present coverage.

Either way, it will be a tough road. But look at the numbers. One way or another, reform must come. We really don't have any choice.

Reprinted with permission from Ezra Klein, "The Elusive Politics of Reform," The American Prospect, Volume 19, Number 5: May 07, 2008. The American Prospect, 2000 L Street, Suite 717, Washington, DC 20036. All Rights Reserved.

The Health of Nations

Reprinted with permission from Ezra Klein, "The Health of Nations," The American Prospect, Volume 18, Number 5: May 07, 2007, The American Prospect, 2000 L Street, Suite 717, Washington, DC 20036. All rights reserved.

Medicine may be hard, but health insurance is simple. The rest of the world's industrialized nations have already figured it out, and done so without leaving 45 million of their countrymen uninsured and 16 million or so underinsured, and without letting costs spiral into the stratosphere and severely threaten their national economies.
Even better, these successes are not secret, and the mechanisms not unknown. Ask health researchers what should be done, and they will sigh and suggest something akin to what France or Germany does. Ask them what they think can be done, and their desperation to evade the opposition of the insurance industry and the pharmaceutical industry and conservatives and manufacturers and all the rest will leave them stammering out buzzwords and workarounds, regional purchasing alliances and health savings accounts. The subject's famed complexity is a function of the forces protecting the status quo, not the issue itself.

So let us, in these pages, shut out the political world for a moment, cease worrying about what Aetna, Pfizer, and Grover Norquist will say or do, and ask, simply: What should be done? To help answer that question, we will examine the best health care systems in the world: those of Canada, France, Great Britain, Germany, and the U.S. Veterans Health Administration (VHA), whose inclusion I'll justify shortly.

Putting aside the VHA, America's annual per person health expenditures are about twice what anyone else spends. That actually understates the difference, as our 45 million uninsured citizens have radically restricted access to care, and so the spending on the median insured American is actually quite a bit higher. Canada, France, Great Britain, and Germany all cover their entire populations, and they do so for far less money than we spend. Indeed, Canada, whose system is the most costly of the group, spends only 52 percent per capita what we do.

While comparing outcomes is difficult because of various lifestyle and demographic differences in the populations served, none of the systems mentioned betray any detectable disadvantage in outcomes when compared with the United States, and a strong case can be made that they in fact perform better. Here, however, I largely restrict myself to comparisons of efficiency and equity. With that said, off we go.

Oh, Canada!

As described by the American press, Canada's health-care system takes the form of one long queue. The line begins on the westernmost edge of Vancouver, stretches all the way to Ottawa, and the overflow are encouraged to wait in Port Huron, Michigan, while sneering at the boorish habits of Americans. Nobody gets to sit.

Sadly for those invested in this odd knock against the Canadian system, the wait times are largely hype. A 2003 study found that the median wait time for elective surgeries in Canada was a little more than four weeks, while diagnostic tests took about three (with no wait times to speak of for emergency surgeries). By contrast, Organisation for Economic Co-operation and Development data from 2001 found that 32 percent of American patients waited more than a month for elective surgery, and 5 percent waited more than four months. That, of course, doesn't count the millions of Americans who never seek surgery, or even the basic care necessary for a diagnosis, because they lack health coverage. If you can't see a doctor in the first place, you never have to wait for treatment.

Canada's is a single-payer, rather than a socialized, system. That means the government is the primary purchaser of services, but the providers themselves are private. (In a socialized system, the physicians, nurses, and so forth are employed by the government.) The virtue of both the single-payer and the socialized systems, as compared with a largely private system, is that the government can wield its market share to bargain down prices -- which, in all of our model systems, including the VHA, it does.

A particularly high-profile example of how this works is Canadian drug reimportation. The drugs being bought in Canada and smuggled over the border by hordes of lawbreaking American seniors are the very same pharmaceuticals, made in the very same factories, that we buy domestically. The Canadian provinces, however, bargain down the prices (Medicare is barred from doing the same) until we pay 60 percent more than they do.

Single-payer systems are also better at holding down administrative costs. A 2003 study in The New England Journal of Medicine found that the United States spends 345 percent more per capita on health administration than our neighbors up north. This is largely because the Canadian system doesn't have to employ insurance salespeople, or billing specialists in every doctor's office, or underwriters. Physicians don't have to negotiate different prices with dozens of insurance plans or fight with insurers for payment. Instead, they simply bill the government and are reimbursed.

The downside of a single-payer system in the Canadian style is that it constructs a system with a high floor and a low ceiling. If you don't like the government's care options, there's no real alternative. In this, Canada is rare. As we'll see with both France and Germany, other countries are able to preserve a largely nationalized system with universal access while allowing private options at the upper levels.


It's a common lament among health-policy wonks that the world's best health-care system resides in a country Americans are particularly loath to learn from. Yet France's system is hard to beat. Where Canada's system has a high floor and a low ceiling, France's has a high floor and no ceiling. The government provides basic insurance for all citizens, albeit with relatively robust co-pays, and then encourages the population to also purchase supplementary insurance -- which 86 percent do, most of them through employers, with the poor being subsidized by the state. This allows for as high a level of care as an individual is willing to pay for, and may help explain why waiting lines are nearly unknown in France.

France's system is further prized for its high level of choice and responsiveness -- attributes that led the World Health Organization to rank it the finest in the world (America's system came in at No. 37, between Costa Rica and Slovenia). The French can see any doctor or specialist they want, at any time they want, as many times as they want, no referrals or permissions needed. The French hospital system is similarly open. About 65 percent of the nation's hospital beds are public, but individuals can seek care at any hospital they want, public or private, and receive the same reimbursement rate no matter its status. Given all this, the French utilize more care than Americans do, averaging six physician visits a year to our 2.8, and they spend more time in the hospital as well. Yet they still manage to spend half per capita than we do, largely due to lower prices and a focus on preventive care.

That focus is abetted by the French system's innovative response to one of the trickier problems bedeviling health-policy experts: an economic concept called "moral hazard." Moral hazard describes people's tendency to overuse goods or services that offer more marginal benefit without a proportionate marginal cost. Translated into English, you eat more at a buffet because the refills are free, and you use more health care because insurers generally make you pay up front in premiums, rather than at the point of care. The obvious solution is to shift more of the cost away from premiums and into co-pays or deductibles, thus increasing the sensitivity of consumers to the real cost of each unit of care they purchase.

This has been the preferred solution of the right, which has argued for a move toward high-deductible care, in which individuals bear more financial risk and vulnerability. As the thinking goes, this increased exposure to the economic consequences of purchasing care will create savvier health-care consumers, and individuals will use less unnecessary care and demand better prices for what they do use.

Problem is, studies show that individuals are pretty bad at distinguishing necessary care from unnecessary care, and so they tend to cut down on mundane-but-important things like hypertension medicine, which leads to far costlier complications. Moreover, many health problems don't lend themselves to bargain shopping. It's a little tricky to try to negotiate prices from an ambulance gurney.

A wiser approach is to seek to separate cost-effective care from unproven treatments, and align the financial incentives to encourage the former and discourage the latter. The French have addressed this by creating what amounts to a tiered system for treatment reimbursement. As Jonathan Cohn explains in his new book, Sick:
In order to prevent cost sharing from penalizing people with serious medical problems -- the way Health Savings Accounts threaten to do -- the [French] government limits every individual's out-of-pocket expenses. In addition, the government has identified thirty chronic conditions, such as diabetes and hypertension, for which there is usually no cost sharing, in order to make sure people don't skimp on preventive care that might head off future complications.

The French do the same for pharmaceuticals, which are grouped into one of three classes and reimbursed at 35 percent, 65 percent, or 100 percent of cost, depending on whether data show their use to be cost effective. It's a wise straddle of a tricky problem, and one that other nations would do well to emulate.

Great Britain

I include Great Britain not because its health system is very good but because its health system is very cheap. Per capita spending in Great Britain hovers around 40 percent what it is in the United States, and outcomes aren't noticeably worse. The absolute disparity between what we pay and what they get illuminates a troublesome finding in the health-care literature: Much of the health care we receive appears to do very little good, but we don't yet know how to separate the wheat from the chaff. Purchasing less of it, however, doesn't appear to do much damage.

What's interesting is that many of the trade-offs that our health-care system downplays, the English system emphasizes. Where our medical culture encourages near-infinite amounts of care, theirs subtly dissuades lavish health spending, preferring to direct finite funds to other priorities.

This sort of national prioritizing is made easier because Great Britain has a socialized system, wherein the government directly employs most of the providers. Great Britain contains costs in part by paying doctors through capitation, which gives doctors a flat monthly sum for every patient in their practice. Since most patients don't need care in a given month, the payments for the healthy subsidize the needs of the sick. Crucially, though, the fixed pool of monthly money means doctors make more for offering less treatment. With traditional fee-for-service arrangements, like ours, doctors gain by treating more. The British system, by contrast, lowers total costs by lowering the quantity of prescribed care. As University of San Francisco professors Thomas Bodenheimer and Kevin Grumbach write, "British physicians simply do less of nearly everything -- perform fewer surgeries, prescribe fewer medications, and order fewer x-rays."

That may sound strange, but it also means that society pays for fewer of those surgeries, fewer of those medications, and fewer of those X-rays -- and as far as we can tell, the English aren't suffering for it. Indeed, a 2006 study published in The Journal of the American Medical Association found that, on average, English people are much healthier than Americans are; they suffer from lower rates of diabetes, hypertension, heart disease, heart attack, stroke, lung disease, and cancer. According to the study's press release, the differences are vast enough that "those in the top education and income level in the U.S. had similar rates of diabetes and heart disease as those in the bottom education and income level in Great Britain."

Great Britain's example proves that it is possible to make economy a guiding virtue of a health system. We could do that on the supply side, through policies like capitation that would change the incentives for doctors, or on the demand side, by making patients pay more up front -- or both, or neither. Americans may not want that system, in the same way that the owner of a Range Rover may not want a Corolla, but we should at least recognize that we have chosen to make health care a costly priority, and were we to decide to prioritize differently, we could.


The German system offers a possible model for those who want to retain the insurance industry but end its ability to profit by pricing out the sick and shifting financial risk onto individuals. The German system's insurers are 300 or so different "sickness funds" that act both as both payers and purchasers for their members' care. Originally, each fund covered only a particular region, profession, or company, but now each one has open enrollment. All, however, are heavily regulated, not for profit, and neither fully private nor publicly owned. The funds can't charge different prices based on age or health status, and they must continue covering members even when the members lose the job or status that got them into the fund in the first place. The equivalent would be if you could retain membership in your company's health-care plan after leaving the company.

The move toward open enrollment was an admission that interfund competition could have some positive effects. The fear, however, was that the funds would begin competing for the healthiest enrollees and maneuvering to avoid the sickest, creating the sort of adverse selection problems that bedevil American insurance. To avoid such a spiral, the government has instituted exactly the opposite sort of risk profiling that we have in the United States. Rather than identifying the unhealthy to charge them higher rates, as our insurers do, the government compels sickness funds with particularly healthy applicants to pay into a central fund; the government then redistributes those dollars to the funds with less-healthy enrollees. In other words, the government pays higher rates to sickness funds with unhealthy enrollees in order to level the playing field and make the funds compete on grounds of price and efficiency. In this way, the incentive to dump the sick and capture the well is completely erased. The burdens of bad luck and ill health are spread across the populace, rather than remaining confined to unlucky individuals.

The system works well enough that even though Germans are allowed to opt-out of the sickness funds, they largely don't. Those with incomes of more than $60,000 a year are not required to join a sickness fund; about 10 percent of these citizens purchase private insurance and .02 percent choose to eschew coverage entirely. The retention of a private insurance option ensures that Germans have an escape hatch if the sickness funds cease providing responsive and comprehensive coverage; it also clears a channel for experimentation and the rapid introduction of new technologies. And the mix of private-public competition works to spur innovation: By 2005, Germany had spent $21.20 per capita wiring its system with health-information technology; America, meanwhile, had spent a mere 43 cents per capita, and most U.S. hospitals still have no systems to speak of.

What the German system has managed to achieve is competition without cruelty, deploying market forces without unleashing capitalism's natural capriciousness. They have not brought the provision of health care completely under the government's control, but neither have they allowed the private market, with its attendant and natural focus on profits, to have its way with their health system. It's a balance the United States has been unable to strike.

The Veterans Health Administration

The mistreatment and poor conditions at the Walter Reed Army Medical Center were a front-page story recently, and they were rather conclusive in showing the system's inadequacy. But don't be confused: Walter Reed is a military hospital, not a VHA hospital. Poor reporting inaccurately smeared the quietly remarkable reputation of the best medical system in America.

Over the last decade or two, the VHA system has become a worldwide leader in both the adoption and the invention of health-information technology, and it has leveraged its innovations into quantifiable gains in quality of care. As Harvard's Kennedy School noted when awarding the VHA its prestigious Innovations in American Government prize:
[The] VHA's complete adoption of electronic health records and performance measures have resulted in high-quality, low-cost health care with high patient satisfaction. A recent RAND study found that VHA outperforms all other sectors of American health care across the spectrum of 294 measures of quality in disease prevention and treatment. For six straight years, VHA has led private-sector health care in the independent American Customer Satisfaction Index.

Indeed, the VHA's lead in care quality isn't disputed. A New England Journal of Medicine study from 2003 compared the VHA with fee-for-service Medicare on 11 measures of quality. The VHA came out "significantly better" on every single one. The Annals of Internal Medicine pitted the VHA against an array of managed-care systems to see which offered the best treatment for diabetics. The VHA triumphed in all seven of the tested metrics. The National Committee for Quality Assurance, meanwhile, ranks health plans on 17 different care metrics, from hypertension treatment to adherence to evidence-based treatments. As Phillip Longman, the author of Best Care Anywhere, a book chronicling the VHA's remarkable transformation, explains: "Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose is the highest ranking health care system? Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the veterans health care system outperforms the highest-rated non-VHA hospitals."

What makes this such an explosive story is that the VHA is a truly socialized medical system. The unquestioned leader in American health care is a government agency that employs 198,000 federal workers from five different unions, and nonetheless maintains short wait times and high consumer satisfaction. Eighty-three percent of VHA hospital patients say they are satisfied with their care, 69 percent report being seen within 20 minutes of scheduled appointments, and 93 percent see a specialist within 30 days.

Critics will say that the VHA is not significantly cheaper than other American health care, but that's misleading. In fact, the VHA is also proving far better than the private sector at controlling costs. As Longman explains, "Veterans enrolled in [the VHA] are, as a group, older, sicker, poorer, and more prone to mental illness, homelessness, and substance abuse than the population as a whole. Half of all VHA enrollees are over age 65. More than a third smoke. One in five veterans has diabetes, compared with one in 14 U.S. residents in general." Yet the VHA's spending per patient in 2004 was $540 less than the national average, and the average American is healthier and younger (the nation includes children; the VHA doesn't).

The VHA's advantages come in part from its development of the health-information software VistA, which was created at taxpayer expense and is now distributed for free to any health systems that wish to use it. It's a remarkably adaptive program that helps in virtually every element of care delivery, greatly aiding efforts to analyze symptoms and patient reactions in order to improve diagnoses and treatments, reduce mistaken interventions, and eliminate all sorts of care redundancies.

The VHA also benefits from the relative freedoms of being a public, socialized system. It's a sad reality that in the American medical system, doctors make money treating the sick, not keeping patients well. Thus, we encourage intervention-based, rather than prevention-based, medicine. It's telling, for instance, that hospital emergency rooms, where we handle traumas, are legally required to treat the poor, but general practitioners, who can manage conditions and catch illnesses early and cheaply, can turn away the destitute.

Moreover, patients are transient, so early investments in their long-term health will offer financial rewards to other providers. And which HMO wants to be known as the one that's really good at treating diabetes? Signing up a bunch of diabetes patients is no way to turn a profit.

As Longman details, the VHA suffers from none of these problems. Its patients are patients for life, so investing early and often in their long-term health is cost-effective; the system was set up to deal with the sick, so the emphasis is on learning how to best manage diseases rather than avoid the diseased; and the doctors are salaried, so they have no incentives to either over- or undertreat patients. Moreover, the VHA is not only empowered to bargain down drug costs; it also uses formularies (lists of covered drugs), and so is actually empowered to walk away from a pharmaceutical company that won't meet its offer.

The results have been clear. "Between 1999 and 2003," writes Longman, "the number of patients enrolled in the VHA system increased by 70 percent, yet funding (not adjusted for inflation) increased by only 41 percent. So the VHA has not only become the health-care industry's best quality performer, it has done so while spending less and less on each patient." Pretty good for socialized medicine.

The goal of health care is to get everyone covered, at the lowest possible cost, with the highest possible quality. But in the United States, there is another element in the equation that mucks up the outcome: Our system seeks to get everyone covered, at the lowest possible cost, with the highest possible quality, while generating the maximum possible profits. Within that context, the trade-offs and outcomes all seem to benefit the last goal, and so we tolerate 45 million uninsured Americans, unbelievably high prices, and a fractured system that lacks the proper incentives to deliver high-quality care.

This makes it hard to move toward a preventive system, as Canada has, because preventive medicine pays less. It makes it hard to address moral-hazard issues wisely, as the French have, because it's unprofitable to insure diabetics, and less profitable still to make their care essentially free. It makes it hard to institute the cost savings that Great Britain has, because with less money flowing into the system, there would be far less profit to be made. It makes it hard to harness market forces while protecting against individual risk, as Germany has, because insurer business models are predicated on shifting risk to employers and individuals, and profits are made when insurers can keep that risk from being shifted back onto them. And it is impossible to implement the practices that have so improved the VHA, because doing so would require a single, coherent health system that stuck with its members through their life cycles rather than an endlessly fractured structure in which insurers pawn off their members as they grow old, ill, or unemployed.

That's not to say that there's no room for profit within the American health-care system, but that it's time the discussion stopped focusing on how to preserve the interests of moneyed stakeholders and started asking how to deliver the best care, for the lowest cost, at the highest quality -- to every American. Such a system will probably still have private insurers (at least at the high end of care), pay enough to encourage pharmaceutical innovation, and allow for choice and competition and market pressures. But it will take as its guiding principle the health of the populace, rather than that of the providers. That, in the end, is what all the model health-care systems have in common. Except ours.

This article is available on The American Prospect website. © 2007 by The American Prospect, Inc.

Young Conservative Pundits in Three Easy Traits

“I’m proud I’m a virgin. I’m glad I’m a virgin. I don’t even mind talking about it. So maybe you wonder: Why am I a virgin? It’s actually very simple. I am a virgin because I choose to wait until I get married.”

Ben Ferguson, the proud virgin in the above quote, is “America’s Youngest Talk Radio Host” and author of the plaintively, pleadingly titled It’s My America, Too. An unnaturally cherubic 22-year-old with little regard for liberals and lots of airtime in which to tell you about it, Ferguson has been riding the airwaves in some capacity or another since the ripe young age of 13, when right-wing radio host Ken Hamblin gave the kid a weekly call-in slot on his Denver-based program and made him one of the country’s best heard young voices. It’s now nine years later, and Ferguson has his own guests, not to mention his own show. Impressive kid, but who is he?

A proud product of home schooling, Ferguson is a charmingly parochial 20-something who attributes his success to time spent in Mom’s minivan. “[W]hile other kids were stuck in boring classrooms, staring at the walls or ripping apart their paper, piece by piece,” Ferguson was firmly planted in the passenger’s seat, listening to Limbaugh in the family Windstar. Ferguson is, further, deeply religious, disgusted by popular culture, in favor of family, in favor of school prayer, and would generally do a great job at dinner with your grandparents (unless they’re America-hating commies).

The funny thing is, Ferguson’s background isn’t unique. In the rarified world of young conservative punditry, it’s no less than archetypal. Joining him in prodigy-hood is Kyle Williams, a home-schooled, deeply religious 14-year-old columnist/author with a stunning mastery of conservative talking points and an unending storehouse of cultural disgust, and Ben Shapiro, a home-schooled orthodox Jew who found UCLA so packed with hardship and adversity that he wrote a column on it for the school paper, a syndicated column on it for conservative papers, and the just-published Brainwashed, a book on all the lefty academicians trying to trick students into tattooing Mao onto their buttocks.

A quick round on Nexis shows that these three boast numerous appearances on CNN, MSNBC, and Fox News, which, for two writers and a radio broadcaster, marks the multimedia ubiquity that transforms a political savant into a true pundit. And they, just like your retired generals and legal consultants, are called in when their expertise is applicable. From reading the transcripts, typical subjects are being young (Ben, Ben and Kyle), being really young (Kyle), being offended by popular culture (Ben, Ben, and Kyle), being offended by college (Ben S.), being offended by liberals (Ben, Ben and Kyle) and why liberals offend other people their age, too (Ben, Ben, and Kyle).

But having these three represent their generation is like learning about international diplomacy from Don Rumsfeld; the gurus know not of what they speak. The young folk the conservative message machine trots out to speak for Generation Y are not exactly representative members. In 2003, 2.2% of students were home-schooled. Religion, though judged important by 34% of high-schoolers, has less to do with piety for them and more to do with youth groups (read: snowboarding and roller-hockey weekends). As Dale Buss wrote in The Wall Street Journal, “The hard numbers say … that, while they may profess the faith and indeed love Jesus, the vast majority of Christian teenagers in this country actually hold beliefs fundamentally antithetical to the creed.” And the demographic driving Jay-Z and Ashlee Simpson (and downloading, watching, and re-watching Janet Jackson’s “wardrobe malfunction”) lacks the monstrous disdain Ben, Ben and Kyle hold for pop culture.

So why are these the personalities trotted out whenever the conversation turns youthful? And how did these three get the permanent slots, while they face off against an ever-rotating cast of young lefties, culled from wherever a desperate producer can find them? (I was once invited on to CNN/FN to talk about the youth vote. The invitation came in a frantic e-mail the morning of the show; the car, dispatched as soon as I responded to the e-mail, arrived 10 minutes before the segment, and I breathlessly entered the argument just as it ended.) It’s possible, I guess, that they are true prodigies whose remarkable talents have earned them premature success. But doesn’t it seem just a wee bit unlikely that all three members of this successful trio would be conservative, home-schooled, deeply religious and disdainful of pop culture? In fact, the repetition of this rare combination of traits suggests that they, in fact, are the reasons for the unlikely prominence of Ben, Ben and Kyle.

These are dream children—living, breathing, maybe even guitar-playing rebuttals to the hostile relationship Republicans are reputed to have with the young. They fit a detailed mold and can be trotted out to cover the conservative flank each time jihad is declared on rap music or Maxim or SpongeBob SquarePants. When it’s old white guys rationalizing the cultural broadsides, they just seem out-of-touch and paternalistic. But if Ben Shapiro is out there, if rap’s target demographic is brandishing a pitchfork and joining the mob, then it’ll throw enough confusion into the argument that the helpless liberal will be lost trying to figure out who he’s fighting for.

In fact, Ben, Ben, and Kyle fit a distinct pattern in conservative media representation. Indeed, leveraging one’s demographic birthright to help the conservative cause is a rich and respected tactic for getting noticed by the Republican Noise Machine. Take Michelle Malkin (please!), an Asian woman who wrote a book defending the internment of other Asian-Americans during World War II and now frequents Fox News demanding a sensible assessment of whether Arabs should undergo similar treatment for the duration of the War on Terror. That Asian internment was warranted isn’t exactly a majority viewpoint, but never mind. Take Ward Connerly, a black pundit who springs forth with jack-in-the-box regularity each time the right trains its guns on affirmative action. And while we’re doing Ward, we can’t forget his partner-in-crime Linda Chavez, a Latina whose primary interest appears to be, yes, assaulting affirmative action. Take Phyllis Schlafly, the woman who led the effort to kill the Equal Rights Amendment, a little constitutional edit that, if ratified, would’ve enshrined gender equality as the immutable law of the land.

In a party that captures a minority of woman, African-Americans, Asians, and Hispanics, it’s statistically stunning for these racially (or, in Schlafly’s case, sexually) charged issues to all find their conservative fulcrums in a member of the affected group. But it’s also good politics.

Color-coding your defenders saves a lot of trouble, as the charges of discrimination that might sink a racially charged proposal fall flat when the initiative’s defender has the correct skin tone. It stands to reason that the proposal can’t be too bad for the affected group, or why would that person be on TV defending it? Similarly, no woman, presumably, would defend something that’s bad for her gender, and no young person would fight for what most of his generation opposes. And yet the ranks of conservative pundits swell with advocates whose primary purpose seems to be using their demographic birthright to defuse criticism of offensive policies. So don’t fault Ben, Ben, and Kyle for their odd upbringings and unlikely prominence – their rare combination of youthful looks and throwback sensibilities are the precise attributes that allow them to advocate and oppose where older, stodgier Republicans dare not tread, just like Linda, Ward, and Michelle use their race to go where white Republicans cannot. As a friend of mine once noted, if these folks didn’t exist, Republicans would have to invent them.

In fact, I think they did.

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