Thursday, November 11, 2010

Campaign in Poetry, Govern in Prose, Reform Health Care in Bureaucratese

An essay “Campaign in Poetry, Govern in Prose,” in The American Prospect, a publication of liberal policy ideas, triggers this blog.

The essay’s author, Paul Waldman, observes, “You campaign in poetry but govern in prose. The poetry of campaigning is lofty, gauzy, full of possibility, a world where problems are solved just because we want them to be and opposition melts away before us. The prose of governing is messy and maddening, full of compromises and half-victories that leave a sour taste in one's mouth. Governing, however, is also specific where campaigning is usually vague. “

Republican Specifics Not Specific Enough

Waldman then goes on to say Republicans, a party of “No,” have nothing specific to offer to offset specifics of the Accountable Care Act.

Never mind this specific list of Republican proposals.

• Shopping for health plans across state lines

• Expansion of the Federal Health Employee Benefit Plan, which now covers 10 million federal employees, including Senators and Congressmen

• Risk pools for individuals and small businesses

• Health care tax deductibility for self-employed individuals and small businesses

• Tax credits for all

• Expansion of Flexible Savings Accounts and Health Savings Accounts

• Letting individuals who wish to buy services outside of Medicare privately contract with doctors

• Caps on malpractice awards

• Independent judicial courts to promptly and impartially award patients injured by doctors or other medical professionals

• Incremental expansion of coverage by the market based on competition between health plans and providers

In Waldman’s view, these measures are not specific at all. Why not? Because they don’t jibe with government-dominated Democratic specifics, as laid out in a 2500 page $1 trillion entitlement program enabled by the health reform law, which many advocates cheerfully admit they have not read because of its impenetrable legalese.

Four Simple Things

Waldman goes on to say,

“Every Republican understands the four simple things they believe in: small government, low taxes, strong defense, and traditional values. Ask a Democrat what she believes in, and she'll give you a laundry list of initiatives, proposals, and programs.”

“As a long history of public-opinion research has made clear -- and as events continue to remind us -- Americans are "symbolic conservatives" but "operational liberals." In other words, they like the idea of limited government, but they also like just about everything government does.”

I’m not so sure about that. “Hope and change” have a poetic ring, but prose, which is rooted in results, has a place too. When “hope and change” fail, then the emotions embodied in such poetic phrases as “coverage for all” and “social justice” fall on deaf ears, particularly in a center right country alarmed by federal spending, growing debts, and stubborn unemployment.

Specifics and Horrifics

One man’s specifics are another man’s horrifics.

Republicans may be short on specifics, but the health reform bill is long on a byzantine list of bureaucratic specifics – from the 150 or so federal agencies, to 13,500 IRS agents required to enforce individual mandates and filing of $600 1099 forms for every $600 business expense, to health exchange regulations, to health plan standards, to EMR financial rewards and punishments, to accountable care organization rules, to comparative effectiveness outcomes, and, last but not least, how to obtain federal subsidies for the new entitlement program.

Horrific Specifics

Here, for example, are the specific bureaucratic details for anyone wishing to be eligible for a federal subsidy from a health exchange.

First, submit an application to the exchange. The application must be accurate and include all information to determine if the applicant is eligible for Medicaid or SCHIP, as well as health reform subsidies.

Second, the exchange must transfer the applicant’s information to the state Medicaid and SCHIP agencies to determine possible eligibility for those programs. The applicant must be notified, and may no longer be eligible for exchange enrollment.

Three, assuming no eligibility for Medicaid or SCHIP, the exchange must determine if the applicant’s income appears to meet subsidy rules. If not, the applicants must be notified that no subsidy is available.

Four, the applicant’s information is forwarded to HHS, which will – in conjunction with the IRS and other federal agencies – verify the submitted information.

Five, HHS will notify the exchange of the results of verifying the submitted information. The exchange must then notify the applicant, including whether any discrepancies were found and must be corrected.

Six, assuming the application meets subsidy rules, the applicant can finally selected an insurance plan from the exchange. However, in order to receive the cost-sharing subsidy as well as a premium subsidy, only Silver plan selection is allowed. Thus, the lower-cost Bronze plan cannot be chosen by anyone wanting to reduce their out-of-pocket costs. The exchange must also notify the applicants of the reduced premium amount and the impact of any cost sharing.

Seven, the exchange must notify HHS of the applicant’s choice of plan.

Eight, HHS must notify the Treasury Department , which will then make the monthly premium subsidy and reduced cost-sharing payments to the selected.

The above describes the most straightforward situation without mistakes in which a well-organized individual applies for subsidies well ahead of the start of coverage deadline, during an open enrollment period, with timely and accurate communication among the various agencies involved.

If anything goes wrong in the process of awarding subsidies to the 15 million expected to apply for subsides, well, that’s another kettle of bureaucratic fish.

This process isn’t poetry. It isn’t prose. It’s sheer bureaucratic specifics, expressed in bureaucratese.

Further Reading

1. Paul Waldiman, "Campaign in Poetry, Govern in Prose," American Prospect, November 10, 2010.

2.Rogern Collier, "PPACA Premium Subsidies: The Govrnment is Here to Help", The Health Care Blog, November 1, 2010.

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