To th' crack of doom

Image via oceanweb.net.nz.

Former New York Times columnist David Brooks ("The Trump Elite. Like the Old Elite, But Worse!") provides an interesting deconstruction of the concept of legislative verticality:

Legislation can be crafted bottom up or top down. In bottom up you ask, What problems do voters have and how can they be addressed. In top down, you ask, What problems do elite politicians have and how can they be addressed?

The "you" there being not the you and I who are reading the column—we're just eavesdroppers—but the legislation-crafters; it's "bottom up" when they see themselves as the elite deciding what the voters need, and "top down" when they regard themselves as the servants of the elite trying to figure out what their masters need. Where in the conventional picture we think of the elite as the "top" of a social pyramid and the masses as its support, Brooks has turned this picture upside down, with the elite at the bottom holding the structure up like Atlas supporting the sky, and the masses idling cheerfully above, which is a decent analogy for the classically conservative view, when you think about it.

And the legislators scurrying around the lower floors, depending on whether they themselves identify as elite or not, which is a Brooksian novelty, and one he might like to rethink—seems to me he'd be compelled to say liberal legislators regard themselves as the elite at the very bottom earnestly caring for the whole population, and conservative ones as the gentlemen-in-waiting on the ground floor keeping the true elite or 0.01% secure, as it sleeps like Smaug in the cellar, with its subterranean treasure.



Or he's entirely unaware of the paradigm in which voters themselves play a role in the process, telling "you" what they want, and "you" try to work it out, which is what the "bottom up"  expression usually refers to, also known as democracy. That said, he has a point when he calls the Ryan tax cut health care bill "top down" in the sense that it

was not molded to the actual health care needs of regular voters. It does not have support from actual American voters or much interest in those voters. It was written by elites to serve the needs of elites. Donald Trump vowed to drain the swamp, but this bill is pure swamp.

Though he immediately deflects our attention from what needs of elites it actually serves, which are to free employers from the Affordable Care Act requirement that they buy health insurance for their workers, liberate insurance companies to whatever extent they can from Affordable Care Act provisions forcing them to place patient protection above profits, and provide an $880-billion tax cut for Smaug by cutting the same amount from the Medicaid program that serves the poor, the same thing Speaker Ryan always wants. Brooksy prefers to think about the sporting aspect:

First, the new Republican establishment leaders needed something they could call Obamacare repeal — anything that they could call Obamacare repeal....

There were just some politicians who wanted a press release called Repeal.

Second, Donald Trump needed a win. The national effects of that win seemed immaterial to him.

I'm not sure what he means by the "new Republican establishment leaders", since they seem to be exactly the same individuals as the old one. That first thought applies to the Trump much better than to Ryan and McConnell and so on, though; it's Trump that promised his voters endlessly that he would repeal Obamacare and replace it with something much better without any actual knowledge of what the Act or its replacement might contain and has shown himself entirely indifferent throughout the process. Ryan, in contrast, has known exactly what he wants to get rid of for the last seven years, and if he doesn't know what he wants to replace it with, that's because he fundamentally doesn't want to replace it; he wants to bring a halt to government spending on health and to regulation of insurance companies with a return to the status quo ante, preferably ante 1965.

Which is Ryan's, and the entire party's, real difficulty, compounded by Trump's insistence through the campaign that his own "replacement" proposal will keep the promises Obama made for the ACA, and keep them better and cheaper than the ACA does. This sticks Ryan with Republican voters' crazed expectation that a Republican Congress could even imagine such a thing, forcing him to tell the most appalling lies, as Dr. Krugman is noting today:

He claims that it would lower premiums; it would actually increase them. He claims that it would end the Obamacare death spiral; there isn’t a death spiral, and his plan would be more, not less, vulnerable to a vicious circle of rising premiums and falling enrollment. He claims that it would lead to “patient-centered care”; whatever that is supposed to mean, it would actually do nothing to increase choice.

And these have terrible effects in the House, between the "moderate" members of the GOP caucus who realize he's lying and fear their constituents' reaction to the devastating consequences that the bill would really have, and the "freedom-loving" true believers who think he's telling the truth and the bill will be too generous. So that he's been unable to cobble together anything a majority will vote for, let alone anything that will survive in the Senate.

Third, the bill was crafted by people who were insular and nearsighted, who could see only a Washington logic and couldn’t see any national or real-life logic.

They could have drafted a bill that addressed the perverse fee-for-service incentives that drive up health costs, or a bill that began to phase out our silly employment-based system, or one that increased health security for the working and middle class.

Or they could have left the Affordable Care Act alone, since it certainly addressed the fee-for-service model, whether Brooks knows it or not, slowly but surely—

Earlier this year [2015], the U.S. Secretary of Health and Human Services (HHS) announced a goal to have at least 90 percent of traditional Medicare payments linked to some form of ACO, medical home, bundled payment, or other value-related approach by 2018.7 A private-sector consortium has set a similar goal for its member businesses.8 In fact, an important effect of the ACA is how it has opened up new channels of communication between providers and CMS about the design and implementation of new payment and delivery models. The CMMI Innovation Awards program, for example, encourages health care organizations to propose new care delivery and payment initiatives for piloting. And provider involvement in the design of the law’s ACO and bundled-payment provisions enabled CMS to create programs that have attracted large numbers of participants. CMS and providers are now sharing much more data to monitor and gauge program performance. While implementation of these new programs has not been without delays and hiccups, the culture change occurring across the health care sector may soon make greater strides possible.

—threatens the employment-based system through the long delays and continuing loopholes in the implementation of the employer mandate—

Insurers like UnitedHealthcare have created insurance packages known as "skinny plans" that give employers the ability to peddle strikingly shoddy health insurance to their workers. Existing in a regulatory gap that only applies to large businesses, these insurance plans do not cover basic health necessities like hospitalization or emergency-room care but still allow employers to avoid the largest automatic fine under Obamacare, which, beginning this month, requires large businesses to provide insurance to all full-time employees.

(compounded by the way the Medicaid expansion allows employers to stiff their low-wage workers entirely and the rise of the "gig economy" in which so many workers are not regarded as employees at all; it's not obvious the employer mandate will ever really work, sadly)—and anybody who really believes the Affordable Care Act doesn't increase health security for the working and middle class is reading too much rightwing propaganda, as House members have been learning for the last couple of months at their town halls.

Brooks is a supporter of Obamacare without Obama, like those angry Kentuckians, and knows even less what he's talking about (they at least know how health insecurity feels).

Sure enough, while I was typing, old Ryan has been to tell the president he can't work it out. Surprise! Looks like we'll have the Affordable Care Act to kick around for a long time yet! Poor Trump must feel as if Obama's haunting him, the way Banquo haunts Macbeth: "What, will the Act stretch out to th' crack of doom?"