Matthew Holt

What I want to happen and what I think will happen

Election day. At last it’s over. A gazillion dollars, mostly wasted making TV stations richer. Two years of
campaigning resulting up in 3–4 months where rushed decision making will create a future that we all have to live with.

It looks pretty clear that Obama will win, with an increase in Congressional control for the Democrats. Although we Dems are used to losing when it never seemed possible…

So what do I want to happen? Certain things need to be done straight away.

1) Guantanamo Bay must be closed & torture renounced.

2) Rampant spying on Americans, national security letters & government abuse of power must be ended.

3) We need a declared route out of Iraq, immediately. (And a truth commission to deal with the lying sacks of **** who got us in there to reward themselves and their now much richer friends wouldn’t be a bad idea).

4) America must rejoin the international community, including
abiding by the principals of Kyoto, the International Criminal Court
& the UN Human declaration of human rights.

5) The drug war should be ended and a rational system of regulation introduced (OK I know I’m dreaming on this one).

6) A Manhattan-type project should be set up to really push the development of alternative energy. (I have some hope this will happen)

7) Complete house cleaning in the Federal departments and agencies
like Justice, EPA, FDA and many more, which have been over-run by
politicization and an attack on science. And a re-adoption of a serious
role for government.

8)  A really broad effort to fix the discriminatory, unfair American health care system

But what do I think will happen?

Less than that I’m afraid. But let’s stick to health care reform
which (other than the drug war) of all the above is the least likely to

The conventional wisdom is still probably correct.

There’s not going to be much money in the Fed’s coffers, so the
expansion of government subsidies to enable the uninsured to purchase
either into an expanded FEHBP or an expanded Medicare, will be delayed
for a long while. In addition, the expansion of pay or play will look
like a big tax increase on employment. So it’ll probably be very hard
to expand that as well. Which all together means no significant change
in the number of the uninsured or in their overall situation.

And as I said a long while ago,
I fundamentally still don’t think Obama cares that much about health
care. And the appointment of David Cutler as chief health care adviser
reinforces that view.

Which means that when health care reform is on the table it’ll be an
incomplete version that passes. Insurance reform may result in the
banning of most of the more reprehensible practices of the big players
in the individual and Part D/Medicare Advantage markets. But it won’t
actually change the fundamentals of how Americans get (or don’t get)
their insurance, and it’s necessary but still totally insufficient for
real reform.

I think we will of necessity see big cuts in Medicare under any
scenario. But Obama has campaigned a little too much on keeping the
status quo in Medicare and employer-based insurance for understandable
reasons of political expediency. It’s hard to see how the radical
reform in payment and incentives, which most THCB readers (and almost
all its authors) think Medicare needs, will come from his
administration. So instead I think Medicare payment reform will equal
similar cuts as in the 1997 BBA, with more hatchet and less rapier. And
its likely that the cost-effectiveness commission proposed in the plan
will be killed by industry before it sees the light of day.

Which will all lead to a continued path towards higher costs and
more and more un-and under-insured. Which eventually will lead to a
baby-boomer revolt that will get us to a modified single payer system
somewhere between 2014 and 2020–-again something I’ve discussed at length  over the years.

So what might upset the conventional wisdom, besides of course a miracle comeback from McCain? I only see two possibilities

1) Obama and the Democrats win so big and take the Senate by so
much, that they really decide to take the opportunity to create the
social programs that Grover Norquist and his buddies fear. In which
case they may enact an Obama style program (hopefully with a little
more sense than what’s been proposed).

2) The recession/depression is so severe in 2009–10 that the
baby-boomer revolt, specifically over the security of health benefits,
becomes a roar. In that case all bets are off on the details, but my
guess is that if this happens in the next 2–4 years you might see the
clock advance on how to cover everyone. And then that modified single
payer will probably crop up too.

Either way, at least by tonight we’ll know the political
landscape. Well done on hanging in there this far, because from now on
the real fun starts.