I wrote last week about how Ted Cruz had not been diminished in the least by his Obamacare faceplant. No; among conservatives, he had become an even greater figure, a martyr and a model. And some of the Republican candidates in the best shape to take over safe, red-state Senate seats were looking to the Cruz model.
One of the Cruz-alikes I didn't get to talk to was Nebraska's Ben Sasse, who went from the Bush administration's HHS to the presidency of Midland College. We met up this week; what follows is a lightly edited transcript of our talk.
Dave Weigel: So what do you expect the country to look like in January 2015 if you get to Washington? That there will be at least a chance to delay Obamacare from being implemented more fully? That people will start paying the individual mandate? What do you expect things to look like, at least in terms of health care, by then?
Ben Sasse: A lot of assumptions there I would want to unpack. I think there’s lots of uncertainty—let's start 10 years in the future instead. I think that Obamacare is fundamentally unstable, it’s unimplementable, it’s the most complicated piece of legislation we’ve ever passed, in the past 28 years. I think it’s the most complicated law since the Great Society programs and arguably ever. Those laws were mostly done, there weren’t nearly as many incomplete strings as there are in this. So I think it’s not implementable, and ultimately it will fail. I think we're ultimately going to end up with a single-payer system, or a more market-oriented premium support model that actually delivers higher-quality, lower-cost care.
I think the inertia motion path we’re on with this program will have a really bad outcome. I think the country is in crisis and the conservative movement is in crisis and so I don’t know how to calculate where we are on the pathway to that by January 2015. But I want something better for my kids and grandkids than the path we’re on right now. That’s why I’m running.
DW: So this inertia is leading to disaster; is that disaster single-payer?
DW: I’ve heard that before. I’m not sure how that would work. How you would get Washington to coalesce around something that’s more European than what we have right now?
BS: So I don’t know the legislative mechanics on how we get there. But, macro, we have two choices right now that both stink, we’ve got Democrats as the part of bad ideas and Republicans way too often as the party of no ideas. It looks to me right now like the median voter is a little bit predisposed towards bad ideas over no ideas. I don’t think this will work, I don’t think the website problems are the core problems. The structural problems are about incentives that are all misaligned, but government can’t afford to run it on 18 percent of GDP. So I think it’s going to fail, I don’t know if it fails catastrophically, or if it fails by incremental accumulation of unworkable incentives and death spirals. I think the vast majority of Obamacare in rural areas will need Medicaid expansions, which is a fundamentally dysfunctional system that we can't afford and that, as has been demonstrated already.
DW: I think that’s already the case in Oregon.
BS: It’s really kind of outrageous that we know—we’re day, what, 28? How is the Obama administration allowed to not give any real answers to real questions? I can’t think of anything this opaque, from supposedly the most transparent administration in history. I can’t think of any program outside the national security space that’s ever been anywhere near this miserly with data. Why don’t we know this? Why don’t we know how many actual enrollments there are? By state, by Medicaid versus by exchange enrollment, on federal-run exchanges for the states of specific state-based exchanges, and what kinds of insurance plans they're adopting, at what prices and what subsidy levels. This data isn’t mysterious, somebody knows it. Why don’t they have to share it?
DW: Do you think it was possible to design something that worked? How much of this is based on being a dog when it was passed? Could they have passed a House bill that was actually more far-reaching? You look at Medicare in 1966, and there were a lot of people not signing up, they were worried doing so would cut off Social Security. How much of this is just it’s completely unworkable versus what they passed is horrible?
BS: That’s a very fair question. We could talk a bit about the timing of December of '09 to March of '10, but I think the Medicare point is a better one. The CBO projections on what Medicare would cost in the first decade were off by 900 percent. It ended up costing nine times as much in the first 10 years as what it was projected to cost. Government’s health and entitlement projections are always wrong. We’re setting the rates for tens of thousands of things, and we know this doesn’t work. I think the numbers are Medicare is setting payment rates for like 11,000 drugs and procedures, crosswalked by 100 different geographies, whatever that math comes out to. It isn’t workable, you ultimately are going to have cost control in this system. The question is whether cost control comes from the center, from power bureaucrats to limit access to those devices and procedures to ration care, or whether cost controls come because, like every other marketplace, we ultimately allow market signals to show what’s higher-value and lower-value quality care delivery. I believe that the American people want to have a lot more control over a process, they want to actually be able to keep their doctor and pick their doctor, they want to be able to make distinctions between catastrophic coverage and routine medical expenses, and we don’t draw distinctions in health care like we do in property and casualty space between catastrophic and the routine. You can't use your Allstate card or State Farm card and swipe it at Jiffy Lube or at the gas station. If you could, Jiffy Lube wouldn’t be open the same hours, its quality would be lower, its prices would be higher, and its locations would stink. Sort of like health care.
DW: What have you thought about the congressional response since passage, on either side? There have been tweaks—the medical device tax did survive this round, but that emerged as something that Semocrats and Republicans realized was gettable in another negotiation. How important is it to end that tax?
BW: I think these are all inside-baseball games. It doesn’t speak to the American people. This is a 2,300-page law that Congress passed with, which the then-Speaker Pelosi admitted, that they had to pass it to read it, to figure out what was in it. Who the heck does their job like that? No hardworking Americans who are serving their neighbors do that kind of stuff. The Homestead Act was a page. Why is this a 2,300-page piece of legislation? Because Washington believes if rules don’t work, lets just add more rules. It’s not workable. I think Republicans are atrocious communicators, and we haven’t put actually forward solutions that give the American people confidence. There are perversions in the health care space created by government. We should remove them. The discrimination against he individual insurance market, because of the accidents that you know well, they’re decades old, but they should have been corrected years ago. In the pensions space, we’ve solved these kinds of problems; it wasn’t that hard to go from a world where everybody used to have job-lock around their one firm, they were given the bad choice of staying at one job forever, or if they leave and go to another job where they could potentially create a life-changing product for somebody, they had to abandon their pension. Well we solved that, we created 401(k)s. Portability was obviously important in the pension space, portability is obviously necessary in the health insurance space, and the reason the market wasn’t innovating to create portability is because of the biases in the tax code. Its tough stuff, but the Republicans should have been communicating about this before this disastrous law and since. And we don’t.
DW: Why do you think they weren’t? You were in the Bush administration, at a point in time in this political space where the conservative base was rising in anger, especially after they lost Congress in 2006. They were saying, so much of the reason they lost is that they met liberals halfway on Medicare, on federal intervention in education. It seemed like they were just saying any kind of government intervening at all is meddling. I don’t think that's actually an election issue anymore, but there’s an idea that Medicare Part D was this horrible sellout by Republicans.
BS: I mean, it was painful. I was opposed to it then and I’m opposed to it now. The mechanism of Part D is less bad than any other government payment methods, but it's still fundamentally and entitlement program that wasn’t paid for, and we ca'nt afford them. I think way bigger than any health policy problems, we have a moral obligation to leave America to our kids and grandkids as great as free and as opportunity-filled as what we inherited from our grandparents, and we're not on a path to doing that, because Washington is filled with people who just want to give out free stuff. Well, it's not actually free. But when you’re playing with house money, known as the citizens' money, it's easy to say you just want to solve all these problems by giving them free stuff. The people who do this are the same people who haven’t passed a budget in five years. So I think Medicare Part D was fundamentally flawed because it wasn’t paid for. There could have been ways to have a different conversation about a prescription drug benefit being added into an old Medicare structure of Part A and B, but it should have been done in a way that holds actual cost savings in the system so that it wasn’t creating just new obligations to pass on debt to our kids and grandkids.
DW: Why do you think it was done that way?
BS: Politicians of both parties love to spend other people’s money. And I mean it's obviously going to come to an end, it's just a question of whether it comes to an end by leadership or by debt crisis. I think leadership would be a better path, but it doesn’t feel like the people in Washington, D.C., know how to do that.
DW: I remember one way the president kept selling health care in the abstract was this: Nobody in America should die because they don’t have health insurance. You can look and find the horror stories very easily, of somebody who, had they had a better plan, or not lost their plan, would have been OK. So what’s your answer to that? In America is there a way to make sure that nobody dies, doesn’t have insurance, without huge transfer payments?
BS: Well, let’s go back. In Medicaid, there’s no demonstrable evidence right now that people with Medicaid have better health outcomes than people who have no insurance. So, just saying, "I empathize and I feel your pain and I want to therefore make the government solve all these problems," we don’t have evidence that that actually works. So if you want to actually help people, what we need to do is create a society that has a lot more people who are healthfully and steadily and stability in a middle class and believe that there is a growth economy, and that there’s opportunities for their kids and grandkids that are as great as what our grandparents knew, when we felt like America was still on the upswing. America should still be on the upswing, but our optimism should be about the American people, and about the ability of communities and neighborhoods and schools and small businesses to solve these problems. Big government programs haven’t demonstrated that they actually ameliorate these problems that you’re talking about. I mean to you, point about Oregon or West Virginia, more Medicaid signups, you can put more names and more numbers on government programs, but it isn’t clear that that actually benefits them, so I think we need to go back to the drawing board.
I think most Americans believe in a basic social safety net. But if there are 3–5 million hard-to-insure people right now, why are we disrupting the 165 million persons in an employer-sponsored insurance market? As of now we don’t know how many enrollees there are in these programs, but we know that millions of people have been kicked off their plans already because of Obamacare. The president said if you want to keep your plan you can keep it. We know that’s not true and right now we don’t even know that the benefits, in scare quotes, of the new exchange programs are even going to add up to the amount of people that lost their individual market insurance in New Jersey and Florida and Nebraska. So I think that this is hugely disruptive, and trying to solve a problem it’s creating unintended consequences that are creating more problems than its even solving. And it’s at a price tag we can’t afford. There are better solutions.
DW: Is there a way to help this? If somebody makes $20,000, they develop a kidney condition. Is there a way that they don’t get wiped out?
BS: Well anyone who makes $20,000 has Medicaid eligibility and can afford this, right? I think we should have a universal, a shared cultural or societal goal, of universal health insurance coverage. That’s completely different from saying the government can solve all of those problems, or that it can micromanage every aspect of the health delivery system. I think we know that it can’t do that. And the question is, what’s the best pathway to having more Americans have a healthier life, and having a more financially stable predictable pathway through potential catastrophic car wreck, cancer diagnosis? I think there are market-based solutions that would accomplish more, deal with the uninsurance problems more effectively, for less cost with higher and measurable quality that would actually power people. I think Medicaid harms people.
DW: How does it harm people?
BS: There’s not data that shows that the health care for people on Medicaid is any better for people who are uninsured. It creates job block at the marginal tax rate and benefit loss level. There are all sorts of marriage penalties. The patchwork of all these social safety net programs we have for people, in the $20,000 space, create disincentives to work, and create disincentives to getting to independence. It’s easy for Washington people to sit around and say they care more because they want more people on dependency programs. That’s not what the actual people who need these programs want. They want to move to independence. We should be reforming our entitlement programs to empower people.
DW: So I’ve asked a lot about health care. Different question: If the Syria crisis is mostly behind us, what do you think of the resolution to that?
BS: What was the resolution? The diminishing of the American brand in the world?
DW: When it came to chemical weapons, having the Security Council setting up the program instead of sending missiles in there.
BS: I’m a guy who’s running a college, and getting to know the people in Nebraska, I’m not an expert on these kinds of issues, but from where I sit and listen to Nebraskans, you don’t hear the president making any public case for why there is a clear national security interest in country X, country Y, country Z, and I think the American people overwhelmingly believe that the first duty of government is to defend us from enemies foreign and domestic, so we need a robust military to fulfill its primary duties, and then we want to be incredibly reticent to ever use it. We want to be strong enough to do anything that we needed to do to protect our people, but reticent to ever get in to conflicts where Congress is voting to send somebody else’s kid to die.
When you listen to people in Nebraska, and they hear the Syria conversation, the thing you hear every town hall you're at is, "If we go to war in Syria, why wouldn’t we be in war in 20 countries right now? How do we know that his one is a higher priority than any other?" And there’s so little trust of and good will toward this city that there’s just not a lot of confidence that serious adults are helping to create order. What are our risks? I don’t think the American people have heard President Obama make a compelling case.
DW: Can you give me a sense of how the debt limit should be debated every time it comes up? Should it be—it's obviously going to be a focal point for something, but what sort of conditions should there be before it’s increased?
BS: The assumption of the people who live in this city is that you govern by crisis, you just wait for the next crisis and then figure out how to put off the crisis for a little while. The crisis is that we’ve made promises that don’t add up, and we’ve known this for years, and we keep kicking the can down the road again, and so it feels like every time we get up against one of these deadline moments, the leadership of both parties just gives us two bad choices. This one was: continue a terribly dysfunctional government shutdown, or kick the can down the road again.
Both terrible choices. It doesn’t have to be lose-lose every time. We could actually have an adult conversation about long-term structural reform. But that would require a bunch of people in this city to actually do the much more serious hard work of admitting that they’ve overpromised, that they’ve overstayed their time. I don’t see when I read my Constitution or my American history any sense that the Founders had a permanent political class, and it feels like when you’ve made promises that don’t add up, the best way to duck having to have adult conversations about adult-sized problems is to try and figure out how you can make it seem like the natural thing to do is just to put it off a little longer.
DW: How much have you looked at the way that the health care system here compares to, for instance, the British system?
BS: When I worked for President Bush, we’d go to all these international health minister summits, and when you look at something like the U.K. system, I don’t know the current percentage but I think it’s somewhere around 15 percent of people just buy around the system with individual insurance, so you have all these political escape valves for some of the problems that don’t work well in the system. They can just have universal, and yet what they really do is ration by waiting time, and in the U.S. system, President Obama and the media are lying and you get away with talking about Obamacare as universal coverage, 47 million uninsured when we passed this, and on CBO calculations we’re on a pathway from 47 to 56 million uninsured. On the most recent CBO revisions, a minority of those 56 million are going to get insured under Obamacare.
But the media allows him to talk about it as universality. It's great rhetoric! It’s just not true. I think the same thing is true in many European systems, which is when you ration centrally, you find a way to keep a cap on certain aspects of costs, but you ration certain things by waiting in line, certain people who are politically connected and empower can just buy around the system, and then inevitably these systems are partly beneficiaries of the fact that the U.S. subsidizes R&D for the world. So there are many things that exist in the British system that are not as horrible as they would be if everybody had a single-payer system. The U.S. does lots of the off-label prescribing, complicated, messy, ineffective and inefficient way, that subsidies oncology research all over the world, and when certain discoveries are found that this doesn’t work for ovarian cancer but it does for breast cancer or vice versa, the British and the French go in, and the Dutch, and they adopt whatever it was in the U.S. system.
So I think that the European systems are a mess in a whole bunch of dimensions, but the most obvious thing that they don’t have is they don't have innovation. They borrow from U.S. innovation. So many of the proponents of a single-payer system in the U.S. understate how big the drop-off would be, not only for us but for other countries if we also had single-payer.
DW: And finally, what did you make of the Supreme Court's decisions on DOMA and Prop 8? I don’t think those will be incredibly active issues in this Congress, but did you agree with those or were you more on Scalia’s side?
BS: I would agree with Scalia. I think that what you find in a place like Nebraska that what marriage has done is prior to government, and so government coming in and trying to decree feels like it doesn’t respect freedom of religion, things that happened outside government.