As I noted in the previous post, there’s been a real lack of active leadership from the president on the whole issue of health care “reform,” which has been quite frustrating to his party. Unfortunately, instead of that, we’re getting more of his patented harangues. This is a bad thing because for all the praise he receives as an orator, Barack Obama is a remarkably lazy and juvenile rhetor; he has a terrible weakness for cheap rhetorical tricks, tending to lean on them heavily whenever he needs to make his case. One he particularly likes is to set up false, simple-minded dichotomies, which he can then use to either a) paint himself as offering a more enlightened third way forward, or b) portray his own position as obviously correct and that of those of us who disagree with him as obviously wrong.

As David Freddoso pointed out, that’s exactly what he did yet again in his prime-time press conference last week:

With his example of the red and blue pills, and another about whether a child’s hypothetical tonsils should be removed, President Obama unwittingly presents the real problem with his plan for reform. Here is a well-meaning government official who so fails to grasp the problem in health care that he can present such absurd oversimplifications and suggest that this sort of thing is the real problem—doctors simply lack the common sense to make obvious medical decisions. President Obama wants us to solve this problem by putting himself and other government officials in charge of rescuing medicine from the medical profession. If medical doctors with a decade of schooling cannot distinguish between good cures and ineffective ones that must be discontinued, then by gosh, we’re lucky that the good folks from the government can.

President Obama thus frames the issue as a false choice between doing nothing at all and handing over to Washington complicated, case-by-case medical decisions that cannot possibly be legislated or dictated by government.

Freddoso’s wrong about one thing: “complicated, case-by-case medical decisions” can in fact be “legislated or dictated by government”—in one way, which he mentions:

There is exactly one thing that government can do to control costs in health care: it can insist on paying below cost.

Granted, he’s thinking here of government short-changing insurance companies and medical providers, which is a significant problem in our current system:

This shifts the cost burden to private insurance companies, which in turn pass along higher premiums to their patients. This is what government-run Medicare does today for many treatments, including cancer. Government will do more of this kind of “saving” when it assumes greater responsibility for funding citizens’ health care, particularly if a government-option health care plan is established.

What he’s missing, though, is that this form of “saving” only has this particular effect when there’s still a sizeable public sector in existence to bear that burden and compensate for it with higher premiums. Kill off that private sector, as the president’s preferred approach will pretty much do, and you get a different result—which is what the Mayo Clinic is worried about:

Under the current Medicare system, a majority of doctors and hospitals that care for Medicare patients are paid substantially less than it costs to treat them. Many providers are therefore already approaching a point where they can not afford to see Medicare patients. Expansion of a Medicare-type plan without a method to define, measure, and pay for healthy outcomes for patients will move many doctors and hospitals across this threshold, and ultimately hurt the patients who seek our care.

You see, when the government bureaucrats need to make “complicated, case-by-case medical decisions,” they’re not going to make them on the basis of the things that truly make them “complicated” and “case-by-case”; they’re going to make them on the basis of the actuarial tables, on a cost/benefit analysis run purely from the perspective of the federal government, and the way they’ll make them is by telling doctors, “We won’t pay that much for that procedure” (if indeed they’re willing to pay anything for it at all). If the figure they set is low enough, the procedure won’t get done. The only variable for medical decisions will be government cost control. In his usual role as the ghoul at the party, Peter Singer has been the only one to come right out in public and tell everyone what that means: rationing of health care.

As cost issues come to dominate the government’s interest in the health care system—which is to say, as the rosy and unrealistic projections of cost savings which the Democrats are currently using to try to build public support for their plan quickly give way to reality, creating a budget crunch—this will also necessarily mean increased taxes. After all, Democrats never have the stomach for huge budget cuts (except from defense budgets), and certainly won’t be willing to embrace the kind of truly draconian rationing of medical care that would be necessary to solve that budget crunch without tax increases. That’s why, despite the promises the president made back when he was trying to get elected, the House’s health care bill already includes a significant tax on the uninsured.

As expected, the House bill would mandate that individuals and families have or buy health insurance.

But what if they don’t buy it?

Then Section 401 kicks in. Any individual (or family) that does not have health insurance would have to pay a new tax, roughly equal to the smaller of 2.5% of your income or the cost of a health insurance plan. . . .

I assume the bill authors would respond, “But why wouldn’t you want insurance? After all, we’re subsidizing it for everyone up to 400% of the poverty line.”

That is true. But if you’re a single person with income of $44,000 or higher, then you’re above 400% of the poverty line. You would not be subsidized, but would face the punitive tax if you didn’t get health insurance. This bill leaves an important gap between the subsidies and the cost of health insurance. CBO says that for about eight million people, that gap is too big to close, and they would get stuck paying higher taxes and still without health insurance.

Ed Morissey adds that “the mandate in the bill would force people to choose between paying the taxes or paying as much as three times as much for health insurance, assuming a family plan.” Still, isn’t that better than having 45.7 million uninsured people? Not necessarily; the crowning irony to this is that, as Deroy Murdock points out, the number of people for whom lack of medical insurance is truly a serious problem is actually about . . . eight million.

Obamacare is propelled by the oft-repeated Census Bureau statistic that 45.7 million Americans lack health insurance. Even if that number were accurate, why would Washington turn the health-care industry upside down for all 300 million Americans in order to help 45.7 million? In fact, as Pacific Research Institute president Sally Pipes demonstrates, public policy should concentrate on a far smaller group of hard cases.

From those 45.7 million uninsured, subtract 17.5 million who earn more than $50,000 annually. Though they can afford coverage, they evidently have other priorities. Of the remaining 28.2 million uninsured, some 14 million are eligible for, yet have not enrolled in, the Medicaid and S-CHIP programs. Meanwhile, as many as 10 million uninsured may be illegal aliens. All told, Pipes estimates that only about 8 million Americans are uninsured due to chronic illness or working-poor status. The latter have incomes too high for assistance and too low for insurance.

In other words: if the House bill passes, it will throw a huge amount of money at the problem of people who can’t afford medical insurance, and the result will be that the same number of people will be unable to afford medical insurance, except that they’ll be paying higher taxes for the privilege. Even for D.C., that will be an amazing accomplishment.

For all the real problems with our country’s health care system, the current fight in Congress is more about Barack Obama’s agenda than it is about what this country needs; you can see that in the way he’s tried to argue that bringing in massive new regulation of our health care system is necessary to fix the economy (a line which, to judge by current polling, most voters aren’t buying). That’s why Sen. Jim DeMint declared that if the president can’t get this bill passed, “it will be his Waterloo. It will break him.” President Obama knows it, too, as an anecdote in a recent National Journal story, told by Sen. Charles Grassley (R-IA), the ranking Republican on the Senate Finance Committee, shows:

“Let’s just lay everything on the table,” Grassley said. “A Democrat congressman last week told me after a conversation with the president that the president had trouble in the House of Representatives, and it wasn’t going to pass if there weren’t some changes made . . . and the president says, ‘You’re going to destroy my presidency.’”

Which makes the president’s lack of real leadership on this issue telling. CNN’s Political Ticker noted last week that Democrats on the Hill are unhappy with his failure to do his part to get a health care bill passed:

One Democratic senator tells CNN congressional Democrats are “baffled,” and another senior Democratic source tells CNN members of the president’s own party are still “frustrated” that they’re not getting more specific direction from him on health care. “We appreciate the rhetoric and his willingness to ratchet up the pressure but what most Democrats on the Hill are looking for is for the president to weigh in and make decisions on outstanding issues. Instead of sending out his people and saying the president isn’t ruling anything out, members would like a little bit of clarity on what he would support—especially on how to pay for his health reform bill,” a senior Democratic congressional source tells CNN.

How did he respond? By going out and picking a fight with the Cambridge, MA police, which “sucked the oxygen out of the health care debate at the very moment Democrats were pleading for him to become more involved.”

President Obama clearly recognizes that in making a huge statist health care bill central to his agenda and staking a great deal of political capital on it, he has made it a bill which he must get passed if he’s to be able to lead effectively; if it fails, it will demonstrate significant political weakness to conservatives, to voters more generally, to the political class, to our nation’s allies, and to our enemies abroad. That’s why he told his party’s congressional wing that they will “destroy his presidency” if they don’t pass it without major changes; that’s why Sen. DeMint called it potentially his Waterloo.

In one sense, of course, that comparison is overstated, because the Obama administration isn’t going to fall if the Democratic health care bill fails; the president will be weakened politically, but he’ll still be the president. In another sense, though, Sen. DeMint’s comparison might not even be strong enough, because the most telling thing about this whole situation is that when faced—by his own admission—with the possible destruction of his presidency, Barack Obama has left it in the hands of Congress to prevent that. He’s happy to go on TV and host a press conference, but when it comes to the nitty-gritty work of leadership, he’s completely hands-off. For whatever reason, he just can’t or won’t do that.

This is the great difference between President Obama and Emperor Napoleon: Napoleon wason the field at Waterloo. He wasn’t on the front line itself, leading a charge, but he was right there with the army, giving orders and calling the shots. President Obama, by contrast, has left that job to Marshal Pelosi and General Reid—he’s back in Paris canoodling with Josephine. I’m not sure what that says about his ability and willingness to be a real leader, but whatever it is, it ain’t good.