What Me Worry?
As far as I can tell, the gist of this piece on what the Obama administration can learn from Massachusetts’s health-care plans is: don’t worry crafting health-care reform that actually works in any sustainable way — just go with whatever gets everyone to agree and worry about the problems later!
Yet, even now, the lawmakers and strategists behind the Massachusetts plan strongly defend their incremental approach. Only by deferring the big decisions on cost containment, they said in recent interviews, was it possible to build a consensus among doctors, hospitals, insurers, consumers, employers and workers for the requirement that all residents have health insurance.…The times and the politics are different in Washington, where the recession has convinced both parties that cost containment cannot wait. But by addressing costs and access simultaneously, the White House and Congress risk alienating key interest groups from the get-go.
“When you start talking about cost, you create winners and losers and that leads to a political challenge,” warned Andrew Dreyfus, executive vice president of Blue Cross and Blue Shield of Massachusetts.
…John R. Sasso, a longtime Massachusetts political strategist who represented the state’s largest insurer and largest hospital network in 2006, said that moderation and gradualism had been critical.
“My experience has been that if you start out trying to design the perfect plan you will fail,” he said. “The goal has got to be to deal with all the levers that affect cost and access and quality but to not overreach in any of those areas. Everybody had a certain responsibility but not so onerous, not so tough on the front end, that it would cause people to lose faith in the prospect of covering everybody.”
Isn’t this sort of like arguing that it doesn’t matter if an airplane’s engine works or not, the best way to get it flying is just to roll it off the cliff and deal with whatever come your way? But shh, don’t talk about that faulty engine — we wouldn’t want passengers and crew to “lose faith.” And isn’t it also a tacit acknowledgment that, in order to get the plan passed, backers had to willfully blind themselves to major flaws — flaws that even now mean that the state’s health-care system suffers from massive cost overruns, health-care plans that are far more expensive than expected or advertised, and — crucially for a “universal” plan — fails to even provide true universal coverage? Libertarians hate the plan, naturally, but even given the benefit of the doubt, its success is mixed, and its long-term future is uncertain even those who praise the program worry over its high cost.
The short-term incentives in politics often run towards passage of large-scale legislation without regard to its efficacy, and so, with an any-bill-is-better-than-no-bill ethos in place, we end up with the legislative equivalent of paying shipbuilders to launch the biggest boat they can, all the while accepting their assurances that, even if it’s leaking now, we can always figure out how to float long-term once we’re at sea.
It would be if we were building a boat or a faulty engine. By contrast, implementing a politically controversial piece of legislation with billions of dollars at stake for interested stake holders (not to mention philosophical values), is by definition going to be a messy, imperfect situation.
From what I can tell, it is in the nature of our politics and our institutions. You either have the status quo or a messy, highly compromised piece of legislation that changes the status quo, which may or may not improve the situation. Speaking from personal experience, I have a chronic health condition that costs thousands of dollars a month to treat. I am an independent contract, whose cobra insurance will soon expire. The thought of being forced onto the individual market absolutely terrifies me. I face the possibility of financial ruin and eventual death. I know I am not thinking clearly. I know am thinking emotionally, but I really have no idea what else I am supposed to do. I am, in other words, desperate. As the economy worsens and more and more people loose their health insurance, that desperation will spread. That’s the political environment health care reform is going to be done in.
And as Ezra Klein pointed out about the cost of health care reform, the question isn’t whether we spend 1 trillion dollars to reform the health care system. The question is whether we spend 1 trillion dollars to reform the health care system or spend 3 trillion dollars maintaining the status quo.
In that context, its certainly possible that health care reform would be worse then the status quo, but it doesn’t seem awfully likely. In other words, the boat we are on has large gaping holes in it and is in the process of sinking. I’d prefer a new boat, even one with some holes.
Do you see things differently? Do you see a better way to craft public policy generally and health care specifically?
— Joseph · Mar 31, 05:57 AM · #
Joseph — my complaint here isn’t about the particulars of any health-care reform, nor is it to defend the massively problematic status quo in U.S. health care; it’s that the article seems to be pushing the idea that the best way to proceed with reform is to ignore a plan’s faults and just run with it, hoping you’ll figure it out later. That seems like a recipe for, if not disaster, large-scale problems in the medium to long term.
— Peter Suderman · Mar 31, 06:12 AM · #
The problem with concern trolling universal health coverage at this point is that there is no redeeming value to the system as is at all. For years there’s been a moral argument for reform. Now, almost everyone agrees that there is also a pragmatic one. No, it won’t be pretty, but how much do we genuinely have to lose in attempting to reform a system that is fundamentally broken?
— Freddie · Mar 31, 11:54 AM · #
That seems like a recipe for, if not disaster, large-scale problems in the medium to long term.
When I hear my life-long Barry Goldwater republican AMA physician father says, “What we have now is so fucked up it’s worth trying anything else,” I’m inclined to give Mass. the benefit of the doubt. At least they’re trying something else.
My belief is that if you want a glimpse into the future of health care in this country, a look at the malpractice insurance crisis of some 30 years ago is instructive.
— Tony Comstock · Mar 31, 11:58 AM · #
And the problem with dismissing concerns like Peter’s as concern trolling is that if he’s drawing the right lessons from the Massachusetts experience, it may well not be long at all before there’s no redeeming value to the new system, either. “Things as they are are broken” decidedly does NOT entail “We should just go ahead and try something or other”, as it matters quite a lot whether the “something else” that Tony C. is praising is a helpful something – indeed, it should be advocates of universal health care most of all who are sensitive to these concerns, since if they get their chance and things go the way of Massachusetts then it’s unlikely that they’ll get much of a hearing when the time comes to try yet another approach. What in the world is so objectionable about trying to draw out some political and legislative lessons from previous attempts at health care reform? I mean, don’t you care about all those people who’ve been going bankrupt from medical expenses and so need a health care system that, you know, works?
— John Schwenkler · Mar 31, 12:55 PM · #
Isn’t this sort of like arguing that it doesn’t matter if an airplane’s engine works or not, the best way to get it flying is just to roll it off the cliff and deal with whatever come your way?
No.
For one thing, we’re already falling. The current system is intolerable and unsustainable. It’s like we’re falling, we have a parachute and we’re trying to figure out how to open it. We’ll try something, that doesn’t work, we’ll try something else. But we know from the experience of watching others falling from the sky that parachutes work better than no parachutes.
The other thing is that it’s easier to reform the system once we actually have one, because as things stand those who oppose universal health care form an alliance with any stakeholders who stand to lose from cost-cutting. Limited government and efficient government are opposed to each other. Post-reform, once we take up the question of costs, they’ll be aligned.
The two questions—should have a universal system, and how should it be administered, should be kept separate. It’s not irrational to support a system before you know what the precise results of the system will be. (e.g. I can be counted on to support democracy or the rule of law even if I don’t know who’s going to win the election or the trial.) First we decide to move to the Pareto frontier, then we argue over precisely which point along that frontier we end up in.
The left has been thinking about these issues over the past couple decades way harder than the right. Concern trolling or not, it is bad advice.
— Consumatopia · Mar 31, 02:35 PM · #
As a matter of simple logic, saying that there is a pragmatic case against the current health care system is not the same thing as saying that there is a pragmatic case for universal health care. That’s about as textbook a case of false dichotomy as I can imagine.
For example (and I am not a health care wonk, so please do not ask me for robust explication), I know that a lot of thinking about health care reform on the Right focuses on “portability,” essentially severing the ties between health insurance and employment. In other words, the focus is on decentralization, rather the opposite of the call for universalization.
Also, all this sinking-boat, broken-parachute stuff is unpersuasive. I take it Ezra Klein knows what he is about when he says we face a crisis in three years, but surely that doesn’t mean we must now implement plans we know to be buggy. Saying that there is no time to deliberate smells of crisis-mongering, and my recent observations tell me that crisis-mongering in place of debate doesn’t turn out very well.
— Blar · Mar 31, 05:25 PM · #
The difference is talking about solving the problem in the abstract perfect world or talking about solving the probelm in the actual imperfect world. Any rational, complete discussion of political polciy has to include “political realities,” which is a phrase meaning current laws and the difficulty of persuading people to do what you want. As a parent I am reminded of the power of “political realities” all the time.
Not considering these is a mistake I think is made over and over in the pundit world. We are seeing a whole bunch of it regarding the financial crisis. For example, people are all over Obama to nationalize the investment houses without considering the fact that he has no leagal authority to nationalize investment houses. He is not king. Even if he were he would still have to deal with “political realities.”
— cw · Mar 31, 05:58 PM · #
As a matter of simple logic, saying that there is a pragmatic case against the current health care system is not the same thing as saying that there is a pragmatic case for universal health care.
There’s a pragmatic case against all non-universal health care systems. Severing the connection between employment and insurance, while seeming like a good idea, leads to more adverse selection spirals in the absence of universality.
Universality is necessary but not sufficient to have a system that won’t drag down the rest of our economy with it. Other reforms have to be made, but universality is the foundation on which they must be built, and the political system has too many points of obstruction to do all the reforms at the same time.
Saying that there is no time to deliberate smells of crisis-mongering, and my recent observations tell me that crisis-mongering in place of debate doesn’t turn out very well.
Recent observations show me that obstructionism enables the corrupt. As long as every single Democrat and two Republicans is needed to pass a piece of legislation, that means all sixty of the bastards can hold our whole country hostage when things need to get done.
— Consumatopia · Mar 31, 07:42 PM · #
My understanding of Marine Corp leadership doctrine is that when faced with a dilemma the decision should be made in favor of the more active solution; for example it is better to attack the fortified positions that have you pinned, then stay under cover and hope to survive the artillery fire that is likely being brought to bear on your position. This probably goes a long way to explaining my father’s position.
I do know this: the cost of health insurance is our number #1 non-revenue dependent business expense. It is already a non-trivial disincentive to our company adding staff. If current trends continue, there will come a point when it becomes a disincentive to staying in business at all.
Should that day come, we will most likely (as it’s popular to say today) “go Galt”; piling onto our boat to head for warmer climes where we can live off our rents. A simple calculation of our gross sales compared to what we pocket suggests that when/if that day comes, we’ll take 7-10 jobs with us. That’s 10-12 people not paying into Social Security/Medicare, and not paying health insurance premiums.
— Tony Comstock · Mar 31, 09:50 PM · #
Coming from a software engineering background, I find your comparisons to boats and airplanes laughable.
You have to take the input from the experience of Massachusetts the way a person would take the experience of the Wright Brothers in building a plane: You look at it as a way you can get things off the ground and make them fly. The point of the MA experience was that that worked. Do you have an example of a state getting something to work in some other way? Do you have examples of numerous failures using other methods? That is the correct, empirical approach to designing this successfully. It isn’t a thought exercise, it is data gathering and prototyping.
— code gorilla · Apr 1, 01:42 AM · #
This is exactly the sort of crisis-mongering that worries me. “Damn it, the time for debate is over!” is much easier to put forth than actual arguments in support of what you want to do. But it is essentially undemocratic and paves the road to soft tyranny.
— Blar · Apr 1, 05:07 PM · #