Re: Keep it Simpler, Stupid
Conor makes a bunch of worthwhile points in his case for incrementalism in health care reform, but while he may be right on the merits I suspect that the strategy he suggests is unlikely to be a political winner. As I’ve suggested before, if conservatives want to take the health care issue away from the Left they’re going to need to find a way to frame and argue in favor of their positions using morally weighty language: taking “smaller, discrete steps” may be all fine and good, but those steps have simply got to be bound up in a narrative according to which conservatives are genuinely in favor of reform, so that voters who are justifiably unhappy with the status quo don’t feel that voting Democrat is their only real alternative.
Proponents of school choice provide a helpful example of how such strategies can be implemented effectively. There is a strong empirical case to be made that school choice improves educational outcomes across the board, but its advocates tend to be most persuasive when they frame the issue as a straightforward matter of social justice, forcing politicians to confront voters over the question of why they’d rather bow to the demands of teachers’ unions than help poorer families to afford the same sorts of schools that their own children attend. It may be that school choice is also a less dangerously ambitious step toward reform than, say, a wholesale overhaul of educational standards, but the latter is the sort of rationale that only a wonk could be moved by – and by a similar token, few people outside the Republican base are likely to be all that alarmed when opponents of the public option in health care reform start raving about competitiveness and the role of the market in encouraging medical innovation.
For a more radical proposal along these lines, see Arnold Kling (via Reihan, who has more here on a similar topic):
The Republicans are not beating up on Obama for reinforcing the status quo. On the contrary, their tactic is to portray the Obama plan as something that is radical and threatening. Maybe that message helps them politically. But it undermines any possibility of a real debate about which direction to take in health care policy.
I would like to see a debate between reforms that free up health care market and policies that entrench the status quo. The fact that the Republicans are not engaging in that debate is just one more reason for believers in markets to view Republicans as unreliable allies.
If Conor is right, it could be that going all-out with pledges to abolish the status quo would not be a politically effective approach, either; but I think the more important point is that simply appealing to the virtues of “free markets” isn’t going to do enough to frame conservative reform proposals as intrinsically desirable. The message ought to be: Here’s what health care reform of our sort can do for you; what the other side is offering is just a costly giveaway to special interests that will do little more than tinker around the edges. Mere demagoguery may be sufficient to win the policy battles here and there, but conservatives need to do more than that if they ever want this issue to play in their favor in the long run. The pessimist in me is pretty confident about which sort of strategy the GOP will adopt.
Friedersdorf is wrong. The whole accumulation of subsidies needs to be junked and replaced with a fairly clean and comparatively simple alternative.
— Art Deco · Aug 11, 12:24 PM · #
In terms of beating Obama, no plan may work better than a plan. Obama wants the republicans to unite behind a single plan, so that he can contrast his plan with a real alternative, rather than getting hit from both sides as opponents just point out what’s wrong with his plan. (Compare the Iraq war, where Kerry refused to say whether his solution was to send more troops or get out entirely, because either choice would lose him a bunch of supporters. Of course, Kerry lost, but publicly picking a war strategy probably would have resulted in an even bigger loss).
If the republicans united behind the Arnold Kling plan, as good as it is, Obama could come out and argue (1) the GOP plan leaves many uninsured; and (2) do you really trust insurance companies over the government? He wouldn’t convice me, but he would have a better chance of winning the day than he does now.
The drag about arguing for the status quo is that of the 5 or 6 interested groups, no one really likes the status quo. But when the argument is the status quo versus any specific reform, there is usually a majority in favor.
— J Mann · Aug 11, 01:03 PM · #
John,
I the individuals invovled in the design of the American health care system actually adopted Ockham’s Razor, we wouldn’t be having this discussion right now. The initial involvement of government regulation in wage controls created health care insurance, the creation of Medicare inflated the costs across the board, the creation of Medicaid abolished compassionate/humanitarian medical care, and the VA convinced the government they could run hospitals. Strip away all that stuff, and we’d have a much easier time.
— Matt C · Aug 11, 01:27 PM · #
This may be right. But in terms of long-term political future (not to mention the state of our health care system)? Having Democrats be able to demagogue them as not being in favor of necessary reform does not play well for the GOP.
— John Schwenkler · Aug 11, 01:44 PM · #
Here’s my speech:
Anyone who’s paid attention to the last 200 years of philosophy knows that there’s a tension between utility and justice, between, in our case, what’s good for America and what’s right for America. This tension is most clear in the debate over healthcare reform. On the one hand Democrats are justly concerned about the moral failings of the status quo, and on the other Republicans are rightly worried about quality retrogression under the proposed reform.
Both utility and justice are valid points of view, and neither is metaphysically prior to the other. When these view points collide — as they must — there is no way to settle the debate with deductive reasoning. Deontology and Instrumentalism are mutually exclusive domains of thought; there is no way to walk from one to the other. Rather, to get from utility to justice and back again, you must alt-tab your mindspace; the necessity of gestalt shift is the great reveal of 20th Century metaethics.
Let’s turn to the Democrats. Their plan to bring justice to the status quo tracks Rawls’s difference principle; it is justice by way of the maximin. Basically, they want to see a system that provides the best healthcare for the worst off.
There is no obvious defect in the ‘maximin’ as a principle of justice. That’s why it’s lasted so long as a serious contender. The only way to attack it is by showing that it’s not useful, and yet that’s precisely what the deontological mindset won’t allow.
But what if there were a way to import empirics into justice after all? What if there was a measure we could use to rank competitive principles of justice? Mightn’t we then be able to judge the wisdom of the Democratic pursuit of the maximin?
And what of the Republican focus on utility? Maximizing average utility (trusting the market) can leave an awful lot of folks behind. Mightn’t there be a way to temper their instrumentalism with morality, a way to find something that we can all get behind as being both good for America and fair for Americans?
Any solution to the debate will need 1) consensus on the underlying principles, and 2) stability of satisfaction over time; to do that we need deontological and instrumental complementarity (think Niels Bohr and wave/particle duality as the solution for quantum mechanics). How nice would it be if there was a book showing which redistribution scheme garners universal consensus, on the one hand, and stable satisfaction over time on the other?
Luckily for us that book exists. It’s not a fix-all, but it is a great place to start a critique of both Republican and Democratic platforms on healthcare.
The upshot: the Democrats’ maximin is unwise, as is the Republicans’ singular focus on maximizing average utility. Instead, what’s required is the installation of a reasonable floor with ‘free market’ above it.
— Kristoffer V. Sargent · Aug 11, 03:11 PM · #
“The initial involvement of government regulation in wage controls created health care insurance, the creation of Medicare inflated the costs across the board, the creation of Medicaid abolished compassionate/humanitarian medical care, and the VA convinced the government they could run hospitals. Strip away all that stuff, and we’d have a much easier time.”
The above gets at a basic problem that conservatism needs to grapple with. The above narrative say that all these things have been done to put us in the situation we have today. What is undealt with/unacknowledged by that narrative is that before all those things were done…we were in a situation that was even crappier than the one we have today. Those things were done to address legitimate concerns, concerns which were not being addressed in other ways.
Underlying too much of conservative thought is the assumption that America circa 1890 to 1915 was some sort of utopia that must be restored.
Mike
— MBunge · Aug 11, 03:25 PM · #
@Mike
“The above gets at a basic problem that conservatism needs to grapple with. The above narrative say that all these things have been done to put us in the situation we have today. What is undealt with/unacknowledged by that narrative is that before all those things were done…we were in a situation that was even crappier than the one we have today.”
Crappier in what way? In terms of life expectancy and medical treatment, probably. In terms of government fiscal balance? Of course not. Are you going to argue that we face less future deficits from Medicare before Medicare was created? I think not.
“Those things were done to address legitimate concerns, concerns which were not being addressed in other ways.”
And in turn created more concerns and problems, which were not being addressed…now we need to address those concerns, which will lead to new concerns and problems…
“Underlying too much of conservative thought is the assumption that America circa 1890 to 1915 was some sort of utopia that must be restored.”
Nowhere in my post do I say that. Underlying to much left-wing thought is that governement solutions to previous “concerns” has made things “better” in all measures. This argument is strictly about fiscal balance and policy, not about social utopias (I think thats more a progressive fantasy than a conservative one.)
My point is simple: America did not face any long term fiscal imbalance due to underfunded/overspent government programs such as Medicare and Medicaid before it got into the business of health care. This cannot be refuted.
— Matt C · Aug 11, 04:04 PM · #
But Medicare and Medicaid is when it got into the business of health care. Your point cannot be “refuted” because it’s a pretty stupid tautology. The long-term fiscal imbalances that existed before health care expenditures were simply expenditures on other things – foreign wars of adventure, etc.
— Chet · Aug 11, 04:48 PM · #
The flaw, here, is in assuming that the Republican Party gives a crap about policy. At this point — and really, this has been the GOP in a nutshell for at least a decade — they are all about the politics. The “discussion,” if I may be so charitable to call it such, is no longer about how the country is run, but who’s doing the running. The majority of the Republican leaders don’t give a shit about good governance, just power.
And it’s going to be a really shitty day for this country when the Democrats complete their tilt in that direction, too.
— Erik Vanderhoff · Aug 11, 04:56 PM · #
You might try reading my last sentence one more time.
— John Schwenkler · Aug 11, 05:19 PM · #
John,
I agree with you and Frum, but I’m not sure I see a solution. The ultimate problem for me as a GOP voter is (1) I think the status quo is untenable; (2) I think that Obama’s plan is worse than the status quo; and (3) I think that it would be impossible to sell any improvement on the status quo to the public.That’s what has me stuck in the current rut, which I agree will lead to a panicked reformation of the health care system 10-15 years out, which in turn might end up being even worse than Obamacare. I’d love to see some free-market principles put into place, but (1) I am deeply concerned that if the GOP tried to sell Kling-o-nomics, we would end up with Obamacare; and (2) as a second best option, we would end up with another prescription drug benefit, which got the GOP no credit and turned out to be just another proof by dems and independents that the GOP was fiscally irresponsible.
I’m not happy with that dilemma, but all I see in front of me is horns, and the status quo seems the least painful of the set, at least so far.
— J Mann · Aug 11, 05:29 PM · #
Let’s be serious. The political ground being set by conservatives is that medicare can’t be tinkered with ever, anything that changes people’s coverage is bad, and concern about fiscal health is bad because people will eventually vote to euthanize grandma.
There is no fucking utility vs. justice argument. There is no free market vs. socialism argument, no deregulation vs. regulation… there is nothing but political opportunism.
— Dero · Aug 11, 06:28 PM · #
John states
then J Mann adds
but feels they’d be impossible to sell.
Could either of you offer some specifics of how free-market principles could be applied through policy to improve the status quo in healthcare? To John’s point, I’m having trouble finding the detailed conservative reform proposals amongst all the demagoguery. Why are they so difficult to sell that an untenable status quo is preferable?
— 62across · Aug 11, 06:50 PM · #
Eliminate or cap the tax deduction for employer-provided health care. Provide individual vouchers instead, and do the same for Medicare and Medicaid. Repeal restrictions that prohibit residents of one state from buying insurance from another. Generally promote policies that encourage patients to confront the costs of medical services. And make Arnold Kling mandatory reading for all policymakers.
— John Schwenkler · Aug 11, 07:03 PM · #
@ Chet,
“The long-term fiscal imbalances that existed before health care expenditures were simply expenditures on other things – foreign wars of adventure, etc.”
So…we created Medicare/Medicaid in lieu of reform directed at expenditures in foreign wars of adventure?
The rationale for more government involvement in healthcare is that we are facing fiscal crises in healthcare expenditures. As I have clearly explained, the root cause of these crises were —-> government involvement in healthcare.
If you think the same entity that brought you Medicare will bring you a fiscally stable healthcare system…good luck.
— Matt C · Aug 11, 07:34 PM · #
“Crappier in what way? In terms of life expectancy and medical treatment, probably. In terms of government fiscal balance?”
I’m sure it was a great comfort to poor and old folks dying of treatable diseases in the past that their suffering didn’t endanger the “government fiscal balance”.
Mike
— MBunge · Aug 11, 07:54 PM · #
“The rationale for more government involvement in healthcare is that we are facing fiscal crises in healthcare expenditures. As I have clearly explained, the root cause of these crises were —-> government involvement in healthcare.”
Then why aren’t single payer systems even worse when it comes to the cost of health care?
Mike
— MBunge · Aug 11, 07:55 PM · #
62across, basically what John said for free market initiatives. I think some explicit subsidies or reinsurance for people with preX conditions is also a good idea, if we can pay for it. I would also like to see some agressive cost containment in the existing government sphere, plus some additional freedom for the insurers to sell clearly labeled, aggessively cost-contained products.
The sales problem is that there are several interest groups: (1) public policy wonks who want to see full insurance; (2) public policy wonks who want to see cost containment; (3) holders of government-sponsored and/or provided insurance; (4) holders of individual insurance; (5) the currently uninsured; (6) holders of employer-based insurance; (7) doctors and hospitals; (8) insurance companies; (9) trial lawyers.
Now some of those groups are more important or influential than others, but for any proposal you make, it seems like a majority lines up against your proposal and in favor of the status quo. Hillary tried selling cost containment by combining it with an expansion of coverage and a public-private partnership, and got hammered. Obama decided to ditch most of the actual cost containment, and sell expansion of coverage, with public competition against private plans and vaguely defined cost containment down the road, and is getting hammered. If I had my choice, I would go for a shift away from the employer based system, with public support for private insurance (i.e. vouchers and reinsurance), and some cost containment, and I would get hammered too.
— J Mann · Aug 11, 08:27 PM · #
62 across, I cannot claim any professional knowledge and am not sure I could comprehend academic literature on the subject anymore if I consulted it, but I have found appealing a schema for a system similar to what obtains in Singapore. The salient features are a public insurance program which applies to expenses incurred over a high deductible and the erection of medical savings accounts through mandatory payroll deductions. You would pay for your family’s mundane medical expenses with funds from your medical savings account and your dealings with your pharmacist and general practitioner would generally be cash-on-the-barrelhead. There is some discussion of alternatives to the proposals in Congress here
http://the-american-catholic.com/2009/08/03/so-what-about-the-other-10-million/#comments
if you are interested.
— Art Deco · Aug 11, 09:45 PM · #
Thank you John and J Mann for your responses. I have seen some of these and I guess I’m going to have to read some Kling. I think the meat is in what John calls promoting
I believe this is possible, but extremely difficult due to how different medical services are from other products and services. One does not forego a kidney transplant until the organ is on sale. The typical medical consumer does not (and likely can not) have the information necessary to make complex medical decisions that balance cost with effectiveness. The disparity between medical services and other commodities needs to be addressed pointedly.
— 62across · Aug 11, 10:13 PM · #
There is an information deficit. However, people can also experiment and consult with their doctor about alternatives. Do you purchase this prescription medicine, purchase a less expensive but less potent medication, or simply suffer the effects. Do you go for these tests or do you wager they are not worth it. I have had experiences of this nature in my own household in the last two years. I think it would help to get less distorted assessments from your physician if we got rid of these litigation jackpots.
— Art Deco · Aug 11, 11:07 PM · #
No, we created Medicare and Medicaid so that seniors wouldn’t end their lives in filth and squalor, which they had been doing since they’re unninsurable.
Well, but that’s absolute nonsense. Health care costs are rising for all, not just those receiving Medicare/Medicaid. And they’re rising in all countries (though not as fast in some), not just ours; our government “involvement” can hardly be to blame.
I don’t believe that any health care system can be permanently fiscally stable given current population trends. But a government-run system of single-payer will be more stable over a longer timeframe than the alternatives; that much is known.
— Chet · Aug 11, 11:27 PM · #
But these are not simple questions the untrained can answer. In fact these are the exact kinds of questions the human brain is known to be terrible at answering. Asking patients, who don’t have the objective distance from the issue – who have the exact opposite of distance and clarity – to make these assessments is insane.
And what alternative mechanism do you propose to disincentivise malpractice?
— Chet · Aug 11, 11:38 PM · #
The very same sort of thing is true in any domain – should we have the government buy our cars, houses, and computers for us as well?
In any case no one is saying that patients should answer these questions on their own, but only that increasing their incentive to take them seriously could allow a sort of collective rationality to emerge. We’ve seen what we get when health care consumers get to treat everything as if it’s given away for free.
— John Schwenkler · Aug 11, 11:58 PM · #
No, it’s not. Full stop. Buying a car doesn’t necessitate the same kind of statistical reasoning that medical cost decisions do. Medical care is an entirely different beast than anything else you can buy. Food is close, but you never have to buy a cheeseburger in a state of unconsciousness in the next half-hour or you’ll literally die. It’s amazing to me that conservatives insist on treating medical care like buying DVD’s off Amazon. Are you really not prepared to acknowledge the difference? Seriously?
Ridiculous. Firstly – there’s no indication that the uninsured are any more “rational” consumers than the insured are; the latter buy medical care that they don’t need, for sure, but the former don’t buy care that they do need. Being uninsured and paying out of pocket doesn’t suddenly imbue you with expertise in statistics and medicine (and certainly doesn’t imbue you with the funding to buy the care you need.) In fact it usually forces you to make bad decisions, like “I’ll skip a month of my heart medication so I can pay for car repairs; I probably won’t have a heart attack and die.”
I mean the biggest problem with healthcare, acknowledged by everyone who’s not a conservative, is that a large number of people are facing medical issues that they know they can’t afford to have treated themselves, causing them to be trapped in jobs they’re overqualified for or don’t like, causing them to gamble thousands in the casino of private health insurance (“will your claim be covered or denied, leading to your death? Let’s see what’s behind door number one!”) or contorting themselves and their lives in other extreme ways to avoid the spectre of medical bankruptcy.
And the conservative perspective, as exemplified by you, is that not enough people are in that position? There really is something tremendously wrong with you.
— Chet · Aug 12, 12:27 AM · #
And the other side of that problem, Chet, recognized by people across the political spectrum, is the many millions of other people who are able to run up the health care bills all they want because the costs are entirely hidden and the government is subsidizing their employers to pick up the tab for them. This hugely distorts the cost of health care, making it that much more difficult for people without the means to buy insurance – to whom, as I noted above, I am thoroughly in favor of issuing vouchers – to afford the care they need.
Being told that there’s something wrong with me by a Palin pregnancy skeptic is pretty hysterical, btw.
— John Schwenkler · Aug 12, 03:32 AM · #
Embedded in this is the ludicrous and absurd idea that people go to the doctor all willy-nilly, out of boredom perhaps, or out of spite. It’s true that people are getting medical care they don’t need – like I said they were – but this is the result of the fact that we pay doctors to perform tests and provide treatment, not to improve health outcomes.
People don’t go to the doctor unless they have a good reason. You’re accusing millions of Americans of being hypocondriacs, which is a diagnosible mental illness, and I guess I’d like you to substantiate that claim. Other sources put that it as less than 1% of the population.
And frankly hypochondria is a medical condition best diagnosed by a doctor, not by political conservatives. (By videotape, I assume.) If there’s really a sweeping plague of costly hypochondria, that’s a medical problem, not a political one.
Laugh all you like. I’m still waiting for you to present even one piece of evidence – of any kind – that she’s actually Trig Palin’s biological mother, besides the word of a woman who’s lied about literally everything else. But do try to stay on topic, John, please?
— Chet · Aug 12, 06:48 AM · #
Umm, no. Embedded in it is the obviously true idea that when people are encouraged to consume, and so doctors to prescribe, health care in ways that are almost wholly insensitive to cost and comparative effectiveness, that’s just what they’ll do, which means that costs will rise in turn; and that if these incentives are removed then patients will make, and – more crucially – ask their doctors to make, comparisons of cost and treatment effectiveness, and will also – and most crucially of all – talk to their friends and neighbors about which doctors tend to provide the best service and recommend the most cost-effective courses of treatments, which in turn will create a significant demand-side incentive for health care providers to drive costs down. If you don’t think the American public can help to accomplish that, then it’s you who’ve got the low opinion of them, not me.
In any case I’m trying to make a habit of not wasting my time with pseudonymous internet trolls whose primary mode of “argument” consists in throwing around insults and generally acting like an asshole, so … toodleoo, Chet.
— John Schwenkler · Aug 12, 03:17 PM · #
P.S. FTW!
— John Schwenkler · Aug 12, 03:19 PM · #
Obviously true in what way? Look – people don’t like to go to the doctor. If anything is “obviously true”, it’s that, and if “exposing” people to the costs of their own care – by, say, uninsuring them – means they go to the doctor less, it’s because they’re not going to the doctor when they should. Having people not get the medical treatment they need – because they’ve inaccurately weighed the cost vs. reward calculation by, you know, not being a fucking doctor – is an asinine “solution” to the health care problem.
I’m still waiting for you to defend your claim that “many millions” of Americans are hypochondriacs, a claim you’ve suddenly retreated from. Is that because you’ve realized it’s ridiculous on its face?
If I told you my real name, would you defend your arguments with evidence this time and answer my questions? I will if you will.
— Chet · Aug 12, 03:40 PM · #
Umm … that was a claim I never made. And for evidence that I am right and you are terribly, horribly wrong, see my latest post.
— John Schwenkler · Aug 12, 03:54 PM · #