red/blue dialogue on health care, part 3

Don posted his response to my blog entry here, and I encourage you all to check it out. Many thanks to him for all the quality thought!

I was inspired by the President's address tonight, and I feel it touched on many of the points we've been discussing. But I don't want his points to drive this conversation. So let me follow Don's lead and use the structure of his blog post to order my thoughts...

1. I disagree that health care reform is like outlawing hurricanes. Hurricanes are a force of nature, there's nothing we can do to prevent them (reinforcing levees is a different question, but I digress.) Health care is something we can do a lot about -- while it is inevitable that we will all die, humans have learned an immense amount about how to combat and slow disease, and to ease the pain of people who have become ill. The question is, how can we as a society maximize the benefit of these medical advances without bankrupting ourselves? I'm sure we'd all benefit from monthly CT Scans, but the cost would be ridiculously prohibitive. So this becomes an optimization exercise -- optimize the benefits realized against the social cost expended. I know that's a very utilitarian perspective, but it does strip the issue down to its core.

Let me also say as a sideline: Don, I don't really think you're cold hearted -- that's the kind of quip Facebook lends itself to, and that's why I'm pleased we've moved this onto our blogs where we can discuss this in complete thoughts. Also, I disagree that "Liberals measure compassion based on how many people are on government assistance, while conservatives measure compassion based on how many people no longer need government assistance." That's an old stereotype. I believe many problems are better solved by the market, and I would prefer that no one needed government assistance. But I do think there is an appropriate role for government -- government can solve problems in addition to exacerbating them -- and I think health care is one such problem that merits appropriate government involvement, though definitely not absolute control.

2. I don't agree that the NYT opinion piece merely "paints insurance companies as greedy, evil corporations making obscene profits by denying treatment to customers forcing them to seek treatment in livestock pens." It actually is a profile of a former insurance company employee who eventually grew uncomfortable with the way his industry operates, and who witnessed such treatments first hand. I agree the image of people being treated in livestock stalls is compelling, but a compelling image does not necessarily communicate the truth. I can think of many compelling images that in fact seed confusion as to actual reality. The piece makes clear that employees of insurance companies are good people with no malevolent intentions at all. I disagree with Nancy Pelosi that insurance companies are "villains" if that was really what she meant -- in fact, all of the plans under discussion in the United States continue to rely heavily on insurance companies as the core of the US health care system. The question is, should insurance companies be regulated to address the problems that challenge health care in the US, and I believe they should.

The issue of Canadian health care has become a bit of a football in this national conversation, but several facts are clear: The U.S. spends much more on health care than Canada, both on a per-capita basis and as a percentage of GDP. In 2006, per-capita spending for health care in Canada was US$3,678,; in the U.S., US$6,714, or 82.5% higher. The U.S. spent 15.3% of GDP on health care in that year; Canada spent 10.0%. Yet life expectancy is longer in Canada, and its infant mortality rate is lower than that of the U.S. -- the 2000 World Health Organization's ratings of "overall health service performance" ranked Canada 30th and the U.S. 37th among 191 member nations. Source:

And in fact, at no point has the US seriously contemplated putting a single payer system like Canada's into place, so the comparisons are almost entirely moot.

3. The question is not how profitable the insurance industry is versus other industries. Diamond mining and car manufacturing and investment banking may make more money, but that doesn't mean there isn't a huge social cost to giving profit-maximizing corporations sole jurisdiction to decide who gets what health care. There are an infinite number of possible ways to make profit in the world, and some of them have enormous social costs -- just because a corporation goes public and has shareholders it doesn't mean the government should do everything to avoid impeding the growth of that corporation. Also, it's now clear most of the insurance companies are pleased with the current batch of health care reform proposals, because they mean a significant increase in profits:

The question of whether these changes will lead to health care resource shortages also seems counter-intuitive. Is the argument that we should leave the 46 million uninsured because we don't have enough beds, bandages, and doctors to treat them? Won't supply grow to meet demand? The well-documented excesses of the current system (e.g. no preventative care leads to much more expensive emergency care, and the numerous inefficiencies of doctors ordering a barrage of tests to protect themselves against later accusations of malpractice) will be reined in once care is universal and there is more oversight. That will go a long way to meeting any increased demand. Also, why would doctors leave the US if we are the only country in the world without some form of universal health care? These changes will just bring us in line with every other industrialized country on the planet. So where would doctors go?

4. I absolutely understand your point around whether government programs are efficient. We all know there are legions of examples of wasteful government programs. But again, calling this program "socialized medicine" is to misrepresent what is being discussed -- the proposal on the table is primarily increased government regulation of insurers to make sure that Americans are not being denied care or being charged unreasonably high premiums. If the government does decide to create a public option, most estimates are that the public option will never cover more than about 5% of Americans. And even the public option does not involve the government in the provision of care -- it's merely a public insurance plan that would pay for services delivered by health care providers in the private sector. Just like insurance for motor vehicles -- everyone who drives a car is required to have it, but all the companies providing it are private. No one would call that "socialized car insurance."

Yes, entitlement spending is ballooning at an alarming rate, and it has been doing so for decades. But it's unclear what alternative you are proposing. US health care costs are about 1/5 of GDP, and they grew faster than inflation by about 3.6 percentage points a year between 2000 and 2005. The costs are going up right now. If you're advocating inaction, you're going to cost society much more than these proposals on the table are going to cost. And the President has made clear he is not going to add one dollar to the deficit as a result of these programs -- all direct costs to the budget will have to be matched with cuts.

5. I think the waiting times issue is a bit of a red herring... first, it's not clear other countries have significantly longer wait times for key procedures. And second, it's not how long you wait for a procedure, it's the overall effectiveness of the care you receive. It's clear on that metric the US is way behind:
If US doctors are calling for unnecessary tests, patients may be receiving those tests quickly, but it's clearly not making them any healthier. It seems clear that the effectiveness of a health care system should be measured on many factors, not just wait times -- on that basis the US is not even in the top 30 countries of the world in terms of quality of care, and all the countries ahead of us have some form of universal coverage:

6. I agree that for profit companies generate medical advances. Remember, I work for one of these for profit companies -- I am very pro-business, and I believe market competition is the engine that drives human progress, so please don't charicature me as the conservative stereotype of an anti-business liberal. It seems to me that the companies generating these new drugs, medical devices, and treatments will have as much if not more incentive to innovate in a post-health-care-reform world. We were just talking about a 20% increase in demand for services as the uninsured come on line, correct? And the market for these advances is not just in the US, it's global. I can't see how any medical innovations company would say, wait, health care reform -- forget it, we're not going to innovate any more. Some have even argued that more effective resource allocation will increase innovation:

7. I disagree that medical insurance and auto insurance are unrelated. Yes, it isn't a perfect analogy -- but it is an an existing insurance scheme where everyone is required to participate. And under the auto insurance rules you can decide how much coverage to get, so long as you meet the minimum requirement. The President's health care reform proposal works the same way -- each individual can choose what policy they want to have, and the insurance company they work with, and the provider they get care from, so long as they meet the minimum requirement. So I could get a gold-plated policy with no deductable and limitless coverage, if I'm willing to pay the high premium -- or I could get a catastrophic care policy with a low premium presuming I'm willing to cover pretty much all my costs short of a major medical event. And all existing coverages are unaffected and unchanged post-reform.

8. As to the public option, which has become the big punching bag for this debate -- the truth is, we already have several public options, each of which have massive support from American citizens. One is Medicare, one is Medicaid, and one is the VA. These programs target populations that are underserved by private insurance options. The reason to create a public option is to extend similar care to citizens who are not eligible for the existing public options, and who are not being taken care of by private insurance. The public option merely provides a channel for these unserved folks to get coverage. The government has no incentive to compete aggressively with the private insurers to take away customers that are deemed worthy risks, because the government has no profit motive -- I'm sure the public option will be designed so as to provide a roughly equivalent experience to private insurance, but it will extend coverage to populations who are ineligible, that's all. As I've said, the insurers are delighted about these health care reform proposals -- I don't think they're worried about being put out of business by a marginal public option that is designed to take the people private insurers don't want anyway. And this speculation about the public option being a trojan horse to move to universal single payer is really outlandish. In the wake of this incredibly difficult debate, you think Americans will just blindly roll over after passage of this modest reform and suddenly be fine with a French-style universal single payer system? Of course not. That's just paranoia and false slippery-slope equivalencies.

9. The Constitution makes two references to "general welfare" -- once in the preamble and once in connection to the power of the government to collect taxes -- and I think any reasonable person would agree that health care is definitely a part of the general welfare of the citizens of the United States -- maybe even the foremost component. The idea of health care didn't even exist at the time the Constitution was drafted -- people went to barbers to be bled if they had medical issues -- so the founders couldn't have specified it anyway. The Constitution is a relatively short document, mostly devoted to laying out how the government works -- it does not spell out any of our current national priorities. To look to the Constitution to decide policy (e.g. How would the founders have regulated the Internet? How would they divide up wireless spectrum? How would they regulate nuclear power?) is a futile exercise. So to say, "Obama's attempt to create a national health care system exceeds the authority granted to the Federal Government by the Constitution, and that alone is adequate reason to stop it" -- I personally find ridiculously oversimplified. Should we also cancel Medicaid, Medicare, Social Security, the EPA, the FDA, and OSHA because they're not in the Constitution? Wait, I shouldn't ask that question if I don't want to hear the answer.

10. Don asked why don't we "leave alone the parts of the system which are working?" I really believe that's what this proposal does -- it builds on the existing private insurance/employer based system and just fills in the gaps. And there are tax credits and exemptions that will protect small businesses. It sounds like Obama is very clearly trying to increase competition -- He even said specifically "My guiding principle is, and always has been, that consumers do better when there is choice and competition." It sounds like this plan will enable people to buy health care across state lines. I was shocked to hear that 90% of insurance policy holders in Alabama are served by one company. He also said he's going to reform the malpractice laws. So the two suggestions you made around reform sound like they're going to be integrated into this plan.

You describe this effort as "forcing everyone into a government-run system which rations care." I believe that is entirely different than what is being discussed here. You agree that the current situation is not sustainable, and you make a wide variety of criticisms of the Obama plan, but I don't hear any alternative. We all agree change is necessary. I hope we won't thwart this opportunity to make progress on this issue by trying to score political points for one side or the other.

11. The last point gets to the broader question of American individualism, social trust, and our connection to each other. I really think that is at the heart of our exchange, and I was pleased to hear it addressed in the President's speech. I found what he said dead on, so I'm going to go with his words on the subject. I'd like to think, based on our conversation here, that you would appreciate some of the things he said... I thought it was interesting that he even talked about "large-heartedness" in light of the back-and-forth between us on facebook ("cold heart") that started this whole conversation:

"One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate... large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people's shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise... our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves... I still believe we can act even when it's hard. I still believe we can replace acrimony with civility, and gridlock with progress..."

So sorry for the long post -- we're tackling a lot of issues and I guess it's inevitable that this conversation will expand in word count as we dive deeper. But I very much appreciate your honest and good faith engagement with me on this topic.

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