red/blue dialogue on health care part 5

This is a great dialogue. See Don's latest post here. I feel like my understanding of the issues we're discussing is improving, and I think I've got a much better handle on Don's perspective. I'll follow the numbering system we've been using to keep the points ordered.

1. Government is getting involved because the current system has become so inefficient and ineffective in addressing society's need for broad based health care. The creation of HMOs in the 80s was an attempt to turn everything over to the private sector, and it has created many of the problems we're now encountering. You can't optimize the benefit of social expenditures on health through a largely unregulated private process, which is based on profit maximization. This reform preserves the private system we currently have but increases the role of government in regulating and managing it. There's nothing in that design that violates the laws of economics -- government is constantly changing rules and incentives in the marketplace, and the market adjusts in response. The only thing that will generate bad outcomes is if the government fundamentally disrupts the incentives for private companies to provide coverage and care, and I haven't seen anything that indicates this reform will do that.

I agree that there are some confounding regulations out there, like the state-by-state limitation (which I understand, ironically, was originally put in place to benefit businesses.) Malpractice law is another one. Fortunately it looks like this reform is going to clean up some of those inefficient rules (see 10 below).

2. The Cuba part of Sicko was the weakest part -- I think it's hard to look for Cuba as something for the US to emulate in any way, actually. But I thought the rest of the movie made some compelling, and relatively measured (for Michael Moore) points... I thought it'd be more of a screed. But I don't want to get defending Moore -- he's a polarizing figure that clouds and clarifies issues in equal measure. I'm not a big fan of the bell ringers on either side.

3. What you're saying is completely at odds with the way I understand this reform will work. Who is creating a government monopoly? All coverage and care will go through private entities. It even looks like the public option is dead. And in a true market, consumers have transparency, and they can easily switch from one to another. In this market, consumers are trapped with their insurer because they don't know if another company will cover them or at what rate, and it's a huge administrative pain to switch. Plus, true costs are hidden from consumers because they don't pay them -- that's how my neighbor's pacemaker cost $77k for just 24 hours in the hospital (and that's not even the surgeon's fees.) Also, consumers don't know what care they need, so doctors order unneeded tests and procedures in order to make more profit. It's about as far away from an efficient marketplace as you could imagine.

4. OK, this is an important point -- it sounds like you're in favor of some reforms. It seems to me that the current reform package is putting in place some of the things you suggested (though the devil is always in the details). "I also support subsidizing insurance for those who genuinely can not afford it. We pay for their care one way or another, and I think that providing basic insurance is better than just waiting until they show up at the emergency room." That is great to hear.

In the same vein, I think talking this through with you has sensitized me to some of the problems with the public option. I think it generates more concern within our country than it generates benefit to have a government-run option... in many respects, it's counter to our culture. Better to have independent non-profit groups running insurance programs that accept all comers, subsidized by government. That should help to reassure those who fear this is a massive power grab on the part of the state, and the beginning of some sort of 1984-esque mandated rationing program.

5. Well, the WHO ranking is as comprehensive a comparison as we're going to get. I don't disagree that free quality medical care should be ranked higher that pay-for quality medical care -- I know which system I'd like to live under. It's clear that finding a universally acceptable rubric to compare systems is difficult. Just seemed to me the WHO effort was the best one out there. I'd still argue life expectancy is a better ultimate metric than survival rates, especially if other countries excel in preventative care. I'd rather be healthy my whole life than get sick and recover.

6. Profit does not inevitably lead to innovation. Some companies invest heavily in innovation and others do not. Some companies use their profits to squelch innovation. I think the argument is that more public involvement and oversight will create incentives to innovate as opposed to obfuscate.

7. I think we're getting too hung up on the details of auto insurance. I'm not saying it's a perfect analogy, just that it's an insurance that government requires every citizen have in order to drive, even if you self-insure (though I presume you have to prove you can cover your costs to go that route.) I think the two compelling reasons for requiring everyone to have health insurance are: a) communicable disease. If individuals get sick they can infect others, so health care is not only about the good of a single person. So there's a clear social rationale for universal coverage. And b) economic burdens, as you noted in 4. It costs more to have someone get very sick and show up in the ER. If your diabetes goes untreated, you may show up in the ER and have to have your foot amputated. It would be easier to teach you how to test your blood sugar and change your diet. Both A and B are valid reasons to make this a requirement of everyone in society, because the effect of an individual's decision is not limited to only that individual.

8. Yeah, I saw that video. It's pretty chopped up, and I have no idea who most of those people are. Seems like a pretty tenuous argument to suggest that's evidence that Obama and Pelosi have these long term nefarious plans. Pelosi will be long dead at that point anyway. But as I said, I've come around (and I think the process has come around) to conclude that the public option is not going to happen. I've also realized that single payer is completely impossible in modern America. Let's see where we are in 2050. Maybe Kucinich Jr. will be President and the US will look like Denmark.

9. "Limited government is a central principle in the Constitution, and the government is to curtail the liberty of the people only to the extent that one person's liberty infringes on another's rights." I absolutely agree that limited government is central to this country. I guess I just disagree on how much this proposed reform curtails it. As I argued in 7, I do think this is a situation where one person's liberty could curtail someone else's rights. As to the extremism of this proposal, Richard Nixon proposed far more aggressive health care reform than is even being discussed right now. Our country has moved so far to the right since 1980 that most Republicans from the 1960s would be considered moderate to liberal Democrats in this debate. I don't think either of us has lived under a tyrannical government, but I agree, it sounds like hell on earth to me, and I'd fight to the death to oppose it. But I think the US is about as far from tyranny as any government on the planet, and I can't see how a modest and pragmatic change like the one we're discussing threatens that in any way. I was much more frightened by some of the secret surveillance activities of the last administration, and even those activities were quickly called out by the independent press and curtailed by the judiciary, which is how our society is designed to operate. We're debating this in public, and there's complete transparency. Seems to me that's the sign of a healthy democracy, not one under siege.

10. I'll do some more research on the cross-state-lines component of this reform package, but as you say, we're still at a pretty high level, and will likely be until the bills come out of committee. As you say, the devil is in the details.

11. I am a moderate, pro-business Democrat. I believe in the death penalty, and I'm not a fan of gun control. When it comes to social issues, I trend strongly libertarian -- government should get out of the business of regulating private behavior. But I agree with FDR that a society should be judged on how it treats those who have the least. It is far too easy for the powerful to abuse the powerless, and I think it's an appropriate role of government to ensure that does not happen. I also think the vital center in this country is where policy is made, and the more our political dialogue moves to the fringes the more damage is done to our social consensus. It weakens the US to have the loudest voices be Hannity and Limbaugh on the right and Olbermann and Moore on the left. On my senior page at Greenhill I left "Colin in 20 years" a variety of things that all came to pass, except "Morton Downey Junior far, far away from power." Sadly, the inheritors of Morton Downey Jr. are alive and well in our current national dialogue.

I think the fears about Democrats are always that they'll be anti-business and pro-regulation, weak on defense, etc. but I think the reality is at odds with that. Clinton was clearly a moderate, and was quite pro-business, and I think Obama fits that mold as well. Imagine if a Kucinich was running things and then you'd see a hard left agenda. There are many, many voices in the far left who are extremely dismayed with the measured approach Obama is taking, but I fundamentally agree with it. I do not see any of his major priorities that are hard left -- on the contrary, he's sending more troops to Afghanistan and siding with the pragmatic middle on most of his reforms. He inherited a country on the brink of catastrophe, and he worked with business to reel things back in from the brink. He's about as far from the Great Society stereotype as I can imagine -- I'm sure you've seen the chart that shows all the run ups in the deficit have happened under Republican administrations... we've been on an unprecedented spending binge for the last 9 years. I don't doubt that Obama will reel in spending moving ahead as well, once we get past this current crisis. Once the economy recovers, as it looks like it's starting to, we'll see tax revenues come back. And that, combined with new fiscal discipline, should trend things in the right direction.

rah