“Government can’t do anything right”
In yesterday’s Wall Street Journal, Thomas Frank writes about the mythology behind the Republicans’ obstruction of health-care reform:
Where the conservative mythologists show their hand is when they use their own monumental screw-ups, committed during conservatism’s long years in charge of the government, to prove that government in general is a futile proceeding, and that Democratic health-care plans, in particular, can’t possibly succeed. [...]
Among former President George W. Bush’s gravest and most characteristic blunders, of course, was his administration’s response to Hurricane Katrina, when the nation learned the true price of government by crony and contractor. But for conservatives, that is too nuanced a view. The real lesson to learn from Katrina as we debate health care is simply that government can never work. “The federal government would run a health care system — or a public plan option — with the compassion of the IRS, the efficiency of the post office, and the incompetence of Katrina,” carps the official summary of the Republicans’ Patients’ Choice Act.
I’ve always thought that P.J. O’Rourke was only half joking when he wrote, years ago, that “Republicans are the party that says government doesn’t work, and then they get elected and prove it.” Conservatives grasp the grand strategic sweep of politics better than liberals, and consequently they have always seemed to understand that what they do when they’re in charge can help to reinforce the myths that put them there.
That’s funny, I thought the governor of Louisiana and the mayor of New Orleans were Democrats. Just goes to show you–never let the facts get in the way of a good myth!
[In an Andy Rooney voice] And another thing…did you ever notice that when the Republicans in Congress oppose a Democrat president they are labeled obstructionists, but when the Democrats in Congress opposed a Republican president they were praised as the loyal opposition?
Happy 4th of July (to everyone reading this blog who considers it something to celebrate)!
I know this is a tiresome complaint, but with a government featuring a Democratic president, a Democratic majority in the hourse, and a now fillibuster-proof majority in the Senate, with that party’s continuing commitment to supporting the legal license for what the bishops consider the gravest current moral evil, a Catholic publication continues to devote significant energy to saying how evil those Republicans are.
I’m not saying you should trash Democrats instead, or that every post should be about abortion. Indeed, I would think it quite appropriate to laud the Administration for its current work with the bishops to produce legislation aimed at lowering the number of abortions.
Nevertheless, it is difficult to escape the conclusion that posts like this are more about confriming prejudice than advancing the common good.
Yes, John, it is a tiresome complaint. You’re not saying every post should be about abortion; you’re just saying that anytime someone at Commonweal is tempted to complain about some piece of Republican misprision or stupidity, he should remember the Democrats’ complicity in “the gravest current moral evil” and keep his mouth shut. It’s not that we always have to criticize the Democrats’ position on abortion; we’re just not allowed to criticize the Republicans for anything (because of abortion). Got it.
Sometimes advancing the common good really does mean calling people out. “Common good” does not equal “Be nice.”
Mark, you brave patriot, I called the Republicans obstructionists because, in this case at least, that’s exactly what they are. (I don’t recall using the term “loyal opposition” to describe members of either party — the phrase stinks of special pleading.) The Republicans’ opposition to health-care reform is based entirely on two things: purblind commitment to antistatist ideology, and purblind loyalty to their donors in the insurance industry. Our private system continues to get more and more expensive, less and less efficient, and they just whistle through the graveyard: “The best health care in the world. How do we know? Because it’s ours. Never mind what the numbers say.”
“with a government featuring a Democratic president, a Democratic majority in the hourse, and a now fillibuster-proof majority in the Senate,”
Precisely. As the Federal government is presently configured, it’s difficult to understand how Republicans are obstructing anything right now, save by the quality of their public arguments. If those are tiresome and inconvenient for the powers that be (and we know they must be because Democrats are working so hard to silence them), perhaps they should just chalk it all up to the inconvenience of wielding near-absolute power. Then they can to about the business of actually governing, and then of living with the electoral consequences of that governing.
Happy 4th of July (to everyone reading this blog who considers it something to celebrate)!
Mark,
You found us out! Those of us who are Democrats don’t think the founding of the United States is anything to celebrate. Only Republicans believe in America.
Oy vey! Ideological schlock in place of thoughtful criticism – that’s why we think of the GOP as obstructionist.
Jim,
The dirty little secret is that enough Democrats vote (and talk) like Republicans on this issue to make the Democratic advantage in Congress very precarious. If every Democrat were really interested in substantial reform, it’s true, we wouldn’t have to worry about the Republicans. So why does Thomas Frank complain about the Republicans? Because only one or two of them are interested in prying health care out of the grip of private insurance companies, and it is they who have devised the bad arguments that are routinely trotted out whenever someone (always a Democrat) gets serious about reforming the system.
“…Republicans’ obstruction of health-care reform…”
“…I called the Republicans obstructionists because, in this case at least, that’s exactly what they are.”
You seem to be have an interpretation of the composition of the Ruling Party caucuses and American parliamentary procedure which is quite different from the publically available information as well as the published Rules of the Senate and Rules of the House of Representatives. Are you saying the American Legislative branch is operating under parliamentary rules which are not public information? If not, could you clarify what rules have been amended to give the minority party the ability do what you are claiming they are doing? I looked at the House (http://www.rules.house.gov/) and Senate (http://rules.senate.gov/public/) Rules Committees websites and did not see the rules changes your statements would imply.
Or are you implying there is a significant number of members of the Ruling Party who caucus with the minority and it is that pro-forma caucus composed of the Ruling Party and the minority party which you are referring to for the sake of this post as the “Republicans”? If that is the case, could you provide the names of those people most would refer to as Democrats and whom you are referring to as Republicans for the sake of this post as?
“…purblind commitment to antistatist ideology…”
Are you being ironic since it’s the 4th of July weekend? Or are you just not familiar with the Committee of Five and the Debate on the Constitution and all that?
When politics and principle converge, there is no reason to negotiate. That’s why a Democratic minority obstructed GW Bush’s social security reforms to death. Given the current economic meltdown, aren’t you glad that the government’s retirement commitments don’t depend on the performance of the stock market? Yet the underlying problem was never solved, and now we’re told that Social Security is closer to insolvency than previously thought. Too bad Bush, Democrats and Republicans on the Hill didn’t all sit down at that time, table the ideology, and hammer out a consensus that would have worked and been affordable. Seems to me we may be saying the same thing about both health care and global warming in about seven years.
“The dirty little secret is that enough Democrats vote (and talk) like Republicans on this issue to make the Democratic advantage in Congress very precarious.”
“Because only one or two of them are interested in prying health care out of the grip of private insurance companies…”
What are these people’s names? You probably don’t realize it but you forgot to name them up above.
Matthew—
So, when Republicans oppose something you support, you call them obstructionists. Now, when Democrats opposed President Bush, did you call them obstructionists too? You didn’t, did you? That’s hardly consistent, now, is it?
David—
“You found us out! Those of us who are Democrats don’t think the founding of the United States is anything to celebrate. Only Republicans believe in America.”
Actually, I was referring to the Brits that read and post on this blog (just look at the recent thread on the corruption in the British parliament). I can certainly understand why the Brits might not celebrate the 4th of July (unless Andy Murray makes the Wimbledon finals). But your assumption that it would be the Democrats who don’t celebrate the 4th of July speaks volumes! In light of your revelation, I revise my valediction as follows:
Happy 4th of July to all Republicans and those Democrats who see it as a day of celebration (and those Brits who have forgiven us).
MAT,
Among the Democratic senators who do not support the president’s public-option plan: Max Baucus of Montana, Bob Nelson of Nebraska, Blanche Lincoln of Arkansas, and Mary Landrieu of Louisiana. Three of these are among the top ten recipients of campaign contributions from the health-insurance industry. The other seven on that list are Republicans. Surprise, surprise: all ten senators on the list oppose a public option.
As for Republican senators who might be persuaded to support the president’s plan…well, there’s Olympia Snowe.
Mark, maybe your point is too subtle for me. Are you saying that I use the term “obstructionist” to describe only those who get in the way of policies I favor? Who, I wonder, uses the term correctly in your view? If I thought there was anything honorable about the Republicans’ opposition to health-care reform, I might waste a few minutes looking for a gentler word.
“The Republicans’ opposition to health-care reform is based entirely on two things: purblind commitment to antistatist ideology, and purblind loyalty to their donors in the insurance industry.”
I’ll mention once again that I am a health insurance company executive.
The “public option” won’t work. Government insurance in the form or Medicare and Medicaid is subsidized by private insurance. It is one of the secret taxes that people with private coverage pay to support public programs. It is what makes government programs “cheaper”. Move a lot of privately insured people to a public plan and the current financing arrangement collapses. And even if we went to a single payer public option now, we would have to move all providers to a flat and standard Medicare fee schedule. I don’t think they would like it.
There are certain assumptions that I see coming from both sides here. On the Right, there is the religious belief that profit making is the only possible thing that can motivate quality. On the Left, there is the idea that the “profit motive” is in general sinister and it should not exist in some areas. I think, speaking as a businessman, that neither of these is correct.
But in general, I find the whole discussion of the health care situation completely incoherant from the point of view of what the actual structure of the system is and what the actual interests are of the participants. So for this reason, I am utterly optimistic that the public option will fail and some sort of half solution (expensive and ineffective) will perhaps be passed.
” So for this reason, I am utterly optimistic that the public option will fail and some sort of half solution (expensive and ineffective) will perhaps be passed.”
It is this prospect that makes me despair of rational policy-making and compromise in the Federal government, and makes me wonder if just muddling through with what we have wouldn’t be better than the proposed solutions.
Frank’s argument can be used to indict Democratic military policy. In catering to the important pacifist segment of their party Democrats hamstring military operations and confirm a self-fulfilling prophecy that only soft power or diplomacy can succeed and projects like the surge operation are doomed to failure. Harry Reid is a good example of this kind of statesmanship.
“Among the Democratic senators who do not support the president’s public-option plan…”
Since this post contains so many words and phrases not consistent with standard usage, are you saying “the president’s public-option plan” is synonymous with “prying health care out of the grip of private insurance companies” and “health-care reform”? I ask as that is the first time you used this particular phrase.
“If I thought there was anything honorable about the Republicans’ opposition to health-care reform, I might waste a few minutes looking for a gentler word.”
So the Constitution and Federalism are dishonorable? What a disgusting thing to say on Independence Day weekend sir. If you don’t like our foundational documents that’s one thing, but to call them dishonorable is really quite shameful.
Matthew—
“Mark, maybe your point is too subtle for me. Are you saying that I use the term “obstructionist” to describe only those who get in the way of policies I favor?”
YES, I’M SAYING THAT YOU USE THE TERM “OBSTRUCTIONIST” TO DESCRIBE ONLY THOSE WHO GET IN THE WAY OF POLICIES YOU FAVOR. And please don’t call me subtle. When you assume those who disagree with you have only the most nefarious of motives, you don’t invite debate, you discourage it. A wise man once told me that you can gauge the confidence a man has in his own argument by the fairness by which he states the opposing view. By that standard, assuming people who disagree with you are obstructionist indicates a lack of confidence on you part.
“Who, I wonder, uses the term correctly in your view?”
Well, let’s say, hypothetically, that you would delete this post because you don’t agree with it. Then you would fairly be called an obstructionist.
Cut the crap, Mark. You can’t lead a thread by insinuating that readers of dotCommonweal aren’t patriotic and then claim your motives have been unfairly impugned by Matt (trust me, not his style).
Mark, aren’t you the wise man who was recently explaining that those on the Right trust in God’s goodness, while those on the Left lack equanimity of soul? I’m not sure we ought to look to you for advice about being fair to those with opposing views.
MAT, while we’re at it, I have similar doubts about your criteria for “standard usage.”
Grant—
In that short post you’ve got two things wrong. First, I did not insinuate that Commonweal readers are not patriotic and two, I did not claim (and do not believe) that Matt (or anyone, for that matter) impugned my motives. Please read the thread again, carefully.
I did, and I have no reason to change my view of your comments.
“MAT, while we’re at it, I have similar doubts about your criteria for “standard usage.””
Could you be more specific? I am more than happy to clarify anything I may have said. As usually, I really have not said much for that matter – just made some queries. If however you are implying it is standard usage to, inter alia, refer to self-identified Democrats who are members in good standing with the Democratic caucus as “Republicans”, then yes, we live in such ontologically foreign worlds that we probably should not waste each others time in unproductive communications. I actually suspect that is the case for myself and Mr. Boudway – it is probably the case that our ontologies are so disparate as to render communication between us futile.
Mollie—
Yes, I am that wise man! I’m kinda flattered you remembered it, but hurt that you’d use my words against me (though, as I recall, my generalizations of liberals and conservatives was fairer than you describe).
MAT,
There you go again with your ontology stuff. You should stay away from it; it’s no good for you. This is not the first time you’ve announced that our differences are so profound that there’s no point in dialogue. And yet you keep coming back to me. Please, feel free to overlook my posts. The pleasure would be all mine.
But while you’re here, we may as well get a few things straight. I never referred to Democrats, self-identified or otherwise, as Republicans; that’s another one of your improbable misunderstandings. I know “public option” isn’t common usage among conservatives like yourself, but I assure you, it’s perfectly standard. Do I think it’s the only way to pry health care out of the grip of the insurance industry? No, as a matter of fact, I don’t. But it is the only proposal now being considered that might begin to do that. A single-payer system would do it much better of course, but no one in Washington is talking about that: too many powerful interests would stand to lose if we opted for the most rational policy. Your certainty about what men who lived two hundred years ago would have to say about twenty-first-century health-care policy is breathtaking. It’s been a while, but I don’t remember reading about health insurance in the Federalist Papers. But you seem to speak their language, sir, so maybe you can refer me to a Federalist working paper on HMOs.
Mark,
I’m just about willing to believe you didn’t mean to call people on the left unpatriotic, but your insistence that my low opinion of Republican health-care policy is proof of intellectual insecurity is just another dodge. I’d call you an obfuscationist, but we all know where that would lead.
Unagidon, in the midst of this hijacked thread (I recite the Pledge every day after the Rosary) your comment about health care intrigued me greatly. Would it be possible–if you are still reading this thread–to sketch out what you, as someone on this inside, with some expertise, see as a viable health care system–that is, a better one than we have now? Perhaps too much to write. I’ll confess to being a single-payer advocate, but a recent New Yorker piece (maybe Atul Gawande or similar?) made a good argument for building on the system we have, much as the Brits and canadians did. He basically said there’s no way we can simply shut down the system and reboot as a single-payer system. Be analogous to shutting down the entire phone system. Your thoughts?
Matthew–
Let’s get it right. It’s not that you have a low opinion of Republican’s free market approach to healthcare. It’s that you call them obstructionist, simply because they want to get their plan through rather than the Democrat’s.
“There you go again with your ontology stuff. You should stay away from it; it’s no good for you. ”
Why?
“This is not the first time you’ve announced that our differences are so profound that there’s no point in dialogue. And yet you keep coming back to me. Please, feel free to overlook my posts. The pleasure would be all mine.”
That is correct. As I stated in both public and private communication I have honored my pledge not to use the phrase “post-modern” or any of its variants nor to refer to the President in any form, either directly or indirectly. Are you implying I have violated those pledges? If so, please tell me when? Regarding the later part of the excerpt above, I will do as you request. I did not realize my comments were so unpleasant to you sir.
“I never referred to Democrats, self-identified or otherwise, as Republicans; that’s another one of your improbable misunderstandings.”
The original phrase you used was “…Republicans’ obstruction of health-care reform…”. Unless you can produce evidence to the contrary, the published rules of the House and Senate I linked to above are operative. By definition, “Republicans” cannot obstruct any legislation whatsoever given the number of votes in their caucuses in both houses of the Legislature within the framework of those rules. Your statement is incorrect on its face. Therefore, you are either using a definition of Republican which includes members outside of the Republican caucus or you are using a definition of obstruction which does not mean stopping a bill from becoming law but has some other meaning. Which is it?
“I know “public option” isn’t common usage among conservatives like yourself, but I assure you, it’s perfectly standard. ”
That is not what you said originally. You originally said “…Republicans’ obstruction of health-care reform…”. You are now defining “health-care reform” so narrowly as to include only two options – a “public option” and a “single-payer system”. In my book, that is not “health-care reform”, nor is it for most Americans. Maybe it is a conservative thing, but “health-care reform” as I am familiar with the term refers to policies which would decrease the number of people without health insurance as well as lower the cost of medical insurance for those who do have it. You however are using a definition of “health-care reform” which only includes two types of policies to the exclusion of all others. I do not think that is standard usage. Do you really think the average person considers only those two things as constituting “health-care reform”? I don’t.
“Your certainty about what men who lived two hundred years ago would have to say about twenty-first-century health-care policy is breathtaking.”
It actually shouldn’t be breathtaking at all. They authored the Constitution and the Bill of Rights. It actually would be quite good experience if you read them actually. They are quite short texts in the grand scheme of things.
“It’s been a while, but I don’t remember reading about health insurance in the Federalist Papers. But you seem to speak their language, sir, so maybe you can refer me to a Federalist working paper on HMOs.”
That’s a shame. Independence Day is an excellent day to flip through them actually although I think your time would be better spent with the Constitution first. I will be at Arlington tomorrow and planned to read some Aurelius among the Glorious there, but you have inspired me to bring the Federalists as well. Anyway, you memory is incorrect – start with Federalist 10. That’s a good place to start regarding the violence of majority faction.
This is a complicated discussion and we might want to separate a few things.
Some of the strongest Democratic supporters of the most radical health care legislation strongly support it because they know that it will fail. We see the same thing with strong Republican opposers of Federal economic legislation in our troubled economic times. It’s the old story of having one’s cake and eating it too. For politicians, it is often just as important to tell the folks back home that “I really tried” as it is to say “I really succeeded”. This is part of the nature of our political system.
One of the things that fuels this system is the way Americans relate “ethical” values to our legislation. I am not saying that we should not vote or legislate on the basis of ethics. But in America, so often this means “I want to get something done and it HAS to be done in a certain way”. It is this mindset that creates our classic legislative failures. It creates a system where the greatest obstructers can look like the greatest supporters of something. In big business, when we run into these kind of people when making business decisions, we have to eliminate them whenever possible or we would never get anything done.
The health care problem is far more complicated than people think. The simplifications of it presented to the public mostly come from interest groups trying to hold their position in the system constant while changing the rules for the other players. EVERY interest group is doing this right now which is why it is so hard to get a real picture of the system as a whole or to determine what is really going on, both with the political and the business side of the matter.
All of this smoke hides perhaps the single most important fact about the whole health care debate. We don’t really know what we want. Health care as a business problem is complex, but however complex any business problem is, it is always only about goals versus resources. To really direct resources properly and come up with a workable and testable plan, we need the goal to be as concrete as possible. What we have now is a goal that looks concrete, but is really very vague. It looks concrete to say that “we want health care for everyone”. But hiding behind this is something that looks more like “we want health care for everyone that is comprehensive but inexpensive; where people can opt out unless they think they are going to get sick; where people can go to any doctor or hospital and get any treatment they want without anyone reviewing whether it is effective or relevant; where the risk system (the claims payer) is federalized, but tied to a for-profit medical system; where people willing to pay more should get more but everyone should get the same level of care and quality of experience.”
We won’t get all of this, because many of these goals contract each other. To mediate these contradictions we need some real political discussions which will involve real trade offs. But we are not prepared to have these discussions. Instead, different interests are demonized, as though the problem is really just the insurance companies, or just the providers, or just the “free market” or just the Republicans, or the Democrats, or government bureaucracies. We can then indulge in the very satisfying American sport of righteous moral indignation where we can spin our wheels for years without getting very much done.
For myself, despite the fact that I am an insurance company executive, I think that single payer would be the way to go in the best of all worlds. But unlike people that are not in the business, I can see what it would take to get there and I’ll tell you that none of the current proposals even begin to scratch the surface. We could get get, we really could, and it would be the right thing to do. But (speaking as a Catholic now) the problems in our health care system are intrinsic to our political and economic system, not to our health care system. It is ironic that we would be talking about the broken health care system in the context of a collapsed financial system and not be talking about whether there is a relationship between the two dysfunctional systems. This is the heart of the problem.
Some people at the office are very worried about the “public option”. I’m not. It’s not going to happen. And since it is not going to happen, I think that in our current impoverished political environment we should take care of a smaller piece of the problem first, which is the coverage of the uninsured. Instead of Medicare for all, we might think about Medicaid for all, simply as a first step.
Unagidon–
I’m curious, why would an insurance company executive want, in the best of all possible worlds, a single payer system? I would think you’d want a free market system with many buyers and sellers negotiating a fair price.
I think a change to the free market system would work best. As is stands now, the users of health care do not pay directly for it, so market efficiencies are not possible. I had to make a doctor’s appointment just yesterday and asked the cost for the service when making the appointment. Response: “I dunno”. Can you give me a range of possible costs? “I dunno”. How crazy is a system where you purchase something today, and find out the cost a month later?
Matthew
The Hurricane Katrina example is very apt. This post and the cited NYT piece both reveal a fundamental problem with progressives. The idea that if you just get the right people, smart people like you, in charge, everything about government will change. I work for the government, and have under both Republican and Democrat administrations, and “the government” doesn’t suddenly – or even gradually – become more efficient or capable just because a liberal is in charge. The idea that the problems of Katrina are based on ideology is nonsense.
The P.J. O’Rourke quote is one of my favorites because it is true. Unfortunately, for conservatives and libertarians we are usually stuck choosing between Republicans who will overspend and over govern and Democrats who will outrageously overspend and over govern. Power seems to do that to people -which is among the many neutral principles traditional conservatives understand. Progressives don’t think in terms of neutral principles. they will never, for example, consider the idea that public schools fail so miserably, in part, because they are public. For them, the problem with any public institution is, if a conservative is in charge that a conservative is in charge, and if a liberal is – not enough money is being spent.
As for the health care obstruction, I would like to see a vote on a single payer system. It is a legitimate alternative. But if we have that debate, it will be nice if the supporters of that system will honestly admit the downside of a government run system. Like I said, I work for the government, and I can tell you even when it does things halfway well, it is slower than the market, it does not promote rapid innovation, it does not reward producers as well or as quickly, it tends to use arbitrary mechanisms to control use of resources (you can see that in the health care programs it already runs). On the upside, everyone will get a basic standard of care, it will be cheaper, but not because it is more efficient or productive but because it is the only game in town. Right now, the President is telling us we can have our cake and eat it too, and that’s just not so.
Dear Mark,
Believe me that I am not speaking for my company when I say that single payer would be best. The business logic is simple. Insurance of any kind is simply about spreading risk. The best way to spread risk is to spread it across the widest possible pool. The widest possible pool in the US is the population of the US. So the most efficient risk pool from an actuarial point of view is the entire population.
If you think that private insurance is therefore about the manipulation of risk pools, you would be right, but only partially. The Michael Moore idea that insurance companies have people who sit around looking for ways to arbitrarily deny claims is simply wrong. For one thing, it is illegal. Insurance is HEAVILY regulated by the States. States love to ding insurance companies for code violations because it is an excellent source of non-tax revenue. (Insider tip: think your insurance company is ripping you off? Contact your local State Department of Insurance.) Insurance companies definitely do not want a risk pool that contains what we call “adverse selection”, which is a risk pool with a disproportionate number of sick people relative to the population at large. And by this logic, one might think that insurance companies would also try to manipulate the risk pool in order to get a disproportionate number of healthy people (relative to the competition). The thing is, in most states, insurance regulations are set up to create pricing bands for insurance premiums. Insurance companies are not free to charge whatever they want. There is a regulatory relationship with how little they can charge and how much they charge. To manipulate a risk pool, the insurance company would need to be able to charge sick people a lot of money and healthy people a little bit. But the rate banding is set up so that the insurance company either has to charge everyone a lot or everyone not so much. It’s simple and rather effective. And despite what the naysayers say, there is competition in the insurance markets. Many markets may be dominated by one or two main players. But believe me, the competition is cut throat, in part because prices for premiums are transparent.
You talk about the “free market” in health care itself. Right now, one of the services that the insurance company provides (and yes, insurance companies do add value) is that the insurance company knows both prices and quality. They know what the doctors and hospitals charge and they know who is and is not effective. The general consumer can’t get price or quality information easily, so of course, there is effectively no consumer market for medical services. Yes, some people will disagree saying that they can now go to a Walmart clinic for just a couple of bucks, provng the power of capitalism. But no one is going to go to Walmart for their brain tumor. The big, scary, serious and important stuff is opaque in the US as to price and quality.
The doctors and hospitals will argue that medicine is so complicated that it cannot be commoditized. They will also argue that medicine is both a science and an art and that the market rules that allow us to compare one car to another won’t work in the case of comparing one doctor to another. They have a point insofar as most people know what they want in a car in some detail, but most people don’t know what they want in a heart bypass. One of the functions that an insurance company (or the government, or SOMEBODY) will have to perform is know about price and quality for medical services. The medical profession does not want price or quality to be transparent precisely for the reason you mention. It is very helpful to them for you to be motivated for the service without knowing the price in advance. (This is one of the reasons that physicians would like private insurers out of the game. They are the main source of cost control in the US today.)
I could write a lot more about this. The financing of health care in the US alone is complex and poorly understood by the general public. But one reason I can say that I support single payer and still work for an insurance company is that I believe that private insurance companies could get out of the risk business altogether and still perform many of the functions that they do today for price control. Someone will have to do this. The government does not do this now. Part of the difference between the government’s operational costs and private insurance operational costs comes from the fact that private insurance has a broader and more effective cost control system than the government does. Just as private insurance premiums subsidize government health care, private insurance price control schemes cover the massive gap that exists in government price control schemes.
Sean,
Let’s agree that the effects of Hurricane Katrina on New Orleans would have been terrible no matter who had been president and no matter who had been in charge of FEMA. And let’s also agree that large federal agencies are always more or less unwieldy. This is true of large organizations in general, by the way: it is a sociological fact before it is a political fact. Large organizations, public and private, benefit from economies of scale, but they usually suffer from redundancy and problems of accountability. Management consultants makes millions of dollars off this fact. No doubt a lot of the anger directed against the Bush administration in the wake of Katrina was misdirected — politically opportunistic or just irrational. But behind Thomas Franks’s vituperation is an important point, which is that the failures of FEMA after Katrina prove not that FEMA and all other examples of “big government” are essentially worthless, but that FEMA was run badly by people who weren’t equipped to run it well.
We have been told for too long that public agencies are necessarily ineffective because they lack the profit motive, that nothing important ever gets done without the incentives of the free market. This is an article of faith rather than an empirical finding, and it is a strangely qualified article of faith. Few Republicans would recommend that we get rid of the military, that largest of government agencies, and replace it entirely with private contractors. And whatever their skepticism about our public schools (much of it justified), few Republicans would recommend abolishing public education. I know there are people who would recommend these things; they are called libertarians. But whatever they say in their campaigns, most Republicans implicitly acknowledge that the free market is not the right tool for every job.
So, is it the right tool for health care? One way to answer this question is to compare the outcomes of our mostly private system with the outcomes of mostly public systems in other developed countries. To listen to the debate in Washington, you might think that ours was the only health-care system in the world, and that the only alternatives to it were purely speculative. Among the more frustrating features of this debate is the assumption that we could have nothing to learn from other countries, as if dogged attachment to the status quo were an evidence of patriotism. Most (not all) public-health experts, who have compared the costs and outcomes of various health-care systems, agree that some version of a single-payer system would be the most rational model for the United States. I have lived in Great Britain and in France, and I have been sick in both places. The quality of the treatment I received there was in no way worse than the treatment I have received in the U.S. No one in those countries has to worry about going bankrupt because of medical expenses; no one is denied treatment because he is unemployed. Are there trade-offs? Of course. State-sponsored health-care is expensive, and to pay for it the government would have to raise taxes. But such a system is not only more effective than what we have now, it is less expensive overall.
Efficiency, expense – these are the terms of the current debate in Washington, and proponents of reform could conceivably win the debate using only these terms. But there is also justice, which should be the criterion in any conversation about trade-offs. In a single-payer system, the costs of illness are shared by everyone in the community. Instead of an actuarial logic, you have a logic of solidarity. The young pay for the younger and the old. The healthy pay for the sick. Everyone shares the burden so that no one is left out, and we think of ourselves as fellow citizens before we think of ourselves as taxpayers.
“The idea that the problems of Katrina are based on ideology is nonsense.”
Mr. Hannaway –
George Bush, cheerfully nominated by Republicans, did not provide the means to maintain New Orleans levees as they very obviously should have been maintained == some levees could be *seen* leaking at their bases for several years at least. Even after the hurricane hit Bush stayed at his ranch for a day or two cutting down bushes. Then he passed by the city in a plane. muttering how awful, and then apparently took no active interest in what was going on. He simply let his incompetent crony (formerly a raiser of horses?) continue in his incompetent way.
I do think that the problem with many Republicans is a lack of empathy with people whose lives are vulnerable in basic ways. Those Republicans don’t even see the moral need for empathy, they don’t realize that not everyone is smart and educated and has a family with means that can help in times of trouble. No, not all Republicans are like that. Many are generous privately and have great concern for the less well favored. But too many of them use the writings of the founding fathers to justify their indifference, claiming that we’re free to climb the ladder of success, and if someone doesn’t, then it’s heis or her fault. They appeal to “natural law” but seem to have no understanding whatsoever of human nature.
What irritates the hell out of us liberals is that Republicans don’t hesitate to accuse Democrats of wasting federal money (that’s what, they say, we can’t afford health care for all), but in fact, in verifiable fact, the worst spendthrifts in my long life have been Reagan and the Bushes — the ones who accuse the Democrats of profligacy. Mauvais foi!!!
“No one in those countries has to worry about going bankrupt because of medical expenses;”
Matthew –
It seems to me that the threat of such bankruptcy here must stifle the initiative of many a potential small businessman, whether he’s thinking of starting a new business or expanding one. In other words, lack of an adequate health care system is bad for business.
Mr Boudway wants us to substitute a logic of solidarity for an actuarial logic.
Before doing so it would be interesting to learn if the logic of solidarity requires, say, younger health-obsessed new agers to subsidize in any way multiple operations for chain-smoking, obese risk-takers.
Or are moral hazard considerations matters of merely actuarial fairness that are entertained only by the heartless?
“Or are moral hazard considerations matters of merely actuarial fairness that are entertained only by the heartless?”
And they say that compassionate conservatism is dead.
Matthew said: “So, is it the right tool for health care? One way to answer this question is to compare the outcomes of our mostly private system with the outcomes of mostly public systems in other developed countries. To listen to the debate in Washington, you might think that ours was the only health-care system in the world, and that the only alternatives to it were purely speculative. Among the more frustrating features of this debate is the assumption that we could have nothing to learn from other countries, as if dogged attachment to the status quo were an evidence of patriotism. Most (not all) public-health experts, who have compared the costs and outcomes of various health-care systems, agree that some version of a single-payer system would be the most rational model for the United States.”
It’s not the claim risk as such that would be the problem for government. It’s the cost control. While single payer would create the most efficient risk pool, if there isn’t some sort of efficient cost control mechanism attached to it, the system will fail.
What we have now are private for profit risk pools attached to private for profit medicine. (I know that people will point out that some insurance companies and some hospitals are “non-profit”. “Non-profit” in health care America means “exempt from some taxes”. Not for profit payers and providers are very much run as profit making concerns, by the very same kind of people that manage their profit making counterparts. And in fact, people frequently move back and forth.)
American insurance companies, whether for profit or not, are in the business of controlling medical costs. In the US, this is where this function is located. If health insurance companies were eliminated by some sort of single payer system, this function would have to be taken over by some other entity. I have heard people claim that the government could use its monopoly to enhance its “bargaining power” with the providers to do this. Nice fantasy, but the government has massive bargaining power now. But they don’t bargain. They dictate a Medicare reimbursement schedule on a take it of leave it basis.
If the government could truly set up a single payer system and then force all providers in the US onto a Medicare fee schedule, then and only then could we duplicate the single payer systems we see in other countries. But I don’t think the medical profession would tolerate this. Right now Medicare (and Medicaid) is subsidized by private insurance. Hospitals especially compete by playing around with private payer fee schedules, not by engaging in good old capitalist cost cutting. Both the Federal and State governments know this, which is why they both under pay physicians and hospitals (relative to costs; which admittedly are too high).
My take is that conservatives only appreciate government law enforcement and military functions of government. All other functions are deemed ineffecient and/or unnecessary.
Liberals are suspicious of military and law enforcement funtions and have faith in most other support functions of government. Both groups think FEMA is worst of all functions. Both are right on this. My hope is that single payer avoids all the downside of the VA and military medicine.
Matthew
I never said that government does everything worse than the market, I only pointed out its inefficiencies. Of course there are things that only the state can do. Even in those things there are inefficiencies and waste, You cite the military – something I know an awful lot about. The military, even with its problems, is the most successful part of the government in terms of accomplishing what it is supposed to do. However, it is also a top down command organization. It has a professional ethic that includes principles of self-sacrifice, obedience, and loyalty that don’t translate very well into other functions. I point out that for a single-payer system to be successful, it will have to incorporate some of those principles. Do you think Americans will want to sacrifice Grandma’s kidney dialisys for the good of the many – to make those resources available for younger, healthier people with more life expectancy?
As for comparing outcomes, there are two problems with this. The first is you are not just comparing medical systems, you are comparing societies. For example, Americans drive more miles than anyone else, we have inner city drug abuse problems, obesity, and myriad other issues. Second, the numbers don’t tell the whole story. The WHO rankings of health care systems a few years ago had Italy ranked, I think, something like 5th and the US down in the high teens based on “outcome” numbers. I lived in Italy for 3 years and used their health care system. Is it adequate? Yes. Can you get basic care fairly easily? Yes. But here are just a few things I experienced or my troops experienced that I don’t think Americans would find “better.”
Son of a Sgt hit by a car -leg badly shattered. I visited him in the hospital, a modern hospital in a fairly affluent medium sized city. He had no air conditioning for his two week stay in August – wasn’t broken, just wasn’t there. No screens on the windows either so his parents were constantly shooing flies of his bandages. There were no TV’s or radios either – but that’s minor. The food was good though.
A Lt who worked for me tore his ACL playing basketball. Emergency doctor stabilized his leg – in a plaster cast up to his thigh – and scheduled him for surgery, in 5 weeks. The military doctors said this was OK medically – he would heal – but not much use to himself or anyone else with 15 lbs of plaster on his leg.
My own experience tended to include long waits for appointments, difficulty filling perscriptions – they were cheap, but try and get an anti-biotic for a screaming toddler with an ear infection after 6pm.
Also, I was a military brat and then a military member for over 40 years. I was used to not getting gold plated medical care, and I am telling you that for responsiveness, attention to patient comfort, and lifestyle needs, the American system is much much better.
In other words, what we get is more expensive, but some of that expense actually buys things people want.