Getting Back to the Actual Issue

If two well-informed and passionate parties argue long and hard enough about something really important – which is a fine way to work things out – they inevitably end up in a bit of a muddle. They stop and stare at each other. What were we arguing about again? Over time, too much time, there were too many analogies and accusations, and too many subsets of important points, and subsets of those. Those who argue passionately discover they’ve been arguing secondary issues, then tertiary issues, then whatever word there is for issues even less germane, and we went through this after those jerks flew those airliners into the World Trade Center and the Pentagon. We took care of things in Afghanistan, which had hosted the guys who did the deed, and then we were off to Iraq, to continue something, but that something wasn’t clear. It nominally had something to do with Saddam Hussein supporting the bad guys, somehow, and about getting rid of his weapons of mass destruction, and him – as a response to what had happened on that sunny September morning. That, we were told, was important, kind of the main point, but not really. That was a subset of the main point, but then al-Qaeda had always despised Saddam Hussein – he was too secular – and it turned out that there were no weapons of mass destruction at all. After that, perhaps by default, we were arguing about establishing a western-style liberal democracy in the middle of the Middle East, which would be secular or at least religiously inclusive, and that would fix everything in that sorry part of the world. Was that the point in the first place? No one had said so, but those who gave us that war said they had said so – you just hadn’t been listening closely enough – but they hadn’t said so. The main point had been lost long ago, and the accusations followed. Are you saying that things would have been better if Saddam Hussein had been left in place? Neville Chamberlin was mentioned a lot. Stalin came up now and then, and the French were somehow always the bad guys. By that time no one knew what the hell we were arguing about, and we left Iraq, now run by a Shiite jerk, not a Sunni jerk, and slowly but surely aligning itself with Iran and Syria, the current bad guys, and also continuing its long internal religious civil war. All this had started out as an argument about the appropriate response to what happened on that September morning in 2001, and we lost the thread of that argument, and we’re still in Afghanistan. Try to explain what we’re still doing there, in terms of what happened in 2001, and you’ll find yourself wandering down some odd pathways – secondary roads, so to speak. What were we arguing about again?

The same thing is happening with Obamacare. The Obamacare website still sucks, but it won’t always suck, and some of the state websites are working just fine, so those whose plans have been discontinued will be able to find good plans, maybe cheaper plans, maybe not, but they’ll be real insurance plans. Republicans are still screaming, but adding nothing new – and there’s something odd about their outrage. They want that website to work, damn it, so people who could never get insurance before can now get insurance, when their position has always been that anyone getting health insurance, or not, is none of the government’s business in the slightest. Of course the man they ran for president last time around, Mitt Romney, had set up almost exactly the same sort of thing when he was governor in Massachusetts, and he said he was mighty proud of that – but not too loudly in certain Republican circles. Somehow, now, Obama’s Affordable Care Act, not his Massachusetts plan, was socialized medicine, with Death Panels and all, just like in Massachusetts, except Massachusetts wasn’t like that all, for reasons no one cared to explain. It was enough to make your head spin, but they wanted a free-market solution to the most inefficient healthcare system in the developed world, which wasted so much money for such meager results and left so many people high and dry.

The only problem is that Obama gave them just that – a way for thirty or forty million more Americans to have the opportunity to purchase low-cost subsidized health insurance, from private for-profit third-party underwriters, which is hardly the end of the world as we know it. There’s no public option, some Medicare-for-all scheme. It’s not a single-payer scheme either, and it’s hardly socialized medicine. The big boys will make big bucks and live even larger – so all that was once good and right about America will be safe, if funneling everything to the private sector, where private profit somehow equals public good, is what’s good and right about America. Insurers will be free to compete for customers, as long as they’re not offering crappy policies – there will be standards. Obamacare is a free-market solution to the problem, but that market will be regulated, and there’s no logical or historical reason that should be a problem. Lots of markets are regulated – cars must have seatbelts and you can’t sell breakthrough wonder-drugs that haven’t been tested and approved as safe and so on. We have the SEC so that what happened in 1929 never happens again. What are we arguing about again?

Forget the website and Massachusetts and all the rest. This has always been about what is none of the government’s business in the slightest, so this has always been an argument about creeping socialism – not the government actually taking over all means of production, but the slippery slope that leads there. Americans hate socialism, except a few years ago there was that Rasmussen poll – only fifty-three percent of Americans believe capitalism is better than socialism. With those under thirty there was a three-way tie. Thirty-seven percent prefer capitalism, thirty-three percent socialism and thirty percent are undecided, so it’s no wonder the Republicans were having a hard time gaining traction with their opposition to healthcare reform at the time – all that scary talk about socialized medicine and rationing and Death Panels. Nothing much was sticking, even if the Democrats would cower and insist that they weren’t socialists, really they weren’t. They didn’t need to bother. No one seemed to care. The Affordable Care Act passed one year after that poll.

Something has changed, and if there is change in the air, people seem to be angry at, or laughing at, the Invisible Hand – Adam Smith’s concept that everyone selfishly competing for the most profit, for their own personal good, will efficiently produce the greatest good of the greatest number, as the selfish and greedy won’t make money if they offer a shoddy product at an absurdly high price. That’s a win-win, but the for-profit insurance industry seems to have made a joke of that. It was time to rein them in. Sure, let them make money, but not by any means possible. The solution is a tightly-regulated free market, which is an absurd self-contradictory concept to everyone on the right, but is as common as the sunrise every day in the real world.

That may be what we’re arguing about, and the argument may be over. Ron Brownstein reports here that a new and quite thorough United Technologies National Journal Congressional Connection Poll shows that, in spite of Obamacare website disaster and the rage over the relatively few who had their junk-insurance policies cancelled, there’s been next to no change in basic attitudes towards Obamacare since their last survey in July:

Amid all the tumult over the law’s troubled implementation, the survey found that public opinion about it largely follows familiar political tracks and has changed remarkably little since the summer on the critical question of what Congress should do next. On that measure, support for repeal has not significantly increased among any major group except Republicans and working-class whites since the Congressional Connection Poll last tested opinion on the question in July.

Those two groups, the professionally angry and the perpetually angry, are angrier now, as would be expected, but no one else has changed their mind, and the Washington Monthly’s Ed Kilgore adds this:

At present, asked if Congress should repeal Obamacare, leave it alone for now, or provide more funds to help its implementation, repeal is opposed by a 59-38 margin, with, as Brownstein noted, repeal sentiment being mainly confined to Republican and Republican-leaning parts of the electorate. That means two things: Republicans will continue to be encouraged by their “base” to screw up the Affordable Care Act, and Democrats will have little real political incentive to cave.

It also means, of course, that if “repeal Obamacare” sentiment hasn’t much risen despite all the hysteria of the last few weeks, there’s no particular reason to think it will go higher before the law has a fighting chance to work. And as everyone should understand by now, come January 1 the ranks of those with a very tangible stake in the law’s survival is going to go up sharply, even as Republicans try to figure out how to square their desire to kill it with their recent “keep your insurance” rhetoric.

Adam’s Smith’s mysterious Invisible Hand is a nifty idea, but it wasn’t working. In fact, The Commonwealth Fund did their own thorough survey of our medical system and they show us how it has been working:

In 2013, more than one-third (37%) of U.S. adults went without recommended care, did not see a doctor when they were sick, or failed to fill prescriptions because of costs, compared with as few as 4 percent to 6 percent in the United Kingdom and Sweden.

Roughly 40 percent of both insured and uninsured U.S. respondents spent $1,000 or more out-of-pocket during the year on medical care, not counting premiums. High deductibles and cost-sharing, along with no limits on out-of-pocket costs, may explain why even insured people in the U.S. struggled to afford needed health care, the researchers said.

Andrew Sullivan flags that and adds this:

When a private sector system means you have ten times as many people failing to get basic treatment as in Britain’s uber-socialized NHS, you realize just how great the market failure is. I’m all for markets, but the facts seem to me to reveal that in healthcare, they are toxic to most people’s actual, you know, health. In what other area does socialism work so much better than capitalism? Isn’t that a first-order question conservatives should address?

Maybe that’s what we should be talking about, or that may be what we’ve always been talking about, when we weren’t distracted by odd analogies and fanciful accusations, and talk of HTML code mistakes at a website and Death Panels. A respectable conservative should tackle the question of why free-market principles would work best here, head on, and in the National Review, founded by William F. Buckley way back when, Yuval Levin actually does that. The item is long, and thoughtful, but the main points are clear enough:

We have the related problems we do – the problem of the uninsured and the problem of unsustainable government and private health costs – because we don’t know something: We don’t know how to run a health-financing system that’s efficient enough to provide the quality coverage and care we want while keeping costs relatively low and stable. So we need to figure out how to do that.

That creates a tension:

The health-care debate basically divides along the lines of two ways of thinking about how we figure out such things – how we address our ignorance and pursue efficiency. Do we empower expert knowledge at the center of the system to impose efficiency based on principles well known to the administrators or do we empower the dispersed social knowledge of market actors to try out different approaches and find what works – allowing sellers to try different forms of the insurance product, allowing consumers to choose among them, and arriving that way at something like an effective balance between quality and price on the whole?

The dispersed social knowledge of market actors to try out different approaches and find what works is the Invisible Hand of course, disguised in more words, but the implications are the same:

Conservative healthcare proposals generally take that second view. They would use taxpayer money to empower all Americans to be consumers in a competitive market where insurers can offer them genuinely different options and they have the resources to turn their preferences into market power and so to drive health and coverage providers to give them more appealing options at more appealing prices. Conservatives want to use the market to answer the question and address the problem at the core of our health-financing dilemma.

Liberal health-care proposals take the first view – they want to centralize design and purchasing decisions in the hands of the government where experts can make those decisions. They would use taxpayer money not to create consumers who would choose among real options designed by insurers and providers but to enact the will of the experts. That approach assumes we actually do have the knowledge of how to solve this problem and we just haven’t applied it, while conservatives tend to think that our lack of that knowledge is the whole point of the exercise.

In short, experts really know nothing, they can’t know much of anything, and the market magically knows everything. Fifty million Frenchmen can’t be wrong, or something like that, and Obamacare is just a mess:

If you ignore the difference between means and ends, you could say it looks like some conservative proposals – and to this day you still hear some otherwise sensible people insisting it’s basically just a Heritage Foundation proposal from the 1990s because it has exchanges and an individual mandate. That proposal was certainly misguided in some important respects (the mandate above all, as its critics on the right pointed out back then), but it was a very far cry from Obamacare. The key to Obamacare is something it doesn’t have in common with conservative approaches to health care: It seeks to impose a very specific model of insurance and compel people to buy into it. It has the government strictly define the insurance product, requires insurers to sell it, requires consumers to buy it, and calls that a market.

That’s not a market at all, or at least not the free market that makes everything as good as good can be:

The result is not just a gross constriction of the economic liberty of all involved, though that is no small problem. And the result is not just high prices, either, though those clearly contribute to the difficulties Obamacare is already confronting. The key consequence of this kind of approach is an inability to find that balance between quality and price that could allow for the greater access and security we want: It is a failure to achieve a more efficient system, which is more or less the whole point of reforming American healthcare financing.

Applying expert knowledge from the center is just not a recipe for efficiency in a system as enormous and complex as America’s health-care system.

Cue the Invisible Hand:

The appeal of a competitive insurance market in which sellers have a constant, huge incentive to give buyers what they want is that such a system is constantly searching for a better answer to our problem, and so is able to evolve as health care and health financing evolve. It doesn’t get stuck with today’s answer forever, let alone with a wrong answer. …

Obamacare simply doesn’t work that way. It is a vast mechanism for imposing a particular liberal idea of insurance – an idea that seems highly unlikely to be sufficient to the problems we confront, and that could very well make these problems significantly worse. The inclination to consolidation and prescription at the heart of that vision is what the right most fundamentally opposes about Obamacare, and what many critics of the law think is its greatest and deepest flaw.

That’s the argument, but if you scroll down to the comments section, you’ll also find this:

The root of “conservative” thinking on healthcare, at least as it is articulated in this space, appears not to have anything to do with centralization versus decentralization of decision making, but with dedication to the proposition that the healthcare market is just like all other markets; that a decision about healthcare follows the same logic and has the same degrees of freedom as do decisions such as whether to buy a new TV, or broccoli. Unless that catastrophically mistaken idea is abandoned, I don’t see how the local variety of “conservative” thinking can address reality and thereby improve.

The reason that the breadth of options that insurers can offer must be constrained is that if it is not constrained, then that variable, and not efficiency, is the lever that will preferentially be used as the profit generating mechanism. What that means in the real world is that the poor will be poorly insured and the rich richly insured, with the same problems of free ridership and poor long term outcomes due to avoidance of preventive care that we have now … In other words, healthcare really is a different beast in that it cannot be effectively treated as though it were a completely free market at the policy level because it can never, in fact, behave like one. That is not an ideological framing but a hard, cold fact. Healthcare is not a market like other markets and it is not even remotely anti free-market to point that out.

That’s the counterargument to the real issue here. Completely free markets are nifty – they really do produce the greatest good for the greatest number – but not at all times in every instance. Sometimes it’s necessary to constrain them, in terms of the products offered, as with cars and pharmaceuticals – because cheap products that people seem to want can kill them, and kill others – and as with securities – because those mortgaged-backed securities and the credit default swaps insuring them ruined the economy for a generation or more. Healthcare is like that. People die. Sure, worship that mysterious Invisible Hand that can work wonders, but it’s not a god that requires human sacrifice – it’s just an economic concept.

Andrew Sullivan puts it this way:

If you want a free market in healthcare, you have to let people die on the streets or in agony at home rather than seeking mandatory help in an emergency room, if they have not been able to buy insurance. Anything else is socialized medicine, which we’ve had in America since 1986. The question is simply whether we want to have the most fucked-up, inefficient and inhumane socialized system on the planet or whether we have the political courage to tackle this. Decry Obama all you like, but he has tackled this.

Some appreciate that, and some still worship that mysterious Invisible Hand. And everyone else doesn’t even know what we’re arguing about any longer. Argue about anything long enough and that happens.

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About Alan

The editor is a former systems manager for a large California-based HMO, and a former senior systems manager for Northrop, Hughes-Raytheon, Computer Sciences Corporation, Perot Systems and other such organizations. One position was managing the financial and payroll systems for a large hospital chain. And somewhere in there was a two-year stint in Canada running the systems shop at a General Motors locomotive factory - in London, Ontario. That explains Canadian matters scattered through these pages. Otherwise, think large-scale HR, payroll, financial and manufacturing systems. A résumé is available if you wish. The editor has a graduate degree in Eighteenth-Century British Literature from Duke University where he was a National Woodrow Wilson Fellow, and taught English and music in upstate New York in the seventies, and then in the early eighties moved to California and left teaching. The editor currently resides in Hollywood California, a block north of the Sunset Strip.
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2 Responses to Getting Back to the Actual Issue

  1. Rick says:

    You’re right about wondering, after a while, what we’re all arguing about.

    I, for one, have no idea what that Yuval Levin guy is saying about the competing conservative vs liberal viewpoints. To me, what it seems to come down to is this: We can reform the so-called “free market” healthcare system, or we can just stick with what we already have — which is a so-called “free market” healthcare system.

    Liberals want the former, conservatives want the latter. Badda-boom. That’s about it.

    Sure, there’s another possible way to reform health care, which we all realize: Medicare for all. But one major problem with that is that it could never be passed into law, or at least Obama thought so. But one other problem, one nobody talks about, is what that would do to American unemployment numbers after we, by necessity, laid off every single person in the country working for a health insurance company.

    But as you say, once we find ourselves wondering whether or not Obamacare was really invented by the Heritage Foundation, we have to ask ourselves what the hell we were talking about in the first place.

    Rick

  2. BabaO says:

    seems that the real probem with the invisible hand is that we never quite know for sure until it’s too late that it was all along giving us the invisible finger.

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