Monday, November 15, 2010

Intellectual Honesty in the Health Care Debate

Yesterday I argued that, when they’re disagreeing about health care policy, liberals and conservatives are usually arguing from a common premise: viz., that the health of one’s self and one’s loved ones is so important from everyone’s standpoint, that anyone is entitled as a matter of social justice, and should be entitled as a matter of law, to access minimally adequate health care. The meaning of the words I’ve italicized is sufficiently elastic to leave room for our seemingly unbridgeable ideological differences over health care policy.

Liberals spend most of their time talking about the redistributive implications of this premise; securing everyone’s access to adequate health care requires a significant redistribution of resources from richer and younger Americans to poorer and older Americans. That’s the rationale for the least popular features of ObamaCare like the individual mandate and the prospect that public cost control measures will deprive people of subsidies for treatments that might do them some good but aren’t cost-effective on a system-wide basis.

Conservatives spend most of their time worrying about the premise’s jurisdictional implications; if access to health care is so important from everyone’s standpoint, no one can reasonably delegate decisions with sufficiently serious implications for the health of himself and his loved ones to the sole discretion of government bureaucrats. That’s the worry behind conservative talk about “death panels.”

Neither side has been very forthright about the terms and conditions of the tradeoff it’s contemplating between security and autonomy within the health care system. Liberals usually don’t have anything to say about the jurisdictional implications of achieving universal health insurance coverage and aren’t above dispensing a little politically expedient disinformation (“you can keep your present policy if you like it”). Conservatives have virtually nothing to say about the redistributive implications of providing for the uninsured and pretend that a few market-based reforms (e.g., selling health insurance across state lines and tort reform) would automatically solve the problem.

Under the circumstances, the mere hint of intellectual honesty sounds positively incendiary. Here, for example, is Paul Krugman acknowledging that, from a liberal standpoint, “minimally adequate health care” does not mean that you won’t be denied subsidies for non-standard treatments that are life-prolonging and medically indicated in particular instances:

A comparably honest conservative might say something like this: you haven't been denied access to “minimally adequate health care” when unforeseen and uninsured medical expenses drive you out of the middle class and into Medicaid eligibility. That won’t happen very often, but it will happen sometimes and we can’t afford, and shouldn’t try, to guarantee that it won’t.

Don’t hold your breath waiting for lots of politicians and pundits to start saying such things. But it’s hard to imagine our reaching a political settlement about the health care system until they do.


Anonymous said...

Good for Krugman and good for Paul Ryan. Let's put the real options on the table and decide once and for all.

Scrooge McDuck said...

Back when I was in College, in a Policy Analysis program, the Reagan administration allowed states some flexibility in how they administered their Medicaid programs.

Oregon chose an approach that is a policy analyst's dream: they had a bunch of doctors rate every known treatment, for how much it extended life or enhanced the quality of life, and how cost-efficient it was. Using the numerical score from this analysis, they ranked each treatment, from one to whatever. Every year, as their Medicaid budget and spending became clear, they would announce that they would cover up to procedure #565, or whatever. Anything below that line was not covered, at all.

From a purely utilitarian perspective, this is the approach to take: if well designed, it should deliver the greatest benefit to the most people for a fixed budget. If we are ever to get a handle on health care inflation (without having to take over the entire medical sector directly, as Britain does), we will have to do something along these lines.

Not surprisingly, the plan met with resistance from all quarters. Physicians were "innovating" ways to bill for non-covered services, people attacked the notion of evaluating or ranking quality-of-life measure, and Medicaid regulators were fighting Oregon's ability to deny treatment to some parties.

These are the kinds of discussions that we will have to have if we are to ration medical care (which we must). That is the only way we will ever address medical costs and public policy. We will always ration, because medical services are a virtually unlimited good.

So, back to your post: right now, liberals are unwilling to acknowledge that we have to limit the medical treatments currently provided by the medical system (particularly the public sector parts). And conservatives are unwilling to acknowledge these real dilemmas, generally positing that medical costs can be addressed by tort reform and competition.

Until such time as both sides just grow up, we will leave our medical system substantially unaddressed. Paul Ryan's plan is essentially a slow phase-in of cost rationing, without acknowledging that that is what's taking place. Obamacare's elimination of lifetime caps on insured medical care are equally blindered.

The sooner we can have this discussion, the better it will be for all of us. Until that time, we will continue to have high medical inflation, and millions of sick will not get treatment.

Anonymous said...

Wow...what a treat, thinking and logic. I have one point that many persons have forgotten. Medical costs will be largely paid for by the employer. This is tru under Obama Care. As a person who does business worlwide this puts all American companies at a disadvantage comapred to thier European firms since these are paid for by direct taxes, larely. Therefore, we are adding a barrier to our intrebnational sales. This may not be large point to many but it will affect our balance of payment deficit.

I would have prefer a single payer approach based upon a direct tax on persons and not insurance purchased by employers