Wednesday, February 17, 2010

The Health Care Follies Continue

Peter Suderman points to a survey that shows 57% of Americans want Congress to start over on healthcare reform. The basic gist of the poll boils down to the emerging reality on healthcare -- Americans find a lot of individual pieces of the reform attractive in the abstract (no bar on pre-existing conditions, expansion of Medicaid to more low-income people, subsidies to purchase insurance), but they don't want to pay for it. Or they want to pay for it on credit and never pay the bill, which appears to be the way we'd go.

The more interesting debate is one Megan McArdle is referencing, which is whether the benefits of health care insurance are worth the costs. That's a debate that may not be settled soon, but in the debate she answers one argument ("If insurance is so unnecessary, why do you have it?") in a way that illustrates how screwed up our system is...

But the answer as to why I have health insurance is simple: my employer pays for it. If my employer didn't pay for it, I wouldn't have it. I'd buy a catastrophic policy from a reputable insurer to cover any amount that might bankrupt me, and self-insure for everything else. That would probably cost me a little more than what I pay The Atlantic for my first-dollar coverage, so I opt for the first-dollar coverage. It's not like I get the money The Atlantic is spending on my benefits back if I choose to go without.

But do I think I would be noticeably more likely to die if I did give up my policy? Certainly not for the next twenty years, because I am unlikely to get cancer much before 65, and everything else that might kill me would be treated on an emergent basis, where insurance probably wouldn't affect my outcomes nearly as much as the fact that I am an upper middle class professional with a (soon to be) husband who writes about health care policy for a living and a father who used to work for the New York City health and hospitals corporation, both of whom will no doubt be sitting on top of the doctors and the hospital bureaucracy to make sure I get excellent care. At 65 I qualify for Medicare, if it hasn't bankrupted the government.

Morbidity? Maybe. But we're more likely to take out a second mortgage to cover physical therapy than we are to go without.

I'm pretty sure my life would be, on net, better if I had the cash wages and a catastrophic policy instead of the health benefits. As someone who's moderately sickly, I've spent a lot of my life worrying over false positives from tests of dubious pertinence, and no time at all treating conditions we caught early. But the system is not set up to facilitate real insurance; it's set up to hide the cost of medical treatment from as many people as possible, because we have developed a social belief that no one should have to consider the cost of medical care, except maybe your friendly neighborhood bureaucrat.
This is one of the problems with the debate that has occurred with health care reform -- we're starting from our current system. So far as I can tell, there wasn't actually a good reason for the development of a system of health care payment whereby our employers pay for our health care -- it was little more than historical accident and the tax system. And so, we have a system whereby insurance exists to cover the perfectly foreseeable and planned for things in life -- your physicals, your mammograms, etc. We largely don't do this with other forms of insurance -- for example, you don't pay for a car insurance policy with the expectation that it will take care of your oil changes. You buy car insurance in case your car gets wrecked or suffers serious damage. McArdle's idea of buying a catastrophic injury policy covers that point.

Now this doesn't answer the question of whether it would be a good idea to institute a single-payer system to cover everyone, or some lesser system designed to make certain people are covered, per the unpopular plans Congress is considering. But it does tell us that our starting point for this discussion is probably less than optimal.

Of course, none of this matters for the politics of the debate. The upcoming health care summit next weekend (which I would only watch if I were paid to do so) is a Hail Mary pass for Obamacare. It will probably generate lots of press attention, but its questionable what it will accomplish. As Ross Douthat notes, this probably won't go anywhere...

Even in the unlikely event that the two sides approach the conference in good faith, they’ll still probably end up talking past each other. One difficulty, as Slate’s Chris Beam has pointed out, is that the White House and the Republicans agree on the idea of bipartisanship, but not its definition. For President Obama, being “bipartisan” means incorporating a few right-of-center proposals into an essentially liberal legislative package. For Republicans, it means doing only those things that legislators of both parties can agree on — a far more stringent standard, and one that would produce a very different bill.

Hence the frustration on both sides with the way the health care debate has proceeded. To Democrats, the right’s complaints about having its ideas ignored are purely cynical. Doesn’t the proposed legislation include ideas endorsed by prominent conservative economists? Don’t some of its proposals resemble those championed by John McCain? Didn’t Democrats eschew a single-payer approach in favor of a reform that retains a role for private insurers?

To conservatives, this misses the point: It isn’t the details of the bill that they object to, it’s the overall design. The right seeks a functioning marketplace in health care, subsidized but not micromanaged by the government. However many small steps the Democratic legislation takes in that direction, its biggest step goes miles the other way — toward a world where consumers are required to buy a particular kind of health insurance, insurers are required to sell it to them, and the cost of health care gets held down, ultimately, by price controls and bureaucratic supervision.

But if conservatives are understandably annoyed by the liberal claim that the bill is already bipartisan, Democrats have a legitimate frustration of their own. Republicans keep insisting that they share the goals of reform, they just want a more incremental and less polarizing approach. But when it comes time to put forward actual proposals, they tend to fall back on ideas that are neither particularly bipartisan nor particularly responsive to the central issue animating the Democrats’ reform effort — the problem of the uninsured.

Actual negotiations, then, would require that each party address the other’s frustrations.

Democrats would need to put the overall structure of the bill up for debate, instead of just offering concessions around the edges. Republicans would need to show up with proposals that have more heft, and more bipartisan appeal, than their predictable calls for interstate purchasing and tort reform.
Douthat mentions a couple of decent right-of-center proposals with heft that exist, but I'm pretty sure none of them will get much discussion. The Obama Administration still wants to find a political solution that will make the current bills more popular, which is the reason for the summit -- it's another opportunity for Obama to try to sell the reform package that the public's not buying. This may provide him with some benefits, since he's likely posing as the moderator (yeah, right) between Congressional leaders, who aren't exactly likable to the public, whichever party they come from (Mickey Kaus also pointed out that the invitation to the summit wasn't all that inviting). But I don't think this will help save health care reform -- I think most Congressional Democrats of a moderate stripe are concerned with political survival right now, and they don't think passing the health care bill that currently exist will help that goal. And since Congress spent the last seven months or so (and counting) fighting largely over this topic, it's not likely the public has the patience to see them spend more time on it.

I don't know if healthcare reform is dead or not. I know there's 260 or so days until Election Day, and each day that passes without a bill makes one less likely. For opponents of this plan, that day can't come soon enough; for its proponents, they'd really love more time. That should tell us something about whether the bill would ever be popular.

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