Thursday, December 24. 2009
I, for one, am pleased that the Senate passed any kind of health care reform bill. Without the reforms it is virtually impossible for me to buy functional insurance at virtually any price. I wish the bill covered more people more affordably. I wish the bill did a much more aggressive job of tackling the critical problem in the system here, which is profit-seeking by virtually everyone involved. This has led to fragmentation and unnecessary complexity, to obfuscation and propagandizing. This leads patients to not understand when they do or do not need treatment, making critical decisions based on all sorts of things that should be secondary or irrelevant. This tempts doctors to give more or less or just different treatment than the patient actually needs. This leads drug companies to mislead us on medications, including covering up major harm. This has led to all sorts of things that have very little to do with promoting public health. Most impressively of late this system has done everything within its considerable power to corrupt political discourse. That anything positive has come out of it is remarkable.
I've been thinking about the health care system for a long time now. I have some pretty straightforward ideas about how to fix most of the problems, and they led me to favor different solutions from the one that Congress settled on. Everyone likes their pet ideas, and I'm no different in that respect, but T.R. Reid's recent book is helpful in showing that there are actually many variations on health care system that all work much better than the one we have, both in terms of lower costs and better outcomes. In theory, I'm inclined to favor a "Beveridge Model" system like the UK has (or like the US provides through the Veterans Administration), where all services are government run. But the UK system tends to be underfunded, resulting in longer delays and fewer options than we are used to (assuming you have reasonably good insurance here in the US). Especially in terms of availability and flexibilty, it looks like the best health care systems in the world are in France and Japan, which use private insurance and providers, but regulate them severely, in effect squeezing the profit motive out of the system. This has led to great cost efficiencies in the systems: for example, an MRI that costs over $1000 in the US costs $100 in Japan -- a situation which allows Japanese doctors to order more MRIs and still save money. But the various systems aren't exclusionary: it's easy to imagine a UK-type system pursuing upstream supplier costs like the Japanese do. It's easy to imagine a Canadian system with adequate funding for specialists: in fact, that's what the US Medicare system does.
Reid offers good and bad news on prospects for change in the US. He shows two examples of systems that were similar to ours (profit-seeking, out-of-pocket) up to 1994 but were then changed successfully: Switzerland and Taiwan. In the Swiss case, the main change was to require private insurance companies to refund any profits. Before the change, Switzerland had the second most expensive health care system in the world at 11% of GDP, just 1% behind the US. Fifteen years later, Switzerland is still second, still at 11%, while the US GDP cut has boomed to 17% and is still headed up. Taiwan did a bit more, and got better results: they adopted a Canadian-style single payer scheme. The good news here is that such change is possible. The bad news is that in both Switzerland and Taiwan the changes were pushed through by conservative political parties, preferring to compete with the left-liberal parties by adopting progressive change on their own terms. In both cases, the decision was arrived at not just politically but morally: in both cases, even conservatives agreed that equal access to health care should be a right for all people, not just for those who can afford it. Of course, that's not bad news for Switzerland and Taiwan; it's bad news for us, where even the Democrats have trouble articulating health care as a fundamental right, and where Republicans are nothing short of shameless. Not a single Republican voted for health care reform this year, despite the numerous deals that Obama negotiated with the AMA, the pharmaceutical industry, and other lobbyists, despite the fact that insurance company stock prices rose on passage. The Republicans have moved past their usual stance of sucking up to industry; on health care they're into pure ideological malevolence. So the near term prospects for conservatives doing anything responsible are close to nil.
For a taste of Reid's book, look here.
Matthew Yglesias: Mitch McConnell's Proud Unipartisanship. Quotes the Republican Senate Minority Leader:
And they say generals always prepare to re-fight the last war. Republicans remember how their intransigent opposition to Clinton's 1993 health care reform effort was followed by Republican wins in the 1994 congressional election, so they figure what worked then will work now. That strikes me as monumentally stupid, both as a political strategy and as a reading of history. The single biggest difference is that Obama passed his bill whereas Clinton failed to get his bill out of committee. Clinton's failure looked incompetent, then when he walked away from the bill like some embarrassing road kill, he gave Democrats little reason to expect more from him. On the other hand, Obama persevered, against tough odds, and he comes out of this with something to defend.
At most, the defeat of health care contributed some moment to the Republicans in 1994. Their big issue was the corruption of Congress under long-term Democratic rule, and it was largely H. Ross Perot who turned the tide in their favor. After that they used every trick of incumbency to hang onto narrow margins until 2006 when their own corruption finally sunk them. During the 15 years between Clinton's failure and Obama's success, Republican intransigence and blindness has allowed a predatory health care industry to increase its share of GDP from 12% to 17%, during which time more and more people were unable to buy or afford insurance, bankruptcies proliferated, and the US sunk further and further on most international metrics of health. Those are costs that fall not just on the poor and working families; they cut into business profits and burden manufacturers, who in turn cut real wages and/or export jobs. Against these trends, the Republicans have done nothing, turning a blind eye to greed and a cold heart to suffering and fear. They've made a lot of noise, and worked themselves up into a frenzy, but it's all been negative, paranoid, surreal. Aside from their fanatic base, will anyone else believe them? Why would anyone else trust them?
I'm not saying the Democrats have no problems. They have all of our problems: continuing pointless wars, economic rot, solutions that don't go far enough. But they can point back to the wreckage of Republican rule, which is all the more credible given that the best the Republicans can claim is that Bush screwed up because he was a big spending big government closet case. And they can point to their own pragmatic moderation, which gets real (but modest) results without upsetting the Establishment. The Democrats would have it made if the Establishment showed them equal respect, but even so, the Republicans seem determined to make sanity the issue the next couple of election cycles turn on. The last time they exposed their conservatism so nakedly was Goldwater.
Paul Krugman: Simulating Single-Payer. A little economic analysis arguing that Hackerish health care plans, like the one in Massachusetts and the one the Senate just passed, approximately simulate single-payer plans: "just imperfect, somewhat inefficient ways of simulating the results of a single-payer system." This is basically the same thing as we get out of Reid, who shows time and again how universal coverage ("community rated") private insurance systems approximate the behavior of single-payer systems. You can take this as reason not to get too disappointed that Obama and the Democratic leadership didn't stick their necks out for a real single-payer system. On the other hand, the inefficiency is likely to be more than "somewhat," and the imperfections glaring. It all depends on how strictly regulated the insurance companies are, and how efficiently the market can be made to work. Up to now the key to profits has been inefficient markets: opaqueness at every stage, lack of standardization in billing, uncertainty in payments, complexity everywhere, monopoly rents nearly everywhere. There is a lot of room here for savings without sacrificing one iota of service, but I expect the interests to fight efficiency as doggedly as they've fought equality. Single-payer may not in principle be any more efficient than a well-managed private system like in Japan. But single-payer would be much simpler, and would show political will to make it work. And while it may not have been politically practical, the main reason is that leaders who know better didn't have the guts to go for it.
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