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Random thoughts on health care

In Massachusetts, they chose universal coverage as a goal before cost-controls, and Ezra Klein thinks that’s the best way to do it.

In 2006, Massachusetts passed a big health-care reform bill. The structure of it was actually pretty similar to what we’re seeing nationally. And, like what we’re seeing nationally, it didn’t have much in the way of cost controls. But nor did it promise to. The short-term priority, officials said, was getting coverage to everyone. The long-term priority was cost control. And the two would work together.

After all, without cost controls, subsidizing health-care coverage would become unaffordable, and Massachusetts would have to abandon the reforms it had worked so hard to pass. Without cost control, there could be no universal health-care system. That would focus the mind, they predicted. That would help them make the hard decisions.

I find it sort of hard to get excited by this being replicated on the federal level. For one thing, those cost controls which are now being considered in Massachusetts have yet to be implemented, so we don’t know how successful they’ll be. This stuff is complicated, and it’s not impossible that the cost controls will be designed poorly and result in reduced quality of care. Also, shouldn’t representative democracies avoid these sorts of “let’s make the situation worse so we can make it better” strategies?

FWIW, it seems to me that one easy win would be to remove the health care tax exemption from companies and put it onto individuals, which would improve health care portability and make it easier to start your own company. It’s not a huge sea-change, but I think it’d be easy to put through, not least because there aren’t a lot of people arguing for it, except for I suppose your shitty Fortune 500 employer who wants you to stay at your job even if you hate it.

I’m also interested in any sort of cost-control measures alluded to in Atul Gawande’s fascinating New Yorker article last month, but those things are complex and hard to get right. And what I don’t particularly understand is why, if those cost controls could be implemented by private health insurance companies, why they haven’t done so to gain a price advantage over their competitors. It could be because, unlike, say, hard drives or t-shirts, health care is a good whose value is very hard for the average person to assess, especially because the product’s good plays out over years and involves unlikely, high-cost events like a cancer diagnosis that are hard for people to reason about. Would it be useful for a government agency to rate aggregate quality of outcomes for different private health insurance plans? Of course, trusting the agency’s ratings is an issue then.

I also believe that increasing taxes slightly on the wealthy to improve health care for the poor is a good thing, though I’m not sure if that improvement should realistically be through government programs, or health care vouchers, or whatever. But I’m not really a huge fan of the government-administered option, primarily because I haven’t read anything that’s convinced me that it’s the profit motive that’s the problem in the American health care system. And what about non-profit health plans?

I am not convinced we should be forcing young healthy people to buy health insurance, and as Massachusetts’ example has shown that doesn’t seem to do much for cost control. Also, going without health care to save some money seems like an option you should be allowed to have, and I know a lot of people who do it here in NYC. Though there is the externality of emergency care that needs to be accounted for somehow.

Anyway, I think it’s a shame these things aren’t being discussed more heavily. It’s not enough to say “something needs to be done”: You have to figure out what that something should be, especially because the wrong something could actually be harmful.

It would be helpful if we had a sane center-right opposition that could force a principled discussion of different aspects of health care, instead of simply trying to set themselves up for taking back Congressional seats in 2010. Marc Ambinder argues that the politics will probably play out in the Democrats’ favor:

Remember: the Democrats are still much more trusted as a party to fix health care (in the generic sense) that Republicans are. The public buys in to the urgency of the problem, even as they’re not officially sold on any solution. What’s now known in liberal circles as the “DeMint/Kristol” strategy is an instinctual Republican strategy derived from the gut; it misreads the public’s ambivalence about Obama and the health care debate as a sign that the public has soured on health care reform in general (nope) or Democratic principles in particular (not really). It may well have the perverse effect of generating sympathy among independents for Obama. Independents want to get health care done; they respect Obama for trying, even as they’ve begun to sour on his leadership skills.

That sounds about right, politically speaking. Not sure where health care itself will be when we’re done with this round.

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Tagged: politics

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