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Health care and incrementalism

So, I don’t know why I keep blogging on this issue; it’s not like I’m some huge expert or that my personal health care situation is really bad. But here I go again:

Conor Friedersdorf argues that the health care reform package is vulnerable to stirring up irrational fears because it’s big and complicated and people are naturally risk-averse to large complex changes.

My grandmother, my mother, and countless other Americans may be misinformed about the particulars of health-care reform, and express certain misbegotten fears, but health care proponents would do well to understand the anxiety’s source: Theirs is ultimately a fear of rapid, sweeping policy shifts, especially those brought about by lengthy, amorphous legislative proposals that leave unclear exactly what might change the month after next.

I think this is a legitimate concern in general, just because of my own personal experience in work, and side projects, in life in general: Getting anything done in the world is about a hundred times more complicated than you think it should be. Sweeping national legislation in a country of hundreds of millions of people always has the potential for tons of unintended consequences, so sometimes it’s not irrational to want to stick with the devil you know. A lot of the thinkers I respect the most are the ones who are most humbled by the unknowability of the world, and I think a lot of well-intended reformers could do well to learn from that just a bit.

That being said, the current system’s pretty horrible, so at some point you have to take risks and change things. And it’s not like the world’s standing still even if you don’t change government policies. Conor argues for a number of small reforms, that individually can be passed and can incrementally improve the situation, instead of one giant reform, as more realistic and ultimately more likely to help more people.

In response to Conor, however, Matt Steinglass is arguing that incremental reforms can become impossible if the status quo is too complex.

Substantively: the reason one often can’t pass individual planks of the reform in isolation is that taken individually, each plank generates perverse consequences that will lead to strong opposition from a particular constituency. Universal community rating, for instance, will make health insurance for the young and healthy more expensive. That creates adverse selection, as the young and healthy will drop out. And adverse selection threatens private insurers’ revenues: they lose their best customers. So to kill such a bill, private insurers will trade on young people’s fear that they’ll lose their health insurance. And they’ll be correct!

I might argue that Matt’s trying to cut along the wrong axis. Maybe it would be useful to imagine keeping most of the planks, but making the individual planks less sweeping. For example, instead of saying everybody is required to buy health insurance, start with saying that everybody age 40 and up is required to buy health insurance, with subsidies to help those who are of age but poor. That doesn’t get you to 100% coverage overnight obviously, but neither does a omnibus package that never passes.

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Tagged: health, politics

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