Saturday, August 15, 2009

Wherein I Speculate About Universal Health Care

I'm surprised at how vigorously people are tearing into John Mackey's recent op-ed about healthcare reform. The dude's not a Rhodes scholar, granted, but in the grand scheme of things he's not spouting complete nonsense either. I mean really, c'mon:

Mackey’s op-ed bills itself as “The Whole Foods Alternative to ObamaCare.” Your first signal of what might be coming, of course, is “ObamaCare,” And your second clue is the immediately following quotation from Ste. Margaret Thatcher:
The problem with socialism is that eventually you run out of other people’s money.
Needless to say, this concern for other people’s money never prompted Ms. Thatcher to renounce the socialism involved in having the taxpayers pay her own salary and give her free lodging at 10 Downing Street. But, of course, all the folks running around saying that all government spending is socialism, or fascism, or Marxism, or evil Kenyan juju, or whatever, really mean only that government spending that they don’t like is socialism.

Thatcher collecting a paycheck for her job as PM has dick to do with socialism; you're abusing the word just as much as he is.

Nevertheless Tintin does finally get down to substantive criticism, as does Jesse over at Pandagon, and their comments provide an interesting jumping-off point for a discussion about what certain aspects of a universal healthcare system might look like. For example, Tintin says

In the event that you’re not paying attention, what Mackey wants is for employers to pay less, and employees to pay more, into the health care system. Seriously.
• Repeal government mandates regarding what insurance companies must cover.
Those of you who were foolishly hoping that MackeyCare would at least prohibit insurance companies from declining care for pre-existing conditions are a bit disappointed now, aren’t you? So not only does Mackey want employers to pay less and employees to pay more, he wants the insurance companies to be able to provide less.

Similarly, Jesse has the following to say

This seems like a great, common sense reform. High deductible health insurance with a significant contribution towards the deductible. I mean, if you ignore the fact that high deductible insurance often doesn’t cover common conditions like pregnancy, have incredibly strict in-network requirements, high coinsurance rates even after deductibles are paid which far outstrip an $1800-a-year contribution, place strict limits on the allowable prices for common procedures and are tied to hour-per-week work requirements that it’s incredibly easy for companies to work around, it’s pretty much like perfect.

Both Tintin and Jesse seem to want expansive coverage of a variety of conditions under universal healthcare, but presumably "expansive" is not equal to "unlimited". If Jesse and Tintin accept that there must be some boundary to what's covered then the question I have for them is "How do you decide what's in and what's out?". I read through Jesse's recent posts on health care1 and couldn't come up with any relevant statement of principles in this area; the entirety of what ey's written recently calls for expanding existing coverage. Which is a problem since one of the legitimate issues which divides and defines opinion on this subject is deciding how much money we're going to spend on it.

Progressives want to expand coverage for everyone, which is a noble sentiment to be sure, but I can't help but feel that this desire rests on a shaky foundation. At some point you either have to say "no" to some particular request or you end up spending a metric fuckton (perhaps, even, an unsustainable fuckton) of money. Progressives aren't, as a general rule, good at saying "no", in part because they lack a coherent ethical/philosphical position which allows them to do so. Consider, for example:

Care near the end of life consumes a disproportionate share of costs and is a logical target for efforts to promote value in health care.

How do Tintin and Jesse propose tackling that? Do they envision a healthcare system that keeps people hooked up to ventilators indefinitely, or do they acknowledge that, at some point, the costs outweight the benefits?

This isn't just idle speculation; Jesse acknowledges as much in another post on the subject:

The debate over the “rationing” of healthcare has come down to two sides: conservatives who reflexively hate government and so live in fear of some government bureaucrat rationing off healthcare, and those of us who realize that healthcare is already effectively rationed off by insurance companies. There’s no way to have healthcare without it being rationed in some way, because it’s a finite good that dispensed by people who know a hell of a lot more about what works and what doesn’t than most of the people seeking it.

If rationing is inevitable under a government plan then who makes the decisions and how do they do it? The reason why the deathers keep ranting about euthenasia panels is, in part, because they're worried that someone is going to come in and pull the plug on grandma. And that, in turn, is due in part to the inability of progressives to articulate a coherent approach to the inevitable rationing which must occur. So I feel that it's incumbent on people like Jesse and Tintin who are calling for expanded coverage to also address the flipside of that particular coin. Which, unfortunately, no one seems inclined to do.

1 Couldn't find much of anything for Tintin 'cause Sadly, No! lacks a convenient "healthcare" category.


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