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October 30, 2007

The Future vs. The Present

This David Brooks column is actually quite trenchant, at least so far as health care politics go. He correctly identifies the central reality of health care politics, which is that most Americans are basically happy with what they have, but worried about keeping it. Policies that guarantee their futures are quite popular. Policies that radically change their presents are not.

This, of course, is what helped doom the Clinton plan -- everyone's insurance would've changed. That was scary to people. The new Clinton plan, like the Obama and Edwards plans, doesn't attempt any such reorganization. If you have, and are happy, with your insurance, nothing changes. If you don't have insurance, you can get it. This is worse policy, because it keeps you from reorganizing the system in ways that make sense and ensure cost control. But it's better -- really, the only -- politics. And the reforms make later cost control measures easier.

October 30, 2007 | Permalink

Comments

Yup. Brad De long made that point recently, too. Only try to implement what would be supported by the House, Senate, and a broad public. Politics 101, imho.
:-/

Posted by: Gray | Oct 30, 2007 12:44:10 PM

It's truly amazing just how far the left has backpedalled on health care reform. A year or two ago, the battle cry was "Single-payer and nothing less!" "For-profit health insurance is inherently evil!" "We must separate health insurance from employment!" Now, all of those supposed non-negotiable principles have been thrown in the dumpster.

I love the comment about cost control: "...it keeps you from reorganizing the system in ways that make sense and ensure cost control." You mean like, um, Medicare's cost control?

Posted by: JasonR | Oct 30, 2007 12:59:00 PM

Who are all these people who are happy with their health insurance? They must not have any health problems.

Posted by: Ron | Oct 30, 2007 1:07:20 PM

"Single-payer and nothing less!"
This has never been true. There always have been Dems proposing other systems.

"Now, all of those supposed non-negotiable principles have been thrown in the dumpster."
Non-negotiable is even more untrue. Who said that? And, btw, the Dems are reality based, the try to get the best possible deal for the people. But the republican battlecry is still "no socialized medicine!". As if there was anything socialistic in those market based proposals. In socialism, everything healthcare belongs to the administration, insurers, doctors, clinics, everything. Well, ok, liberals get used to this spin. Show me a republican talking about healthcare and I show you a liar.
:P

Posted by: Gray | Oct 30, 2007 1:09:54 PM

Not at all sure why one can say that 'most Americans'

[that ubiquitous and egregious label which is so favorite with establishment media...Brooks come to mind]

when 46 fuckin' million don't have insurance.

Ever actually try to do the community health thing..
Or to get onto Medicaid...
or pay for the Medicare B cut with a really small SS check?

Try it before you say anything so inclusive about most Americans.

Posted by: has_te | Oct 30, 2007 1:23:26 PM

OK, Brooks is still Brooks:
"Democrats do as well among top earners as Republicans. People are more interested in repairing the nation’s health than in boosting their personal bottom line."

Nonsense! Those are Brooks' prejudices, not facts. Krugman just recently has shown the first point to be false, and there's no evidence whatever that the second is true.

Posted by: Gray | Oct 30, 2007 1:24:45 PM

I think it was in the NYT Magazine this week that the key unrecognized stumbling block was discussed: the lack of primary care physicians. That primary care is no longer attractive to new doctors, and that those already in primary care are retiring or leaving (as mine did this summer). Any reasonable reorganization of health care provision would depend on good, knowledgeable, engaged primary care providers - but there ain't any.

Cranky

Posted by: Cranky Observer | Oct 30, 2007 1:36:39 PM

Gray,

As if there was anything socialistic in those market based proposals.

But I thought private health insurance was supposed to be inherently evil. How dare those evil insurance companies make money off of other people's misery! And I thought centrist, moderate Democrats like Hillary and Obama were supposed to be part of the problem, because they're "corporatists" (a favorite lefty term of contempt) who take lots of money from the health insurance industry and other business interests.

Posted by: JasonR | Oct 30, 2007 1:37:50 PM

JasonR, you are welcome to rail against the straw liberals of your own choosing on your own blog. Those of us who actually exist come from all sorts of different background with different beliefs, but we all agree on universal health coverage. Who gained the big support of the straw liberals of your imagination 4 years ago? Howard Dean, the candidate who was quite up front about the idea that single payer wasn't necessary in order to get universal coverage.

Posted by: Tyro | Oct 30, 2007 1:43:52 PM

So you're okay with a health care system based on private, for-profit insurance now, are you? You're okay with health insurance "corporatism?" You're okay with most people getting to keep their existing employer-based health insurance? Single-payer is out the window, now, is it? Just trying to keep track of this constantly-moving target.

Posted by: JasonR | Oct 30, 2007 1:57:07 PM

"But I thought private health insurance was supposed to be inherently evil."
D'oh! You really have to get rid of all these prejuduces and start all over again. Who ever said that legally regulated private insurance, offerring a standardized product under administrative oversight, was evil? Really, you got us libruls so wrong!
:P

Posted by: Gray | Oct 30, 2007 1:58:20 PM

Ezra,

A little too much hand-waving for me.

Politically speaking, these two statements don't mesh for me:

"He correctly identifies the central reality of health care politics, which is that most Americans are basically happy with what they have,"

"And the reforms make later cost control measures easier."

What political reality do you envision centralized, government-driven cost-control measures being politically feasible?

Posted by: wisewon | Oct 30, 2007 2:00:31 PM

"Just trying to keep track of this constantly-moving target."
Uh, I haven't been moving on this issue. But, ok, you might want to track all the other supporters of universal heathcare. You know how it is: Ten heads, eleven opinions.
:D

Posted by: Gray | Oct 30, 2007 2:00:53 PM

"Any reasonable reorganization of health care provision would depend on good, knowledgeable, engaged primary care providers - but there ain't any."

Hi Cranky! Well, in Germany, they bolstered the position of the primary doctor by making him the obligatory first contact for any patients seeking a specialist appointment. The idea is too make many off those expensive visits unnecessary, in those cases where the doc can provide help. At the same time, this provides these general practitioner with a steady flow of income abd assures that those jobs stay attractive. Of course, patients still have the right to change their doc if they are unsatisfied with his advice. Imho a good cost saving measure that seems to work well.

Posted by: Gray | Oct 30, 2007 2:12:20 PM

I think Ezra is right in his diagnosis but wrong on the prognosis. The health care debate right now is focused on generalities--uninsured + cost increases. Most voters agree that these things in general should be "fixed" but most voters are not about to pay the price to get these things done. Just like most voters think they should lose 20lbs but very few are willing to do what it takes to actually lose it.

The future crisis will be driven by corporate costs of providing health care plus government costs--medicare and medicaid. The uninsured problem is really a by-product of the first two. At the point corporate, or more specifically, business, can no longer afford to insure their workers and stay profitable and state governments can't afford their medicaid and the feds can't afford medicare without significant tax increases or budget cuts, then the crisis will have enough momentum so that all the players will have the need to find a workable solution, probably some form of single payer or hybrid with signigicant cost control.

Part of the danger of the the left's present half-ass attempts (or benefit of them, depending on your view) is they will make the future necessary reforms harder and will allow the opponents of those reforms to blame the implemented programs for the problems, since everyone knows those proposals will not solve the over-arching problem, which is medical inflation. The left's best gameplan right now is probably to let the system fester to get to the crisis point faster because until you get there, the necessary reforms will never be politically saleable.

Posted by: Scott | Oct 30, 2007 2:26:22 PM

JasonR, you are free to rail against the straw liberals of your own choosing in your padded cell, or on your own weblog. Railing against them here does not qualify as a coherent argument, only an exercise in self-humiliation.

Posted by: Tyro | Oct 30, 2007 2:32:48 PM

"everyone's insurance would've changed. That was scary to people. "

True. So what you should be doing is trying to reassure people and convince them that:

The effect of the expensive things that health insurance covers has only a small aggregate effect on health (see the rand health insurance experiment).

That by buying less high cost low impact medical care they can have more money to spend on other things.

That the most affective medical care like vaccinations and antibiotics are cheap.

20 minutes 3 days a week on the tread mill and 10 2 days a week in weight room will have more positive impact on health than access to hospitals.

That even radical changes will have little impact on health ether way but can save big bucks.

Posted by: Floccina | Oct 30, 2007 2:54:51 PM

"The effect of the expensive things that health insurance covers has only a small aggregate effect on health (see the rand health insurance experiment)."

What? Cancer treatment is a small effect on health? Heart surgery?

Posted by: verplanck colvin | Oct 30, 2007 3:02:41 PM

One thing that could be done would to allow people who have been turned down for health insurance by multiple insurance companies to get on Medicaid at some means tested price.

Posted by: Floccina | Oct 30, 2007 3:03:37 PM

"Cancer treatment is a small effect on health?"
On national health, I guess. Look at that statistic again: Only a very small percentage of people get prostrate cancer, and even less get expensive treatment.

Posted by: Gray | Oct 30, 2007 3:06:29 PM

Ron We are only one family but, my wife had breast cancer and another $30,000 problem but we are happy with our insurance. BTW we have Blue Options from blue cross not through our jobs and it is cheap (plug).

Posted by: Floccina | Oct 30, 2007 3:08:13 PM

Hmm, Floccina, cherry picking only the healthy customers ought to be forbidden for private insurers, too, or else Medicare will get stuck with all the expensive cases (speaking about the Clinton plan now). The system won't work if the odds are so uneven.
:-/

Posted by: Gray | Oct 30, 2007 3:08:43 PM

Gray medicare will get stuck with many of the expensive cases but if the taxpayers understand that it will be OK. It could lead to insurance that pays to the policy holder on diagnosis and this could lead to cost reduction in costs. BTW WWW.Overtreated.com is interesting.

Posted by: Floccina | Oct 30, 2007 3:22:57 PM

Scott,

At the point corporate, or more specifically, business, can no longer afford to insure their workers and stay profitable and state governments can't afford their medicaid and the feds can't afford medicare without significant tax increases or budget cuts, then the crisis will have enough momentum so that all the players will have the need to find a workable solution, probably some form of single payer or hybrid with signigicant cost control.

If businesses can't afford it, the federal government won't be able to afford it either. See Medicare. Single-payer national health care is a fantasy of the far left that has essentially zero chance of being enacted in the foreseeable future. Health care costs will continue to rise dramatically, regardless of the way funding is organized, as long as there is continued public demand for expensive new drugs and tests and surgical procedures.

The left's best gameplan right now is probably to let the system fester to get to the crisis point faster because until you get there, the necessary reforms will never be politically saleable.

Tyro, here's one of your "straw liberals."

Posted by: JasonR | Oct 30, 2007 3:42:08 PM

"It could lead to insurance that pays to the policy holder on diagnosis and this could lead to cost reduction in costs."

Hmm. My understanding of an 'insurance' system and of 'risk sharing' is a bit different, I'm afraid...

Oh, and thx for the link, very interesting, even though the cynical part of me keeps saying "this fantasy is too good to be true...
:-/

Posted by: Gray | Oct 30, 2007 3:46:10 PM

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