A couple of months ago, I started typing up a long post bashing David Goldhill’s Atlantic Monthly cover story on health care that everybody was lauding (especially David Brooks). The article had appeared in the midst of August, when health care reform was on the ropes, and it seemed like just another antagonist helping to push the process to defeat. But by September, when I was drafting the post, the prospects for reform had brightened dramatically. It was revived! With a public option! In the Senate, even! So I put my post away.
Another article, in the New Yorker this time, is getting my dander up again. (OK, it’s a blog post, but for any other publication it would have been an article.)
These articles perpetuate the belief rampant in journalism that systemic change happens in sweeping gestures. And very, very occasionally, it does. But over the past 90 years, almost every sweeping change proposed to overhaul the health care system has gone down to crushing defeat. The real changes have been step by step, bit by bit. Even Medicare when enacted was a mere condolence for the death of the comprehensive insurance system Truman had envisioned 20 years before.
But the worst thing about these articles is that they’re not content to just paint a grander vision than is practical or possible. They also spit at the seeds of change reformers have fought hard to embed within the legislation that’s proceeding.
At the heart of both Cassidy and Goldhill’s arguments is a familiar contention and one I agree with – that one of the biggest problems with the US health care system is the way it distorts costs by shuffling most payments for health care through a gruesome patchwork of employers and private insurers. Goldhill would reboot the current system in favor of a more libertarian solution, establishing affordable options for catastrophic coverage and handing out vouchers for individuals to purchase more routine care. Cassidy suggests he’d like a more progressive solution, perhaps straight-up single-payer insurance.
If their arguments stopped there, I’d appreciate them. Either of these proposals could be part of a good conversation about what health reform might look like in an ideal world. And I think it’s tremendously important that folks continue to paint these alternative visions of what health care can become.
What I find most maddening about these articles, though, is the pose of the lonely iconoclast. The way the authors pretend their ideas are so novel and transgressive that no one’s pointed them out until now. The way they ignore the past 90 years of attempts at health care reform. And worst, worst of all – the way they off-handedly dismiss the real reforms that try to incorporate those ideas into actual legislation as pragmatically as politics allows.
Both men frame their arguments as though they’re the hard-headed realists pointing out the truths no one else will acknowledge. But both are ignoring (or dismissing) reality themselves, not even really engaging with politics as it exists in the real world.
If you don’t mind a bit of wonkiness, read on.
The wonky stuff
Here’s John Cassidy’s nut graf:
So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.
Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be virtually impossible to rescind. At some point in the future, the fiscal consequences of the reform will have to be dealt with in a more meaningful way, but by then the principle of (near) universal coverage will be well established. Even a twenty-first-century Ronald Reagan will have great difficult overturning it.
Even if you agree with Cassidy’s predictive analysis – that Congress is likely to scuttle the aspects of the health reform bills that are intended to hold down costs or pay for reform over the long term1 – you should begin wondering why he’s criticizing the legislation, and not Congress’ willingness to follow through on it.
He gives a nod to the practical challenges of reform:
The proposed reform may be the most that can be accomplished today. But we will be dealing with its consequences for decades to come, and I think it’s important to be clear about what the reform amounts to.
But then he goes on to say that the bill is fiscally unsustainable, pretending that all serious attempts to control costs have already been thrown out the window. To do this, he has to do a little two-stepping. Note how he elides the distinction between the two chambers of Congress in this paragraph:
If it decides to forgo soaking the rich, the Administration could return to its earlier proposal, which was included in a Senate Finance Committee bill that Senator Max Baucus put forward, to tax firms that provide their employees with costly “Cadillac” health-care plans. “A policy such as this is probably the number one item that health economists across the ideological spectrum believe is likely to stem the explosion of health-care costs,” Christine Romer, the chair of the White House Council of Economic Advisers, said in a recent speech. But this idea wouldn’t work politically, either. To raise enough revenue, the tax on swanky insurance plans would have to be set as high as forty per cent. When labor unions, some of whose members enjoy coverage in these plans, learned about this punitive levy they objected loudly, prompting [Speaker of the House Nancy] Pelosi to drop the idea, which, broadly speaking, amounts to taxing the upper middle class to provide benefits for the lower middle class. [Emphasis mine.]
In fact, the Senate tax on high-value health-care plans remains … in the Senate version of the bill, where it originated.2 Pelosi, of course, doesn’t have the power to change the Senate bill before legislation is passed in both chambers and reconciled.
Fundamentally, Cassidy just doesn’t believe Congress will do what it says it will. And that’s fine, healthy skepticism. But that’s neither an argument for short-circuiting reform, or an excuse for misrepresenting the legislation. His argument really concerns a breakdown in the process of government. But he’s not bold enough to criticize that process, or to recommend the sort of structural change that could force Congress to follow through – a supermajority requirement for altering the legislation down the line, for example.
Instead, he jumps on an easy bandwagon, and just blames the legislation.
Goldhill’s “novel” idea for blowing up the US health care system conforms to the basic structure of the Healthy Americans Act, also known as the Wyden-Bennett bill. This was one of the first pieces of health reform legislation out of the gate this year, and wonks loved it. It was deficit-neutral in its first year (i.e. it completely paid for itself), and reduced the deficit within 10 years. It blew up the employer-based system entirely, and empowered individuals with tax credits to purchase their own coverage. Messirs Wyden and Bennett are Democratic and Republican senators respectively, so the bill had bipartisan bona fides.
But it was way too radical to make any headway. One of the political realities reformers have had to grapple with is the fact that our byzantine health insurance system is now so solidly entrenched that vast, sudden change is not possible. The majority of Americans who have employer-sponsored health insurance or Medicare really don’t want their coverage to change. In addition, large industries have built themselves up around the status quo. For most of a century, US Presidents from Truman to Nixon to Clinton have tried to effect vastly ambitious reforms that have gradually been whittled down to the legislation we’re debating today – certainly less ambitious up-front, but secretly containing the potential catalysts for long-term change. This is why we are as close to enacting health reform as we are.
David Goldhill doesn’t mention Wyden-Bennett. He doesn’t even throw a bone to Wyden’s pared-down amendment to the Senate bill, which 1) at least had a chance politically, and 2) would have done a lot to tilt the final legislation in the direction Goldhill prescribes. He just tosses out assertions such as, “These ideas stand well outside the emerging political consensus about reform,” and walks away.
Goldhill’s article is filled with these omissions. His sole acknowledgment of health care systems abroad – many of which are better than the US health care system by any reasonable measure of effectiveness or cost – is this little nugget:
The experience of other rich nations should also make us skeptical. Whatever their histories, nearly all developed countries are now struggling with rapidly rising health-care costs, including those with single-payer systems. From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. Cost control by way of bureaucratic price controls has its limits.
Expressing health care spending growth in percentages obscures the fact that we spend much, much more on health care as a share of GDP than any of these countries. As Ezra Klein explains:
The author is quite surprised that the U.K.’s spending growth outpaces ours. But of course it does. The U.K. spends $2,992 per person. The U.S. spends $7,290 per person. To put this in real terms, the U.S.’s 5.8 percent growth works out to a $422 increase per person. The U.K.’s 6.9 percent growth is a $206 increase per person. Which would you prefer? Moreover, the U.K.’s system is underfunded, and in recent years, the British government has been trying to increase spending. That’s not true with the American system, which is overfunded (although in recent years, the government has also been increasing spending).
Peter Orszag would love to have our per-capita health-care spending approach U.K. levels. Can you just imagine? We’d spend a third of what we do today! Talk about fiscally sustainable.
Again, Goldhill fails to engage seriously with real-world, working examples of better health care. He just paints his libertarian dream as though it’s the only hope for real reform. And he leaves us with this:
I hope that whatever reform is finally enacted this fall works—preventing people from slipping through the cracks, raising the quality standard of the health-care industry, and delivering all this at acceptable cost. But looking at the big picture, I fear it won’t. So I think we should at least begin to debate and think about larger reforms, and a different direction—if not for this round of reform, then for the next one. Politics is, of course, the art of the possible. If our health-care crisis does not abate, the possibilities for reform may expand beyond their current, tight limits.
Having bashed the ongoing effort at reform, then, having not even sifted through the various piles of legislation for a scrap that might favor his approach, Goldhill wants to spark the debate about “the next round of reform.” Really? What on earth makes him think that after 90 years, we’ll finally get the political will to scrap our health-care system? And that next time around, reformers will scour the archives of the Atlantic to find his oh-so-unique approach? Our system’s been “in crisis” forever. Why won’t reform just continue to follow the trajectory it has – an ever-diminishing plan, whittled down every 15 years or so until it finally lacks enough ambition to pass?
The hard part
This ugly combination of cynicism with the most vapid idealism is what breeds inaction.
Being the lonely iconoclast is just so much easier than bothering with nuance and process. It’s harder to make an Atlantic cover story around “Why Ron Wyden’s Free Choice Amendment Is So Essential” than to make it around “Why We Should Ignore Reform and Plot to Bring About My Libertarian Utopia.” Fighting for a deeply flawed plan that’s much better than the status quo is far harder than throwing up your hands when it lacks a strong public option.
Real boldness – on the part of both Goldhill and Cassidy – would have involved taking a hard look at the process that’s taken us this long to get an outcome this mediocre. Criticizing the legislation itself is a cheap thrill. Calling out the systemic flaws requires some radicalism. This is why I love Hendrik Hertzberg. He’s been out there for decades, flogging the National Popular Vote initiative every chance he gets. Sloooowly, the idea is spreading, and one day, it or its successors might just change the country.
The one trait the Founders shared to the greatest degree is the one most worth striving after today – but also one that is often forgotten in the praise of their asserted genius. These men were no smarter than the best their country can offer now; they weren’t wiser or more altruistic. They may have been more learned in a classical sense, but they knew much less about the natural world, including the natural basis of human behavior. They were, however, far bolder than we are. When they signed the Declaration of Independence, they put their necks in a noose; when they wrote the Constitution, they embarked on an audacious and unprecedented challenge to custom and authority. For their courage they certainly deserve our admiration. But even more they deserve our emulation.
1 – This analysis itself is suspect. Cassidy’s main prediction is that the CBO scores for the legislation likely to be signed into law are wildly optimistic. But history shows us the reverse: “Over the last two decades, the CBO has routinely overestimated the costs of expanded government health care benefits and underestimated the savings from program changes designed to reduce expenditures.” It’s not a partisan thing, either; the CBO overestimated the five-year cost of President Bush’s Medicare drug benefit by more than 35%.
2 – The tax has shifted slightly; it’s no longer a tax on employers, but an excise tax on insurers. Here, Ezra Klein talks a bit about the difference between the House tax (on income over $500k a year) and the Senate tax (on high-value health plans). Generally, the Senate has been more hawkish about covering costs, and the bill that emerged from the Finance Committee and will form the spine of the Senate floor legislation goes further than the House bill to try to pay for health reform with revenues incurred within the health-care system, rather than with income taxes or other non-health-care-related means.