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. Read the rest of this entry »