Thursday, July 21, 2005

Healthcare is for Geeks

I want universal healthcare. I believe all the normal liberal lines about it. Risk-pooling is efficient, not a government monstrousity. Keeping citizens healthy is a basic function of government, and not something left to consumerist fate. Perverse incentives drive costs up (lack of preventative care, emphasis on unnecessary procedures). Costs are spiraling upwards faster than GDP or inflation. Our private healthcare system costs more than most national healthcare systems. It creates more labor-market rigidity than any minimum wage. The ways we differ from the other Western democracies (both more liberal and more conservative) are usually a cause of embarrassment, and this is definitely one of them.

So I hope people take me seriously when I say, this sort of thing has got to stop!

The main lesson of HillaryCare is that when the right moment comes along politically we need to get whatever form of universal reform can be agreed on shoved quickly through the Congress. Make no mistake, universal insurance is a big bang and a necessary big bang. Getting it through will be a hell of a confluence of opportunity and tactics. Once we get it done, then we have a while to worry about sorting out the system to the purists' satisfaction later.

That’s Matthew Holt giving a Speaker of the Dead style post-mortem for Clinton’s attempt at universal healthcare. Other liberal bloggers pushing for this lately include Ezra, Yglesias, Neil, etc. They make the argument that a) we desperately need something, b) when we have something it will be uber-popular and impossible to kill of, and c) sniping about wonky details makes liberals look eggheaded and detatched while not convincing any voters. All true.

But gah! We’re supposed to be technocrats here people! This is entirely the wrong way of thinking.

1. A huge institution that can’t be destroyed once invoked, is not attractive to people who are nervous about universal healthcare. Capitalists’ fears that once such a system is created, they will have no control over it’s excesses and growth are only exacerbated by this argument.
2. It does matter what the details are. I don’t know what the best solution is, and there are more moral hazards than I care to ponder. But being complicated, and a lack of a perfect solution, does not mean that there aren’t solutions that are significantly worse than others.
3. The details are going to be darn near impossible to change. Does anyone think we’ll set up a huge government institution, and while deleting that institution would then be impossible, systemically changing it would be quite simple. Even something as pure as universal healthcare will have plenty of corrupt agents who have an interest in maintaining that status quo. In fact, setting up institutions like MediCare are what got us into this situation. Instead of Truman’s vision, Johnson pushed for a compromise he could get. Now, we might like the results of that compromise, but it’s been nigh impossible to change.
4. You don’t need to give politicians advice on Machiavellianism. Tell them what the right policies are. If there really is a way to push something through, I doubt any Congresscritter or President is going to err on the “not political enough” side of things. Sure, we can now say Clinton probably did things wrong back then with hindsight… but there’s no reason to believe at any particular time that we have better knowledge for Congressional dirty work than the Big Dog or other party leaders.
5. The paradox of “giving cynical explanations for proposed rhetoric” continues to confound. If you say “say X because it will get votes” loud enough to actually convince Democratic leaders, there’s little chance the moderates or aisle-crossers won’t hear you as well. This particularly comes up during campaigns where every liberal pundit is saying candidates need to express their Christianity more… and then wonder why no one is convinced by the Democrat’s expression of faith. Glenn Reynolds is not afraid to quote you, people.

Go wonk off about healthcare. Tell me why various systems in other Western democracies would work or not work here. Explain how a high level of private care can co-exist with a base level of public care. Argue with economists who say government catastrophe insurance is the optimal solution. Leave the dirty work to the ambitious bastards.


At 8:10 PM, Blogger Neil Sinhababu said...

I like the point about how we shouldn't be giving politicians advice on how to be Machiavellian. This echoes something Matt likes to say a lot about how we should keep trying to build support for single-payer health care rather than pushing half-measures for expediency reasons.

At 9:37 AM, Blogger Rousseau said...

Nod. Matt is still one of the leaders for "get anything, fix it later". But he's right that we shouldn't be going to corporate interests with compromises if they haven't expressed interest yet. When they want to compromise, they'll let us know.

Universal healthcare seems so inevitable, such a rising tide (that has swept every other affluent nation) that the measures conservatives use to stop it seem so foolish. If I were a top Republican, I'd pass something just like Matt says while I'm in power, so at least it would benefit me and it wouldn't get changed. Shrug.

Anyway, I'm curious what wonks think of the proposition that private health insurance in this country is so tenacious and so profitable BECAUSE the government is already funding the most expensive healthcare.


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