Saturday, February 6, 2010

The two great myths of health care - part 1

I'm returning from my self-imposed exile because I'm finally fed up with the rhetoric surrounding the endless and, almost certainly, failed bid to create a health care plan that will actually help Americans at a reasonable cost. Having read endless amounts of prose on the two sides over the past year, I don't need to articulate the very real concerns that the right has over these proposed plans (of course, 95% of everything they've said is garbage - death panels? - but worrying about future costs is perfectly reasonable), because they seem to be carrying the day.

No, I have a problem with the left, particularly that segment of the left which says, "We're not getting everything we wanted at the beginning, but it's still a good start; let's not make the perfect the enemy of the good." I'm with them up to a point. I think something should be done, and the bills that are on the table represent some progress toward treating health care, to some level, as a right of citizenship rather than just another consumer good.

But it is profoundly unhelpful to advance arguments that are wildly speculative and questionable as justification for passing such major legislation. And, as I've had the opportunity to read and ponder much of the rhetoric, I've identified two such arguments that are seen as "proof" that we must move ahead with what's on the table. In this post I'll take up the first: the idea that whatever is passed will inevitably be improved in the near term, so we better get the ball rolling.

Any number of bloggers and pundits have taken up this idea, this utopian vision of "It must get better, so let's get started." Matt Yglesias, Ezra Klein, et al seem honestly to believe that flawed legislation will inevitably be followed by better legislation ad infinitum, that somewhere in the future we will end up with a near-perfect system in which everyone gets what they deserve and no one has any problems. This viewpoint is exemplified by a Kevin Drum post from today:
In 20 years this bill will be entirely forgotten except as the first step toward broad national healthcare. The excise tax, the public option, the subsidy levels, the exchange — all forgotten because they will have been steadily replaced by an entirely different infrastructure. It's true that some of that infrastructure will be path dependent on the details of the current bill, but most will simply evolve as a result of technology and public demand. By 2030 arguments over the public option will seem as antiquated as rants against the tin trust.
Wow, that sounds great. But do these folks have any evidence to offer along this route to perfection? Well, they love to cite both Medicare and Social Security, which started out in limited ways, requiring years of pressure and legislation to achieve their current status.

And I will admit that these programs, each of which were thought wanting in their original creation, have been refined over the years and become closer to their original intent. And national health care kind of looks like those programs, so it is natural (if somewhat pat) to believe that the arc of development will be the same.

However, the rationalist must then look more broadly, across all government programs, and must ask: "Has that been the fate of all large-scale government programs? Do they inevitably start out small and limited, and grow to something wonderful over time?"

The answer must, alas, be no. I'm sure there were people who felt that our periodic stabs at creating better schools would eventually lead to, yes, better schools. And some of those people have been waiting for three generations to see those schools improve, and they're still waiting. The war on poverty was going to stamp out the injustices that prevent people from achieving their dreams, and it is a war as yet unwon.

There is very little evidence that there is political tide which inevitably makes bad or flawed legislation into good policy; there are numerous examples on both sides of that ledger. I'd like to see those who are willing to settle for whatever Washington may eventually pass to concede that it may not ever get a whole lot better than what we start with. If there are flaws in National Health Care 2010, they may well still be there in 2030 (and 2050...), and we had better be prepared to live with that. [The other myth later...]

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