Not Politically Realistic

Cohn writes, “But if [Kling]’s going to dismiss single-payer as politically unrealistic, then I have to ask him: Does he think his vision politically realistic?”

No. I wrote here:

I should start by saying that the book does not contain a single major policy recommendation that is politically palatable today… Maybe some years down the road, after the public is fed up with health care gimmick policies that don’t work, the policy establishment will discover the ideas in Crisis of Abundance.

As that essay emphasizes, no serious health care policy approach (including the status quo) works well politically, because no approach is painless. The economic analysis says that we have to absorb pain in terms of limiting access to health care, limiting consumer insulation from health care costs, committing extravagant resources to health care, or some combination of all three. However, those trade-offs are evaded in political debates. Instead, there is strong demand in the political marketplace for gimmicks that purport to provide painless solutions.

Cohn and Kevin Drum (whom he cites) argue that individuals will pay a premium in order to avoid the stress of having to factor in cost when making health care decisions. That’s fine! There are all sorts of things that individuals pay for that I think are not worth the value. Cable television, for example. No one forces me to get cable TV, and I don’t force other people not to buy cable TV. I think it should be the same with health care insulation. If people want insulation, they are welcome to pay for it. And if they cannot afford it, meaning that they choose to spend their money on other things, so be it. Doing without insulation is not the same as doing without catastrophic insurance or doing without health care.

Also from this issue

Lead Essay

  • In this month’s lead essay, Cato Institute adjunct scholar Arnold Kling draws from his book, Crisis of Abundance, to argue that the health coverage most Americans enjoy is not insurance at all, but what he calls “insulation.” “The problem with insulation,” Kling argues, “is that it is not a sustainable form of health care finance… Insulation leads people to over-consume health care services. Americans make extravagant use of services that have high costs and low benefits.” Kling explains how real health insurance would work, and how it would help solve the crisis in health care, and explores how we could transistion to a system over time institutionally and culturally in order to resolve the inconsistent demand for insulation and affordable, effective care.

Response Essays

  • According to health care strategist Matthew Holt, Arnold Kling is correct that consumer insulation from the costs of “premium medicine” is partly responsible for the rising cost of health care, but Holt dissents from Kling’s solution. Holt examines what he takes to be the three main strategies for dealing with “the insulation and overuse of medical care in the U.S.”: a nationalized “single payer system; a system of “managed competition”; and “individual consumer control of spending at the point of service.” Holt argues that the latter two options face deep problems, and that a nationalized single-payer system “is the likeliest outcome in perhaps a decade or so,” even it is not politically feasible at present. “Kling has provided a decent analysis,” Holt argues, “but has proposed a solution that both ignores the political and cultural realities of the health care system, and probably wouldn’t even work in theory.”

  • Clark C. Havighurst agrees with Kling’s “diagnosis of what’s wrong with health care” in the U.S. “as far as it goes.” Havighurst goes further and digs into the reasons the U.S. health system “has evolved into an entitlement program under which everyone expects nothing less than the very best that ‘modern medicine’ has to offer.” Havighurst lays the blame at the feet of the government’s choice to subsidize the purchase of health care by “excluding the cost of employer-sponsored coverage from employees’ taxable wages and income” and lucidly details three different mechanisms by which the tax subsidy insulates workers, consumers, and voters from the costs of health care. Havighurst proposes that “something approaching [liberals’] goal of universal health coverage could be achieved by ending the current tax subsidy and offering refundable tax credits of, say, $6000 to families that spend at least that amount in health plan premiums or contributions to a health savings account.”

  • Jonathan Cohn, a senior editor at the New Republic, agrees with Kling that our current health care system doesn’t function according to the widely understood principles of individual insurance, but he doubts we’d do better at fighting rising costs and maintaining quality if citizens with “real” insurance were free to take price into account in their choice of care. “We have precious little evidence to believe that people can distinguish good care from bad care,” Cohn writes. And the notion that consumer choices will improve over time is, according to Cohn, “a lovely idea, but one that seems highly dubious.” Cohn argues that we need a broader notion of insurance – social insurance – to shield people not only against unexpected illness and harm, but against “genetic and economic bad luck.” Cohn argues that many nations do just fine in managing the cost/quality tradeoffs inherent in a state-controlled system of universal coverage, and that Americans would be happy with such a system “if only they knew how those systems really worked.”