I was going to answer Kling’s original response – and still plan on doing so, shortly. But I just have to jump in and comment quickly on his reply to Holt. I’ll let Holt explain why the vision Kling paints of technocrats secretly cooking up medical guidelines is grossly misleading. Instead, I am curious about this line in Kling’s piece:
Finally, Holt’s version of single-payer is politically unacceptable. He wants to reduce the power of physicians, not only in the political process but in day-to-day decision-making about medicine. That is going to meet resistance not just from the medical profession but from the typical consumer.
Whoa, when did political reality enter the situation? One of the things I appreciated about Kling’s original essay (and book) was its frank acknowledgment that his ideas for reforming health care were at odds with the desires of most Americans, who had become accustomed to “premium medicine” at low cost. In other words, he was proposing a reform – but he recognized that it was not one that most Americans would embrace, at least initially.
But if he’s going to dismiss single-payer as politically unrealistic, then I have to ask him: Does he think his vision politically realistic?
Kevin Drum, who writes the “Political Animal” blog on the Washington Monthly site, had a great entry the other day – responding to our exchange here – in which he pointed out just how unappealing the idea of turning medical care into a giant marketplace really might seem to many patients. Here’s the money quote: Kling, Drum says,
thinks the healthcare biz need less insurance and more free market capitalism in order to drive down costs and force people to buy only the care they need. I doubt it. More likely it would result in what I saw today: medical offices becoming more like Turkish bazaars (or used car dealerships), filled with distraught patients trying to decide whether they can afford a crown today or if they should wait and run the risk of needing a root canal later. No thanks.
Drum’s story is pure anecdote, I know. And I’m sure there are some people who really would be prefer a more consumerist model (which is why, within reason, I’m willing to give people at least an option of having it — if it’s within the context of a universal health care system). But there’s actually research to show that people prefer security, even if it means earning less money, to risk, even if it includes the possibility of making more money.
I’ll be talking more about that research shortly; I have to go back and read up on it again in Jacob Hacker’s book – which, reminds me, I have some issues with Kling’s characterization of Hacker’s work, too. But before I do that, I want to offer my best evidence that Kling’s vision is not politically viable (at least, not more so than single-payer). That’s the experience of two other countries.
One is Singapore, a country the advocates of Kling’s consumerist approach often tout as proof that Health Savings Accounts work. Singapore has universal health care, but not of the traditional sort. It offers just catastrophic coverage; then it gives people special savings accounts, which they can fill and then use to cover routine medical expenses. In effect, it’s just like HSAs here.
But guess what’s happened? Affluent people ran out and bought private supplemental insurance to cover what the catastrophic insurance didn’t. It turns out that, when faced with a choice, they really did prefer to have more insulation and less risk.
The same thing happened in France. It will boggle the minds of conservative Euro-bashers, I know, but some time ago the French decided to increase cost-sharing in their national health insurance plans – imposing up to 30 percent co-payments – for outpatient services. And what did the affluent French promptly do? Exactly what their counterparts in Singapore did. They ran out and got supplemental insurance, which is why very few people in the French middle class actually face high cost-sharing now.
You may have noticed that, in both cases, I referred specifically to the affluent (by which I mean the middle class as well as the poor). That’s because the poor couldn’t afford the supplemental coverage. In France, the government decided to subsidize supplemental insurance for low-income people, which is why you don’t have serious financial barriers to care in that country. In Singapore, they’ve been less successful at solving the problem. (Singapore, to its credit, does have an extensive public clinic network that helps provide routine care, particularly to the poor. So that helps offset the effect of the high-cost sharing on poor people who can’t afford the supplemental insurance. But I don’t gather that the advocates of consumerism here would support a scheme to develop a similarly massive network of government-run medical clinics.)
Truth be told, part of me hopes that conservatives keep promoting this. It only makes universal health care seem that much better by comparison.