The Agnostic Crusade

The time for conservatives to oppose national health care reform has passed.  The existing system is a hopeless jumble of public and private bureaucracies, and its costs are outrageous and rising with no end in sight.  A majority of Americans want reform, and will continue to want reform.  Conservatives now should work to shape the reform to maximize the cost-effectiveness and minimize the bureaucracy in the coming national health care system.

For a long time, I was staunchly opposed to a national health care system.  As one inclined toward the libertarian wing of conservatism, I insisted that it was not constitutionally within the federal government’s jurisdiction.  I said it would cost too much, that it would create unprecedented bureaucratic inefficiency.  I said it would inflate the demand for unnecessary care, leading to snowballing cost increases.  When I was feeling really cynical, I imagined national health care would consume the whole economy—younger workers would be taxed into poverty to pay for extravagant efforts to sustain the growing ranks of the elderly and the terminally ill.  Or alternatively, I said national health care would arbitrarily deny people the care they needed in order to control costs.  Here the dystopian vision in the corner of my mind was a Soylent Green scenario of forced euthanasia.

I started to change my mind in the mid-’90s, when my grandmother was hospitalized with dementia, and physiological problems created by her inability to care for herself properly.  For many years afterwards, she lived in a series of rehabilitation centers, “assisted-living” facilities, and nursing homes, broken up with occasional hospital stays.  The cause of her dementia was never firmly diagnosed—it could have been Alzheimer’s, or something else, and since at least 1950 she had never been very healthy, mentally or physically.  Anyway, when she was hospitalized it was clear to all of us in the family that she was on an inevitable, slow decline into helplessness, followed by obliviousness and death.

The relevant thing that struck me then was the way her doctors and caregivers made decisions about how to treat her, when to admit her to a hospital and when to release her, and when to send her to other institutions.  They often made these decisions not based on what was best for her health, not based on what it was worth doing for a patient who was terminally ill, but based on following arcane rules to maximize the number of Medicare benefits for which she would qualify.

Eventually I realized that the political question of national health care wasn’t whether or not the government should impose a giant bureaucracy on the health care system.  We were already there.  The question wasn’t whether or not taxpayers should pay many of the medical costs of the elderly and the sick.  We were already there.  The question was whether the government should step in with both feet and try to keep the costs of health care from growing without limit, as they have been since the failed Great Society of the 1960s.

The trouble with the U.S. health care system now is that it is neither private nor national.  Control is divided between numerous federal agencies, state agencies, giant manufacturers of drugs and medical equipment, giant insurance companies, HMOs, and corporations that run chains of hospitals and other care facilities.  Very little control is left for doctors and patients.  The corporations and government agencies often ally with one another to serve their own interests in money or power, showing little consideration for the health or finances of the patients they claim to serve.

The conservative in me would still like to see the government get out of the system and repeal its volumes of regulations that only sizeable corporations have the capacity to keep track of (and the lobbying funds to influence).  It would be nice to see a return to an old-fashioned system where individual doctors serve small communities out of small offices with little supporting staff, where insurance companies are also small and close to the communities and individuals they serve, where communities band together and make sure the poor get the care they need.

But the pragmatist in me sees that it’s never going to happen.  The political reality now is that a majority of the population wants national health care.  They don’t want the personal hassle of dealing with insurance companies, their employer’s benefits departments, and starting all over again every time they change jobs, or get married, or have a child, or retire.  They want health insurance that’s universal, lifelong, and transparent.  People won’t stand for any rollback of federal health benefits—they want an expansion of federal benefits.  Besides, the level of technology, expense, and complexity in medicine today is such that large organizations—either government or powerful corporations—will necessarily play a central role.  Given the choice between relying on a government accountable to the people to provide health insurance, or a cartel of corporations accountable only to their stockholders, I have to choose government.

Many of those on the left, who have been pushing for national health care for decades and preaching that health care is a fundamental human right, would have the government provide care of unlimited extravagance for everyone.  They will have little concern over the cost, and will happily expand the federal bureaucracy to achieve it even if they must satisfy the insurance companies by preserving their private bureaucracies too.  Opposing this tendency is where conservatives must find their role in the legislative debate.  In order to succeed, health care reform must reverse the incentives and inefficiencies that have made care as costly as it is today.

Three examples:

1. Health care providers, insurers, and manufacturers of drugs and medical equipment too often are large corporations driven more by greed than by any sense of professional responsibility to patients.  Through deceptive marketing that preys on the ignorant, these corporations artificially inflate demand for needlessly expensive products and health care techniques.  In particular, drug companies spend millions of dollars advertising prescription drugs in the mass media, not to the doctors who prescribe them, but to patients, most of whom cannot possibly make an informed decision about which drug will be most effective for them.

To address this problem, we should make sure public funds or subsidies cannot be used to pay for drugs or treatments advertised in this manner, and should consider banning mass-media ads for prescription drugs altogether.  We should reduce the financial incentive for care providers to use more expensive treatment methods, by making sure that publicly funded health insurance reimburses providers with only a fixed dollar-amount margin above their cost for each treatment, rather than a percentage.  And finally, the government should provide incentives for researchers and manufacturers of drugs and medical equipment to lower costs, by awarding grants to those who develop new products that cost less than older equivalents.

2. Malpractice insurance has become enormously costly to doctors, and they must pass this cost on to their patients.  The optimal solution is not to interfere with the judiciary by imposing arbitrary caps on damage awards, but to change tort laws to adopt a sensible definition of what constitutes actionable malpractice in the first place.  Those, like doctors, who make a good-faith effort to help someone in need should only be assessed damages if their efforts display true negligence or incompetence.  Doctors who, in the heat of a crisis, make an informed, reasonable decision that later turns out to be wrong should not be liable.

3. Health care providers spend a lot of excess time and must hire excess staff to deal with myriad intersecting bureaucracies.  Too often, they make treatment decisions based more on gaming the bureaucratic rules than on the patient’s needs.  The federal government is a primary contributor to the situation with its patchwork of health care programs for different constituencies.  Comprehensive reform intended to guarantee health insurance to all is a unique opportunity to unify and simplify the bureaucracy.  There is no reason why we should have Medicare for retirees, Medicaid for the poor, CHIP for children, the VA for veterans, and yet another separate program for uninsured workers, each providing insurance and imposing its own regulations.  Each of these groups of people needs similar care, and each should be insured under the same set of rules.

With an issue as complicated and involving as many interest groups as health care reform, it can be easy to get caught up in the mechanics of exactly who has how much control over what and exactly who and what to tax to pay for it.  But if the government creates intelligent incentives for private providers and manufacturers to cut costs, while making sure that government itself doesn’t contribute unnecessarily to costs and inefficiency, the mechanics will take care of themselves.  If medical care becomes more affordable, more efficient, and easier to use for the society as a whole, everyone involved will be happier in the end, no matter what shape the bureaucracy and the tax structure end up taking.