Sunday, November 15, 2009

Health care reform shorts:
The Massachusetts plan corrals the "left"

Health policy writers seem to be filling the lull between passage of a House bill and Senate Majority Leader Harry Reid bringing forward some as-yet-not-fully-defined legislation by writing about the Massachusetts experiment that has been underway since 2006. That state has greatly increasing nominal insurance coverage, reaching almost all residents, though a Kaiser Family Foundation assessment from September 2009 reports that 21 percent of insured people still don't feel they can afford medical care. And the wonks applaud it even though Massachusetts has not succeeded in lowering costs, either in the form of insurance premiums paid by individuals or to the state.

But Ezra Klein at the Washington Post and Jonathan Cohn at the New Republic are fans of the Massachusetts effort -- and they highlight one very similar observation. Klein, interviewing Jon Gruber, a health economist at MIT, elicited this quote:

We passed our bill. The lobbying group Health Care for All was incredibly important in that. But they were primarily about coverage. But then they realized that they would lose all this coverage they'd gained if it didn't control costs. So they got behind real cost-control measures. ...

Cohn makes the same point in his own voice.

If costs continue to skyrocket, the state's health care reforms will become unsustainable, requiring either large cuts or tax increases. Then again, until recently, Massachusetts hadn't seriously tried to reduce costs. The goal was simply to expand coverage and, perhaps, deal with costs later--which seems to be what's happening now. ... [T]he new system, by giving the state a greater stake in health care costs, has focused public attention on the problem and provided the government with more leverage to solve it. The left also seems more invested in the cost issue now, if only because it recognizes that controlling costs is necessary to sustain the recent coverage expansions.

I read both of these men to mean, more or less, that the good thing about passing some sort of health care reform structure is that it will shut up those annoying idealists who think health care is a human right and simply a proper benefit of living in a wealthy, civilized society. A coverage reform would get these bleeding hearts on to the serious business of controlling costs -- without the baggage of their fantastic egalitarian policy prescriptions.

I find this galling as policy prescriptions for controlling costs doesn't look so hard to imagine when a right to health care is assumed: simply make the government the payer for all health care and pay what the society decides democratically to allocate to health. We'd probably be willing to go for 15 percent of the government's tax income and that's a lot. Some variant of this is what every other developed country does, one way or another. There are still doctors and hospitals in those countries -- they just don't make mega-bucks.

For a more skeptical consideration of the Massachusetts plan, Cohn pointed to an extensive series in the Columbia Journalism Review by Trudy Lieberman. That reporter had this to say about what the state plan implies about cost control:

It's no secret that Massachusetts' lack of cost controls, deliberately avoided when reform passed, threatens to undo the law. Ultimately, if the state has no way of paying for subsidies to cover insurance premiums, the law is doomed. Same goes for national reform. ... People I interviewed mentioned the lack of a dedicated funding source, similar to that which exists for Social Security and Medicare, that would pay for the subsidies. Without such a source, financing is always at the whims of politics and competes with other state priorities. ...[W]e urge reporters to stay on top of this one, because it will mean the difference between life and death for any health plan politicians try to sell to the American people.

She doesn't want to rein in the idealists -- she just looks for the shortest distant between two points. If the government needs money, tax someone who can pay to raise it. Taxes are the price we pay for living in a civilized society. A society that refuses to pay for its own welfare is well on the way to death. (I know, I live in California which works that way.) This posture strikes me as realistic, while elaborate schemes to cajole profit-seeking entities to moderate their profits seem the flights of fantasy in the health care discussion.

UPDATE: Jonathan Cohn has written me to protest that he has

been making the case for universal health insurance, purely on moral grounds, for more than a decade. And i've always supported single-payer, although I also support lesser measures that, in my view, still do a lot of good.

It so happens I also think we need to get a grip on rising costs, simply because the system is becoming financially unsustainable. And, as a practical political matter, I do think that taking care of coverage makes it easier to interest liberals (a label I've always embraced) in the cost issue.

But, for me, health care reform has always been -- first and foremost -- about making sure all people can get the medical care they need at a price they can afford. Guess you could say I have a bleeding heart too.

I think I owe him an apology or at least an explanation. I write about health care reform out of an ongoing fear that the realities of people's experiences will get lost in the fog of policy and political claims and counter claims. Responsible citizenship, in my view, requires repeatedly getting back to what it like to live in this mess and also reiterating ethical imperatives. I often fear that "understanding health care reform" almost requires forgetting what we know experientially. I've worked hard enough on understanding reform that sometimes I fear I am doing that myself.

Cohn presented the horrible present realities in his 2007 book, Sick.

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