The Realignment of the (Perpetual) Future
I’m reluctant to riff on such a small bit from Lisa’s truly excellent post on political realignments. Still, there’s a brief speculation about the future realignment that I can’t help but note. She writes that “any future realignment … is usually assumed to be along pro-government/anti-government lines.”
Sadly for my side, I doubt this future realignment will ever happen. To get elected, a political party almost always has to hand out goodies of some type to someone. But rarely will a party go whole hog and offer the entire goodies package to everyone — health care, education, wars, corporate welfare — because doing so makes that party look authoritarian or even fascist. A lesson lately re-learned.
So instead, most parties propose half of the menu of direct, forcible transfers that the state can offer, and they call the remainder freedom. That is, they give either the social welfare basket or the military/industrial one. Campaigns tend to focus on which basket is better or worse.
Almost never does a party say to the voters “our platform won’t give you anything up front. In fact, our policies kind of hurt in the short term. But they are just, and they set the foundations for a better long-term future. This long-term future is one that we personally can’t envision, because American society does better without a central planner. Under my administration, the future belongs to you alone. Now quit watching this silly party convention and go get a job. Politics matters less than you think, and when I’m president, it will matter even less than that.”
That’s the campaign I’d love to run, but it’s also a guaranteed loser. People want goodies and freedom. Splitting the difference wins.
Fantastic. Fan-freakin’-tastic.Report
@Jonathan, Wasn’t this basically Paul’s campaign?Report
@Cascadian, That’s a fair analysis.Report
by goodies don’t you mean things we think the gov should do. that seems like a bit of childish swipe to suggest everybody else preferences are candy and not deeply felt policy preferences. Some of the goodies i wanted, like HCR, directly involve the gov so saying the gov doesn’t matter is just a way of saying you want a platform that you like. Bully for you, you’re just like the rest of us, you want a platform you like.Report
@gregiank,
I think Jason would say that his policy preference is that the government doesn’t do stuff not that it does the stuff he wants.Report
@Matty,
Precisely.Report
@Matty, yeah, his goodies are just a different flavor then mine and yours.Report
@gregiank, how’s that HCR working out for you?
Feel like your tax dollars have saved the lives of any children yet?Report
@Jaybird, HCR is working just fine….its the right vector after all even though its not as expansive or just the way i want it to be.
I’ve known many people saved from bankruptcy by EVVILLLLL government health care. Our current admin assist had a child in ICU for a few weeks which would have wiped them out and i’ve known others who got trt they couldn’t afford through gov programs. In fact i used to work with many indigent mentally ill folks who only got care through gov programs. so thanks for asking, yes. its not like anybody doesn’t get the connection between access to health care and health….i mean that would be ridiculous……Report
@gregiank, you *DO* know that it doesn’t kick in until 2014, right?Report
@Jaybird, i do know that it kicks in between now and 2014. that was done to mollify pols who wanted a lower price tag and for whom doing HCR correctly was a distant second. but still its the right vector.Report
@gregiank, the “right vector” is to create more health care.
This does not create more health care.
You’ll find that out, though.Report
@Jaybird,
Surely the right vector would be to create moreaccess to health care. I don’t know a lot about your reforms and don’t much like what I have heard but I was always under the impression was that people couldn’t afford to see a doctor not an actual shortage of doctors.Report
@Matty, if you see price as a signal of the relationship between supply and demand, and if you see that the trend in health care is that the price is continually going up, the creation of more access will create more demand which will create more price and, if prices have ceilings, longer queues.
We do not need more “access”.
We need more “doctors”.
Let’s say we have one doctor now. He works 48 hours a week. If we create more “access”, we have done little more than, what? Create a guy who now works 55 hours a week?
If, however, we create a new doctor, we create 48 hours of access.
And we do that *EVERY* time we create a doctor… compared to the idea that we just need more “access” to the doctors we already have.Report
@Jaybird, \
So if more doctors is what we need how would you recommend that we get more doctors without pricing people out of getting the medicine they need?Report
@ThatPirateGuy, here’s what I said here:
http://www.ordinary-gentlemen.com/2009/12/the-state-of-reform/
Well, there are a handful of ways, I’d reckon. The first is the “Northern Exposure” technique. Go to medical school and pass the equivalent of the bar exam and then spend five (or was it six? I don’t know how to count that last year) seasons in Cicely, Alaska. After your time is up, your med school bills are paid. Just have the government print out some money and pay those med school bills off. After putting your time in for half a decade (or whatever) in some remote place, any given doctor will have experience enough to move to somewhere else (maybe become a specialist) *OR* will have put down roots in a nice little local community and will become a nice little local doctor with established roots in the community.
I wrote more than that (visit the link! full of fun memories!), but that’s the thing that I think would give the best bang/buck ratio.Report
Sorry, TPG. My comment awaits moderation. Must be the link.Report
@Jaybird,
I can wait.Report
@ThatPirateGuy, I linked to the essay called “The State Of Reform” from December 2009. I had a bit of an extended comment in there. I have two or three different plans in there (that, coincidentally, can work together or individually).
If you feel like googling, it’s there.
If you don’t, I’m sure Scott or E.D. will unlock my comment shortly.Report
So you’re selling them the sense of morally superiority basket. Or is it the “one true way” basket? What abstract thought experiment will you be trying to sell them as political realities next, “Freedom”?Report
I won’t be selling them anything new. I will be asking the government in almost all cases to do less — not out of a sense of moral superiority, but because I do believe that in the long term, it’s generally best for all of us, and it delivers more of the goods that people say they want.Report
So when you have an interest that others do not agree to, that expands the services offered by government, you are not making a choice of what you want–you are claiming a right to take that good from others. So PJ O’Rourke described it long ago as:
Government should do nothing that you would not shoot your grandma for. Because everything the government does requires taxes which are taken from someone. And if your grandma does not pay her taxes, she becomes a criminal and can go to jail. And if she breaks out of Jail tries to run to Canada, they will send US Marshalls after her. And if she won’t give up, they will shoot her down like a dog.
Why do you hate grandma?
And some of you may not remember that during the Carter administration, it was the received word that more doctors made medicine more expensive. And med Schools were paid to reduce class size. Alas, it was before the internet age, and I can’t find a nice link on the web.Report
@Toby, “And some of you may not remember that during the Carter administration, it was the received word that more doctors made medicine more expensive.”
I’d *LOVE* a citation or something. Anything!
“And med Schools were paid to reduce class size.”
I’m pretty sure that this happened. It strikes me as something a lot more likely to be the result of a cartel putting out bad information in order to protect the members of their trade union.
Seriously, imagine someone saying that more blacksmiths means that smithing prices will go up.
More coopers means that barrel prices will go up.
More tailors means that clothing prices will go up.
Therefore, to protect *YOU*, the consumer, we need to restrict new folks engaging in smithery, cooping, and tailing.
See? I can only see a trade union making that argument.Report
@Jaybird,
I support an increase in the number of doctors, though it could very well be that an increase in doctors will lead towards escalating costs.
As the doctor shortage has increased since the 1990’s, health care costs have skyrocketed but physician pay has been pretty stagnant. One theory is that doctors, to keep up their lifestyle, simply upped the number of tests and procedures done to make up the difference.
It’s not hard to imagine an increased number of doctors all doing the same. What makes doctors different from blacksmiths? At least partially that they have a lot more discretion over the volume (and nature) of services that they provide compared to other fields.
More doctors can therefore simply lead to more tests and more procedures of dubious necessity. It doesn’t have to be that way if we can get better auditing in place, though auditing what a doctor says is necessary is tricky business, politically speaking. It’s something that needs to be done regardless.
As I said, though, I do support increasing the number of doctors. I am skeptical that it will save money in the longer run, but it will improve access to care. I also support leaning more heavily on mid-level providers.
Disclaimer: My wife is a doctor. Despite that, I support more “competition” for the services that she provides. Given the low portion of health care expenditures (between 8-10%) that go to docs’ bank accounts, I remain skeptical that you’re likely to see huge savings in that area and am concerned that, without additional change, it could very well lead to increased costs.Report
@Trumwill, One thing I’ve noticed recently is advertising for dental care on my television and radio (though, hurray, we got rid of cable last week and will no longer be plagued with tv commercials).
There are a ton of these things popping up. Academy Kids Dental, Perfect Teeth (apparently, Perfect Teeth is a, get this, CHAIN). They talk about how affordable their care is, how they take insurance, how they’ll work with you if you don’t have insurance, so on and so forth.
I have never, ever seen an ad for a Doctor.
I think that we (as a society!) would benefit from a marketplace where there were enough doctors out there to the point where they felt like they’d benefit from advertising on the telly. “Got a hernia? Got a stomach bug? Recently stabbed? Come on down to Doctor Barber’s! We’ll fix you up and fix you up *RIGHT*.”
(The closest I’ve seen is “have your baby at the birth center”. I reckon that’s because my city is big enough to have two competing hospitals who want you to have your baby here rather than there.)
I cannot imagine a situation where a significant increase in supply would not result in downward pressure on price… unless, of course, demand was significantly increasing even more.Report
@Jaybird,
I see it with doctors. Lasik, for instance. Botox and whatnot also advertise their affordability. The main difference is that these are markets in which the consumer pays for the service. Even though there’s a dental insurance market, there are so many people without dental insurance that it’s worth their time to advertise their low prices. That’s not really the case with basic health care. A copay is a copay and your doctor doesn’t really decide that. Beyond that, the system gets so complicated that you don’t even know how much you’re going to be paying until you’re given the bill.
The best that can be said of increased supply (as it pertains to prices) is that it gives insurance companies and Medicare more leverage in price negotiations. Which brings me to…
I cannot imagine a situation where a significant increase in supply would not result in downward pressure on price… unless, of course, demand was significantly increasing even more.
Which, since doctors have a lot of flexibility when it comes to demand, is a real problem. Cut the doc’s pay on a particular test or procedure from $100 to $50 on a procedure or test with $200 overhead, they can run twice as many tests or recommend twice as many procedures. Even if only a small number of docs actually do this, the result is increased costs. Say we’re looking at 100 doctors who ran this test twice a weak for a year (104 tests). They collectively made $1.04 million ($10k a piece) and cost the system $3.12 million. Their rates are cut and a quarter of the doctors respond by running the test (or a similar test) four times a week. The result is that the doctors are getting paid less per procedure and are on average making less overall (because 75% of them took the hit without drumming up new business/procedures/tests because they’re that honest)… but the system is actually paying more than it was before ($3.25 million).
Now in your case, not only are we cutting the amount per procedure, but we are creating more doctors to boot. Doctors that have a degree of discretion over which tests to order and which procedures are necessary. The government doesn’t want to be accused of rationing care. The insurance companies don’t want to be accused of denying tests and procedures that doctors are saying are necessary. Most importantly, patients who are only paying for a fraction of the cost of the tests (if that) want the medical care they believe they are paying for which of course includes any test the doctor seems necessary. Even if most docs are as honest and pure as the driven snow, it doesn’t take many dishonest docs to rack up some pretty hefty charges.
I’m not saying that these things cannot be dealt with. It’s a tricky subject, though, to say the least. And it’s very, very easy to imagine how more physicians will result in more money being spent.Report
@Trumwill, this is very interesting… and, yes, I can totally see how more doctors would result in more gaming of the system.
Hrm. Well, if we had a discussion of the difference between “first dollar coverage” and “major medical”… Ah, well. I can’t help but wonder whether something like “Perfect Teeth” for doctors wouldn’t work… we could call them “HMOs” or something…Report
Jaybird, yeah, if we had a catastrophic insurance system, that would deal with a lot of this. Of course, it would have the potential for creating a number of other problems. I’m sympathetic to HSA (with subsidies as needed) plus catastrophic myself, but others consider the idea laughable on its face.
Never heard of Perfect Teeth. A quick googling suggests a chain of dental care providers? Is it something like the Kaiser model, where the docs work for the insurance company itself? The Kaiser model holds some promise, but people are pretty much glued to the idea of having their choice of doctors. It could work in a system where consumers could choose their own insurance company rather than having it chosen for them by their employer.
Unfortunately, every potential solution requires a number of other changes, each of which somebody or some group will find very objectionable.Report