a broken system ctd.

By now we are all aware that should liberal health care reform pass through Congress we will face government-sanctioned euthanasia of the sick, elderly and mentally incompetent; we will sit in lines longer than the opening night of the third Lord of the Rings film just to see our primary care physician, who will then turn out to be a disgruntled DMV worker with a stethoscope replete with Gestapo uniform; and when we do receive “care” it will be so subpar as to be in fact harmful – far more harmful, in fact, than no care at all.  Obama will quite probably set up a “death panel” to determine which citizens are worthy and which have outlasted their usefulness.  This panel will quite possibly include the judges of popular left-wing television show American Idol.  (They’d call the panel a “Life Panel” though, wouldn’t they?)

And yet…

Reading over Philip Giraldi’s piece at the American Conservative on our no good, very bad health care system, I’m reminded of just how prohibitive health care costs really are for most Americans.  There are a number of reasons for this, of course, but at least part of the reason is the fact that benefits are tied so closely to employers and outside of that partnership you really do find yourself with few options – especially if you’re older, sicker, or poor.

I remember looking at COBRA as an option after I lost a job several years ago.  We’d been living paycheck to paycheck and the costs to buy into COBRA, even as two young, fairly healthy people, were impossibly high, especially given that we no longer had a revenue stream.  My wife was pregnant and a student and not working.  Even when I did get a job, my benefits didn’t begin right away.  So we were left with no option other than  state-provided insurance which we qualified for, thankfully, given that we were totally broke and had a baby on the way.

After a few months we were back on employer-provided-benefits.  This is how safety nets were meant to be – temporary.  Far better than having to rely on the government, right?   Then again, I’d rather not rely on my employer either.  That’s hardly “insurance” is it?  When you lose your job you lose your income and your health insurance.  That’s a rather precarious situation.  And it’s hardly insurance.

Right then, Kain, so why do you oppose government insurance?

I don’t, actually.  I realize that at this stage of the game the only player that can enact real reform is the government, and that the politics of the country demand a modest proposal, or at least something middling that can please a broad swath of the country.

I think government probably could run our health care fairly decently, actually.  It can run a top-notch military, after all, and provide health care for military personnel that is considered quite good.  I think we can do better, and I think we should try to avoid the cost of an yet another massive federal entitlement, but I think the hysterics over all of this have gotten out of hand.

A single-payer system (which I know, is not on the table) might even be more efficient than the mess we have now – a heavily bureaucratic status quo that is neither efficient, nor a real market solution, nor particularly fair for those who need insurance the most.  It is the worst of all worlds in many ways, and could certainly stand to be overhauled.   I think health care, whether or not it is a right is certainly an essential piece of a stable and aging society.  Either way, I think we need to achieve as universal coverage as possible, and I think we should do it right.  Implementation is everything.  Once entitlements are implemented, they become terribly difficult to reform.

What I don’t want to see in health care reform is:

• Retrenchment of the status quo and a continuation of employer-provided insurance as the only viable means of acquiring health care, especially if we remain heavily unemployed.
• Further monopolization of the insurance market or health care providers, suppliers, etc.
• Along these lines, an end to competition both in the insurance and in the provision of health care, driving up costs and decreasing access, innovation, outcome, etc.  (a public option wouldn’t necessarily do this, but certainly without breaking from the status quo a public option could easily perpetuate and increase these trends….)
• Any reform that is fiscally insolvent, cannot pay for itself, or leads to massive deficits or a great deal of new taxes.
• Any reform that does not achieve close to universal coverage.
• Any reform that requires employers to provide insurance, thus perpetuating the status quo.

Regulations and reforms I’d like to see:

• Taxation of employee benefits: insurance should be personal and portable rather than temporary and tied to a job.
• Deregulation of insurers to allow national competition: with proper rules in place, more competition will only help consumers.
• An end to “pre-existing conditions” clauses and abuses of rescission.  These smart regulations can be achieved with…
• Two-way mandates: insurers would be required to provide insurance and citizens required to buy it.  In the end, if we want costs to be well distributed across the system, everyone needs to at least have catastrophic coverage, and we should not maintain a system that crowds out those who need it the most.
• Cost-assistance in the form of vouchers.  Any public option should be offset by vouchers to keep it honest, especially if the public option is a national one.  This also helps stave off monopolization.
• Any reform should be fiscally sound and not be a drag on the economy.  Reform should work to bolster the economy, free up businesses to be more competitive, and free up employees to be more mobile and confident.

• An end to protectionism in the health care market, especially in the form of pharmaceuticals which keep costs artificially high.
• Relaxing of medical provider regulations that have led to cartelization of the industry.  You don’t need an M.D. to sew stitches.

Some of these reforms, like two-way mandates, can quickly become pernicious if monopolization occurs.  So many of these also hinge upon one another.  A public option will work better if there are also vouchers; mandates will only work if there are provisions against pre-existing conditions; insurance providers will only remain competitive under these circumstances if the current barriers to real, robust national competition are removed – and so on and so forth.  No bill will perfectly implement every needed reform, of course.

Wyden-Bennett, for instance, does not fit this equation perfectly, but it does a pretty good job.  Now that Reihan Salam is writing at NRO, I can even claim that it’s gained some support there.  And, as Mark points out, conservatives have many more reasons to oppose HR3200 than they do Wyden-Bennett.

So what is making bipartisan efforts to reform health care so difficult?  Is it just bad faith?  I think in politics there’s always plenty of bad faith to go around.  But there is something fundamentally broken about the process in this country which boils down, I think, to deep and widespread distrust: of the government, of markets, of each other….

In Europe real reform has occurred with concessions to progressives and conservatives alike.  Often liberal agendas – the welfare state, generous safety nets and so forth – are achieved through conservative means and paid for by more conservative taxes (such as VATs).  This, in turn, has lead – in countries like Denmark or Ireland – to greater economic freedom, a lower and broader tax burden, and competition that is good for business, good for state budgets, and good for those in need of a safety net and those out to save money on the free market as well.  Compromise is seen as a series of trade-offs that can be made to work together, rather than merely a gradual watering-down process.

Denmark’s unemployment remains low, its economy strong, and its citizens universally in possession of health insurance.  And yes, this is largely the result of good governance, of a smart and limited government working to implement its safety nets by giving people as much freedom as possible, thereby also limiting the potential side effects of government overreach.  This is not the only example of smart, limited government.  (Via Mark, check out the Heritage Foundation’s index on economic liberty.)  It can be done.  Limited government is good for everyone involved, but it takes reasonable compromise and concessions to achieve.

And it’s one reason I’m not a minarchist like commenter and friend of the League Mike Farmer or a Randian or very fond of the tea party movement.  I don’t have much faith in government, but I also don’t have much faith that society will act voluntarily for the public good enough to provide meaningful safety nets.  I believe that for capitalism to work, safety nets need to work, and never is this more true than in an increasingly globalized economy where industries themselves rise and fall in the space of a generation.

David Frum writes:

If we win, we’ll trumpet the success as a great triumph for liberty and individualism. Really though it will be a triumph for inertia. To the extent that anybody in the conservative world still aspires to any kind of future reform and improvement of America’s ossified government, that should be a very ashy victory indeed.

Frum is wrong to draw the line in the sand at the public option, and if he really wanted to dig into this debate he would offer up some smart alternatives to funding or implementation rather than a list of fairly banal talking points that don’t actually address governance at all.  But he’s right about one thing – a conservative victory that is little more than a defeat of reform in general is no victory at all.