In October of 2009, while the debate over “Obamacare” was in full swing, the Public Editor of The New York Times (at the time Clark Hoyt) used his column to discuss the difficulties of reporting both on the actual health care bill and on the debate about it. His scope was broad — the complexities of legislation, the vagaries of economics, the different values people bring to their positions, and the infighting over electoral politics. I had a narrower question for him: how do we get past the fact that so much of the debate hinges not on what the policy will be but on how people might be expected to react to it — and to change their behavior in response?
I sent this to ask that question. I got no reply. I certainly don’t know the answer and, I suspect, neither does he.
11 October 2009
There are many reasons why the health-care reform debate is so confusing — not the least of which is that many of the people driving it come into the debate with their minds made up, so they are really engaging in advocacy more than debate, and new voices (like the Atlantic cover article which was the most accurate assessment I’ve seen of what the real issues and problem are) never make it into the conversation.
But one of the main problems is that so much of the outcome hinges not on what is explicitly stated in some bloated and arcane piece of legislation but on what the unstated incentives are that get built into it and in how people react to those.
I am reminded of debates over various civil rights and affirmative action legislation in an earlier era. Hubert Humphrey famously defended the 1964 civil rights act against charges that it would lead to quotas by pointing out that nothing in the law called for quotas and that he would eat a copy of the law if it led to quotas. He was right that the law didn’t call for quotas and, as far as I know, he never actually ate a copy of it. But, that it resulted in quotas being imposed cannot be doubted. The point is that, notwithstanding its silence on the issue, people found the only sure-fire way to avoid charges of discrimination under the law was to be able to demonstrate statistical parity in their workforce or student population; and the only way to guarantee that, in a world of unevenly distributed talents and qualifications, was to impose unofficial quotas — that is, they reacted to a (perhaps) unintended incentive built into the structure of the law by changing their behavior in a way that the law never explicitly called for.
The same may be said about the various health care proposals floating around. Joe Wilson’s outburst in the House during President Obama’s speech was unequivocally a rude breech of both protocol and decorum, but the reports that he was “wrong” about whether Obama’s health care proposals would provide medical care to illegal immigrants — whether you think that should be a decisive issue or not (I don’t) — focused exclusively on the language of the bill, on the fact that it declared illegal immigrants ineligible. But the beef Rep. Wilson had was not in whether the bill authorized such a benefit but in the fact that it provided no enforcement mechanism to prevent it — that, in practice, such benefits would be given regardless of what the bill said because the incentive for people in the field would be to treat and collect rather than to investigate and deny.
The same is true of the “public option” that is supposed to “keep insurance companies honest” by giving people another choice. On paper (and in the proposed language of the bill) it may sound great and be merely another option equivalent to the private market, not intended to drive private companies out of business. But those who oppose it don’t believe for one second that the Congress and the plan administrators will be able to resist the temptation score political points by rigging the rules in favor of the public option and against the market, or by providing financial support from the federal treasury to prop up otherwise unsustainable public option policies and practices. Even the fact that a public option can depend on the “full faith and credit” of the United States government to provide its capital reserves rather than having to raise those reserves in the marketplace and pay interest on them gives such an entity a built-in market advantage — an advantage that is sustained politically rather than economically. Hence, opponents of such an option believe the inevitable consequence of putting a public plan in place — and despite the protestations (perhaps not wholly sincere) of its advocates that they have no such intention — would be to drive private insurers out of the market and leave everyone with only a single option — the public option — which would have to be, by definition, aimed at the lowest common denominator rather than adapted to individual needs and circumstances.
It is similar with the price controls that government-care advocates want to impose by having a “single payer” “negotiate” lower prices with pharmaceutical companies and doctors. It sounds great on paper — we all get lower prices. The concern is, “What happens next?” How do those companies producing the things we want to buy at the lower prices change their behavior as a result of having to sell into a monopoly market rather than a competitive one? To anyone who’s ever actually worked in a business which depends on R&D for future products, the answer is obvious: as the profit motive is undermined, so will be investment; and a great deal of the technology innovation that has extended lifespans from something like 50 years to 75 years in the course of a century would grind to a halt. That result is not prescribed in any piece of legislation and no supporter of such legislation would tell you that it is their goal. But it would, nonetheless, happen.
Unfortunately, such results are based on predictions about human behavior rather than on observable facts and statements written into legislation. Hence, it is very hard to report “objectively” or, perhaps, even “accurately”. People disagree on the likelihood of such results occurring, and often the conception of that likelihood depends as much on what people want to believe as it does on observation and experience.
Here is my question to you: How do we create a process for reporting on these kinds of issues — for informing the public so they can make intelligent decisions — in the face of such ambiguity?
© Copyright 2009, Augustus P. Lowell