The problem of health care

Throughout the extended debate over “Obamacare”, David Brooks wrote a series of thoughtful columns at The New York Times about the issue and about what he saw as the good and bad elements of the law that was being proposed.  I appreciated the level of calm and perspicacity he brought to his efforts, so different from the hyperbole that we saw from almost everywhere else.  At some point, I decided to offer a perspective that I felt, despite his care to explore the subject from all its different angles, was missing from the discussion.  This was my offering.  I don’t remember seeing it reflected anywhere in subsequent discussions.

26 November 2009

I have been following your hope and discomfort with what is going on in the “health care reform” debate.  Let me offer an observation about the fundamental problem with which we are all grappling, couched in organizational terms.

What everyone is after is that they get to retain all the authority over their health care while giving someone else all the responsibility for it.

They want to be allowed to decide (with their doctors) what health care they get and they don’t want interference from “the government” or from “the insurance companies” or from anyone else.

But, they want someone else — the government or the insurance companies — to pay for everything they choose to receive.

Gee, that would be nice. Now let’s get back to the real world, where any attempt to control costs must violate that ideal or fail utterly; where, in fact, it is precisely the misalignment between authority and responsibility that has brought us to this point and where re-establishing that alignment is the only cure that has a hope of working.

The problem is that there appear to be a huge number of so-called “experts” on health care, and politicians aiming for the next election, who keep telling people they can have authority without responsibility. And, until that changes, people will keep expecting to get that, and will keep being disappointed with (and hostile to) anything less.

The argument over whether it is insurance companies (aka “the market”) or the government (aka “the public option”) that pays the bills is really an argument over who people think will try to interfere the least and pay the most. Since that’s an argument over a perception about how government and the market each work, it is heavily influenced by an almost religious attachment to beliefs about those institutions, beliefs that are, like all matters of faith, resistant to being changed by inconvenient facts about past outcomes.

And, alas, there appear really to be people — at large in the “MoveOn” crowd and within the Democratic caucus — who believe achieving that goal — having authority over your health care and handing someone else the responsibility for it — is possible without bankrupting us. These are, in general, the same people who seem to believe that anything the government provides is “free”, that resources they want the government to spend on their pet projects somehow appear by magic (perhaps spirited out of the endless stash that “rich people” keep sitting idle in their vaults and will therefore never miss) and with no deleterious consequences in the broader economy.

But I would ask: When, in the history of the world, has separating the authority to act and the responsibility for the consequences ever resulted in anything good?

© Copyright 2009, Augustus P. Lowell

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