I have not posted much about the debate over health care, mostly because the real issues are so nuts-and-bolts that anyone who does not have a clear understanding of how the system works (such as me) is well advised to stand clear. A little learning is indeed a dangerous thing. But the arguments became so heated and positions ultimately defined with so little flexibility, that a larger perspective may be useful - and mine tend to be ultra-large. So here goes.
Public Socialization v. Private Socialization. I have friends and family members who view the entry of the Federal government into the area of health care as an ominous and completely negative change in the structure of US society. But step back for a second for perspective. Socialized medicine in this country is nothing new. The system of health care first introduced in informally World War II, and codified in the Internal Revenue Code of 1954, of near-universal employer-paid health insurance, is nothing else than a system of private socialization. Insurance in large concept is nothing else than the socialization of risk. Whether it's private or public makes is conceptually irrelevant.
Which makes the 'change', in my in-this-case-genuinely humble opinion, in the ultra-high concept that I am discussing, is far more formal than substantive. There is no meaningful difference between the collection of premiums and disbursement of benefits by a distant conglomeration of private bureaucrats, and the collection and and disbursement by public bureaucrats. I am aware that there are those who have a Manichean view of the matter, that massive private organizations are Good, and massive government organizations are Bad. But I don't see it. 'Good' or 'bad' depends on the details of administration.
Which leads to the inference . . . .
Inflexibility. I don't identify with either political party, but it seems to me that the Republican Party picked a very poor issue on which to draw a line in the sand. The principle 'it it's not broke, don't fix it' doesn't apply to US health care. The system is very badly broke. Our scheme of private socialization has failed, both in the extent of coverage and in controlling costs. The most compelling criticism of the bill is one that the Republicans never made (to the best of my knowledge) that the candle wasn't worth the game, i.e., the changes are too slight to justify all the executive and legislative energy that went into the enacting of it. But equally so, all the sound and fury generated in opposition made no sense.
(It seems to me the Republican opposition to this bill in its excesses bears some analogy to the Democratic position on the war and security between 2002 and 2006. The extremists in the Democratic Party, the Demented Left, were so furious in opposition to the war and George Bush that they belittled the underlying cause, the threat of terrorism. By 2004, the public was lukewarm and mildly oppositional on the war, in the manner of most popular democracies. But it took the threat of terrorism very seriously. By giving the extremists voice, the Demented Left succeeded in losing a Presidential election it might otherwise have won. The Demented Right of the Republican Party, in fomenting a reaction to the Administration bill that is wildly disproportionate to the actual changes, risks doing the exact same thing to that party.)
Which leads to the truly substantive comment . . . .
Cost Control. The basic issue with respect to health care is controlling soaring costs. Private insurance companies have been pilloried for premium hikes, but to my way of thinking, that's to mistake the disease for the symptom. No doubt profits are too large and top executive salaries as out of line as they are in other segments of American business, but these are not the reasons why premiums are soaring. The reason is out-of-control costs.
To my way of thinking, the bill simply does not address those issues. To be sure, there was a great deal of talk about this. But here the equivalence of private with public socialization is compelling. If the private system of socialization now in place has been a dismal failure in terms of containing costs, why should there be any realistic hope that a public system will do any better? At any rate, I for one don't see any.
There is no revision of the fee-for-service protocol for the provision of medical services, which is the basic engine of cost expansion. Nor was there any meaningful tort reform, which might reduce the amount of GDP consumed by the parasitic medical malpractice 'industry'. I am fully aware that the great triumph of the bill is the expansion of coverage to the previously uninsured - but aren't the two matters directly related? The point of the exercise is to reduce the total percentage of GDP consumed by the health care system. If society is successful in reducing the costs of the fully insured, on a macro basis, the savings become available to apply to the uninsured. On the other hand, fail to reduce costs, and we all go broke together.
So the ultimate bottom line to me is that I am not seeing all that much in the way of actual reform. We are still going to over-compensate medical and legal professionals as we have for three generations now.
Which is why I re-wrote Gilbert to begin this piece:
It really doesn't matter how the system's rearranged
Because it hasn't really changed - nothing's really changed.