THE TREATMENT NOVEMBER 25, 2009
Efficiency versus equity. Risk versus predictability. Vitality versus security. The dichotomy goes by different names in different contexts, but it's basically the same idea. We can have a society that grows quickly but unevenly, or we can have one that grows more slowly but with more similar benefits for everybody.
It's an idea that seems true enough in the extreme and, quite possibly, it is true more often than it is false. But is it true when it comes to health care reform?
David Brooks thinks so. Writing in the New York Times yesterday, he suggested that the debate over health care has come down to a choice over values:
In the real world, there’s usually a trade-off. The unregulated market wants to direct capital to the productive and the young. Welfare policies usually direct resources to the vulnerable and the elderly. Most social welfare legislation, even successful legislation, siphons money from the former to the latter. ...
Early in this health care reform process, many of us thought we were in that magical sweet spot. We could extend coverage to the uninsured but also improve the system overall to lower costs. That is, we thought it would be possible to reduce the suffering of the vulnerable while simultaneously squeezing money out of the wasteful system and freeing it up for more productive uses. ...
It hasn’t worked out that way. The bills before Congress would almost certainly ease the anxiety of the uninsured, those who watch with terror as their child or spouse grows ill, who face bankruptcy and ruin. ...
But, alas, there would be trade-offs. Instead of reducing costs, the bills in Congress would probably raise them. They would mean that more of the nation’s wealth would be siphoned off from productive uses and shifted into a still wasteful health care system. ...
Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one.
The argument here is worth debating, not least because Brooks has grappled with the health care issue honestly and thoughtfully over the last few months.
When he says "many of us thought" health care reform could control costs even as it expanded coverage, he's being quite literal. He's been an enthusiastic supporter of efforts to control costs and repeatedly urged fellow conservatives to engage in this issue seriously. He is, in short, as good a proxy for sensible right-of-center thinking as you can find in the political universe today.
But in this particular case, I think, Brooks' analysis is off--both in the narrow, technical sense and the broader, philosophical one.
First, to the narrower point, Brooks is far too pessimistic about the potential of the bills moving through Congress to achieve meaningful cost control. As Ron Brownstein has detailed, the Senate bill Majority Leader Harry Reid delivered includes a wide variety of cost-cutting efforts, more or less fulfilling the wish list of experts in and outside of the health care industry. Many of these efforts don't go far enough. David Leonhardt has written about this, most recently today. (I've written on it, too.) But there's a vast middle ground between doing nothing and doing everything you can.
Brooks says "the general view among independent health care economists is that these changes will not fundamentally bend the cost curve." That's overstated, by a good bit. More than twenty highly distinguished economists recently issued a letter suggesting that the Senate bill does include real cost control. The roster included conservatives and well-known skeptics of cost control, including Robert Reischauer, the former Congressional Budget Office director who gave the Clinton Administration such fits during the 1990s.
On the broader point, health care reform actually demonstrates the many ways in in which security and vitality can be not only compatible but, sometimes, mutually reinforcing. The most obvious example is the phenomenon of "job lock."
Imagine you're an employee of a large firm, with an entrepreneurial spirit and an idea you believe can make you money. In an ideal world, you'd strike out on your own and give it a shot. That's precisely the sort of risk-taking that Brooks (rightly) wants to encourage.
But suppose now you have diabetes. Or that you are a cancer survivor. Or that you have a child with a congenital defect. Leaving your job will mean leaving your group health benefits, which means braving the individual insurance market--where coverage is generally less reliable, less comprehensive, and simply less available to people that bring pre-existing medical conditions to the table.
Chances are good you'll stick with the job you have. (I can tell you, from my own reporting, I've heard such stories countless times.) For you, lack of health security is actually an impediment to risk-taking.
Whether health care on the whole increases or reduces dynanism is, of course, a more complicated debate. And a lot of it boils down to the details of legislation, some of which are still being negotiated. But there's no reason to conclude, now, that health reform will lead us to a safer, but more sluggish, society. If anything, I would argue, the opposite is more likely to happen.
Update: I just noticed that the Brooks column also caught the attention of Ed Kilgore, whose analysis is a bit less charitable than mine.