That can’t be healthy

In a previous rant, I went on and on about the meaning of liberal. In specific, I made it clear that it refers to a moderate left position that is distinct from the radicalism of the left-wing populists who call themselves “progressives”. Apparently, someone didn’t get the memo.

To wit, here’s a Politico article entitled “Democrats’ plan to neuter Medicare for All irks liberals“. If you read it, you find that no liberals were irked in the making of this policy. The article even contradicts its own headline when it says that the “more incremental approach is nonetheless frustrating for some progressives”. Progressives, meaning populists: low-information extremists who are left-wing but not at all liberal, and are only Democrats for lack of any alternative.

So what’s the real issue here? Once again, it’s about words having meaning, so that when you twist that meaning, you generate confusion and propaganda. Take single-payer healthcare, which means that the government provides the insurance and pays for it through taxation. It’s sold as being the only alternative to what we have now, but it’s only one of the many ways to achieve what is actually important to us: universal coverage.

The big problem with the status quo is that, before ObamaCare, about a sixth of the population had no health insurance coverage. The true number was higher than that, as many were under-insured or had huge gaps due to such things as the pre-existing condition loophole. With ObamaCare, it’s dropped to under a tenth, and would be lower still if not for Republicans desperately trying to hold it back.

What we want and need is for everyone to be covered, so that illness does not mean financial ruin, or suffering or even dying due to lack of treatment. It’s common decency and something that first-world nations must provide their population, if only as a practical necessity for economic reasons.

Voltaire famously quipped that “the perfect is the enemy of the good”. Even if we can’t flip a switch and get 100% coverage, it’s entirely worth fighting for an increase from 91% to, say, 95%. That’s literally millions of people whose lives will be bettered. But that means compromise, and populists do not compromise. That would go against their performative ideological purism. They stand by their demands, come hell or high water, and fuck the little guy who gets screwed in the process.

Even if we take for granted that a single-payer system would be the best possible solution—and we shouldn’t—this isn’t an argument for focusing exclusively on the ideal when it’s not politically feasible instead of working to improve what we’ve got. Better to compromise to help millions than to stand our ground and let them suffer for our idealism.

The real Democrats—the liberals—know this. To quote, “[Pelosi is] not going to have people walk the plank for the sake of it because we’ve gotta satisfy some of our vocal friends on the far left.” Brown goes on record with, “It’s easy to say ‘Medicare for All’ and make a good speech, but see no action. I want to see action.” Hard to argue with that, unless you’re a petulant extremist who’d rather lose than settle for less. Perhaps they believe they can afford to lose, but there are people who cannot and will instead go to the grave prematurely.

It doesn’t help that, as I alluded to above, it’s not at all clear that single-payer is the best answer, or even a good one. For one thing, it would be a huge shift with painful consequences. There are hundreds of thousands, if not millions, of people employed by private health insurance companies, and still more who indirectly owe their livelihood to them. If we provided government insurance to everyone, we’d be shutting down these companies and putting their workers out of their jobs overnight.

Sure, maybe these jobs should go away in the long run, and maybe the government could find a place for some of these workers. But if we rush to radical change in medical insurance, we violate the medical maxim of “first, cause no harm”. We reduce a complex issue to a sound bite or rallying call, like the bluff of “54° 40′ or Fight“. (Polk compromised on 49° instead of fighting, but the lie got him elected.)

Not everyone even wants to switch to Medicare. To quote Merkley, “If you tell people the only choice they have is Medicare, that could produce a lot of folks being concerned about, ‘Wait a minute, I like my health care and you’re telling me I have to leave it.’” Even in a world with Medicare for All, some people will want more convenience or more coverage, including services that are luxuries, such as elective cosmetic procedures. There will always be some need for doctors who are paid out of pocket.

This is a good place to note that that single-payer is also distinct from single-provider, where all the doctors would work for the government and all the hospitals would be run by the government. This is the way the VA hospitals work, and they’re a complete mess. Libertarians claim that the government is necessarily bad at running businesses, which is nonsense. But the opposite is also nonsense: the government is quite capable of running businesses poorly, continuing on even when private owners would have folded from lack of funds. Medicare for all could become a nightmare for all, if it means removing all alternatives first.

So what do we do? We don’t have to lock the door and throw away the key by going fully public all at once. There are many choices, but the most obvious one is to restore some version of ObamaCare’s original public option, which lets Medicare coexist with private insurance on the open market. This was and is a great idea because the competition from the government effectively sets an upper limit to how greedy private insurers can get.

If they don’t provide enough value—if their coverage is weak or their prices are high—then Americans will switch to the opt-in Medicare. But if Medicare buckles under the weight an entire nation and starts serving us as badly as VA hospitals do, then private insurers pick up the slack. Essentially, each side keeps the other honest, so the people win. It’s neither market fundamentalism nor forced nationalization, but rather the very liberal notion of taming a market to our desired ends through regulation and participation.

Now, my suspicion is that, if we go this way, private insurers will find themselves unable to compete. They lack the economy of scale and the ability to control costs by regulation. Over time, they’ll shrink, if not entirely go away. There’ll be just enough left to provide boutique coverage that Medicare does not (and probably should not), and this will keep up some of the competitive pressure to keep Medicare honest. But even if I’m wrong and private insurance remains competitive or somehow wins out, then this hybrid plan protects us from the extremes of going all-in.

None of this is new. The article talks about incremental approaches, under the label of Medicare for More, and admits that these are much more likely to actually happen. It also references over a half dozen variants under serious consideration. Some expand the scope of Medicare by making more people eligible. Others offer it as the public option, allowing anyone to pay for Medicare, even if they’re not eligible for the government to provide it. Note how, for the employed, paying for it with tax-deductible payroll exclusions isn’t really much different from paying for it with taxes.

Whatever realistic plan we go with, they are all designed to be improvements over today’s ObamaCare. And it almost goes without saying that pretty much anything is better than repealing ObamaCare and returning to the bad old days, which is apparently all the Republicans have to offer. This is serious business and the proper domain of boring, competent policy wonks who crunch the numbers, do the math, and go with what adds up. This is not a place for empty rhetoric. (See above regarding Polk.)

If we wind up with de facto single-payer, so be it, but it’s better than doing it by fiat because the risks of putting all of our eggs in one basket are too great. So long as we have a system that works for everyone, the details of how we get there are something we should figure out as we go along, based on the data, not overcommit to in advance just to satisfy ideological needs and create simplistic slogans. In the end, the good is better than the perfect, for the same reason that horses are better than unicorns.

Still, I don’t recommend horse meat for your burgers; beef is fine. Which bring us to the real question: Do you want fries with that?