Monday, May 10, 2010

What Progressives Know For Sure About Health Care

Cross-posted from The Agenda on National Review Online.

Mark Twain may or may not have once said, "It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so."

In an unintentionally ironic blog entry for The Economist, Matt Steinglass cites this aphorism as an explanation for conservative ignorance about Obamacare. In Steinglass' telling, conservatives hold "factually incorrect ideological beliefs" about the Patient Protection and Affordable Care Act, and engage in "mis- or disinformation" about the law.  ("Factually incorrect ideological beliefs" is a bit of a mouthful; perhaps we could call them FIIBs for short?)

He contends that there were two especially egregious examples of conservative disinformation in the healthcare debate: (1) that Obamacare was a "government takeover" of the healthcare system, when in fact it is "an entirely private-insurer, free-market-based reform"; (2) that Obamacare "involved government 'death panels' that could decide to withhold care from elderly patients on a cost-benefit basis." Even worse, "the better-informed [conservatives] thought they were, the more likely they were to be wrong" (i.e., to believe the two great FIIBs).

For a guy inveighing against the "epistemic closure" of the Right, Steinglass makes no effort to defend the proposition that these two contentions are, in fact, FIIBs. Rather, he accepts as fact, and/or believes it obvious, that Obamacare is free-market-based, and that newly-established government panels would not attempt to withhold care from the elderly.

However, very few observers on either the Right or the Left would agree with Steinglass' outlandish assertion that Obamacare "is an entirely private-insurer, free-market-based reform." Ezra Klein and other liberals describe the law as a "huge progressive victory" precisely because it moves us further away from a free market for health care (not that we had much of one to begin with). The law contains sheaves of intrusive regulations that redefine how insurers must operate, what their policies must contain, and what their profit margins must be. It adds 20 million people to the rolls of Medicaid, a government-run health insurance program, and federally subsidizes the care of millions more. Finally, it, for the first time in American history, it requires that all Americans, simply by virtue of residing in the United States, purchase a product (i.e., health insurance). These are all, dare I say, obvious points; but in the interests of epistemic aperture, I raise them.

Perhaps what Steinglass means to say is that, because Obamacare does not create a government-run single-payer system, it is "entirely private-insurer" and "free-market-based." But this would be a misunderstanding of the terms "entirely" and "free-market." The government does not have to completely take something over in order to effectively take it over. If you have the right to free speech, but a new law says you can only express yourself freely in certain designated areas from 9 a.m. to 7 p.m., and that criticism of any institution except the government is allowed, do you live in a "free-speech-based" system?

And then to "death panels." This has indeed been a sore spot on the Left. I can understand why; most liberals sincerely believe that their policies will make the world a better place (and that their opponents seek the opposite). Hence, to them, it is preposterous that they are trying to kill Granny by instituting an Independent Payment Advisory Board and/or end-of-life counseling.

On this question, the controversy is not about facts, but about predictions. Progressives believe that because their policies are intended to result in quality health care for all, they will. Conservatives believe that there are unintended consequences to major policy changes, that things don't always turn out the way they are intended. (The most cynical conservatives suspect that Obamacare had nothing to do with health care, and is instead a big Trojan horse for income redistribution.)

For FIIB number two, conservatives have more evidence than do progressives to support their predictions. Jim Towey's harrowing accounts of developments at the Department of Veterans Affairs demonstrate what can happen when advocates of physician-assisted suicide infiltrate the end-of-life counseling process. And the new Medicare Independent Payment Advisory Board (IPAB) is explicitly charged with capping Medicare spending, by denying reimbursement to doctors and hospitals for tests and therapies it deems less cost-effective. To argue otherwise is simply not honest. Conservatives see no reason why the IPAB would not ultimately evolve into a facsimile of Britain's National Institute for Health and Clinical Excellence (NICE), which now assigns a monetary value—£20,000-30,000 per "quality-adjusted life-year"—above which NICE denies treatment.

Steinglass may not have a lot of expertise on health care issues; it may be that his rather basic errors are the result of trusting the assertions of other progressives who have made similar arguments. But isn't that the epitome of "epistemic closure"?

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