Map of life expectancy at birth from Global Education Project.

Friday, August 31, 2007

Doing my Duty

I'm getting e-mails from all directions saying I have to do a post on the prospects for health care reform following the landslide presidential victory next year for Sen. Clinbamdwards and a filibuster proof Democratic Senate. At least I assume that's the timing people have in mind because it sure ain't gonna happen before that.

Proximal stimuli for this barrage include the new census data on the number of uninsured Americans, discussed here by Karen Davis; and from the capitalist side of the aisle by the Kiplinger letter (Tip o' the hat to the tipsters -- and keep those cards and letters coming folks); and the decision of the American Cancer Society to pull its PR resources from telling you to get a colonoscopy, to demanding health care reform. (Of course everybody thinks Sicko is going to have a big impact, but I do need to remind you that Farenheit 911 hasn't exactly gotten us out of Iraq.)

It does seem as though something has to give, but unfortunately, good public policy doesn't translate directly, or even necessarily indirectly, into political outcomes. Politics is the system, however it may be constructed in a particular society, for resolving conflicts among interest groups, not for serving some abstract national or public interest. Actually, of course, there is no such thing, the "public interest" is just a rhetorical trick. My interests are similar to yours in some respect, but not in others.

To figure out politics, people's individual interests (which are a function of both subjective and objective factors) have to be multiplied by two factors: the resources they possess to influence the policy making process, and the intensity of their interest in the particular issue. Uninsured people have a strong issue in change, but generally speaking have very limited political resources, in most cases actually quite close to zero.

People who have private insurance might want things to be different, for various reasons: every year the percentage of the premium they have to pay goes up, along with their co-pays; the've had problems with denial of specific services, or they've been forced to change doctors when their employer changes insurers; they have relatives or friends who are uninsured or who have been wiped out by long-term illnesses; they feel insecure about keeping their insurance; etc. But this is usually not the biggest problem in their life and they might feel as insecure about change as they do about the status quo.

The political resources of people in this category vary, but the ones with the most resources are also likely to have the best insurance, the easiest time affording it, the least insecurity, and even quite possibly something to lose if the new system is progressively financed. Some might welcome that in the interest of equity, but others are more selfish. So in general, the people with the strongest interest in change have the least ability to influence the policy making process.

Then you have the people with an interest in the status quo. The most important of these are drug companies and insurance companies. For insurance companies, reform is an existential threat, and they'll fight it with everything they've got, which is plenty. Drug companies stand to lose a huge chunk of their profits under a system that doesn't allow them to continue ripping off the public to the tune of tens of billions of dollars every year, and they've got plenty to fight that with as well. Doctors are a mixed group. Some of them -- notably those high priced specialists -- do stand to lose income under serious reform -- but many doctors are for change anyway because they actually give a shit about their patients. That's far from universal however, and it makes the AMA very cautious about this. (Historically, it's been the most powerful opponent of reform, but that has changed recently.)

So Mitt Romney's idiotic rhetoric about Marxism and socialism might have an effect on a few people, but the real problem is that we live in a moneyocracy, and while the overall economy, average standard of living, public health and social justice would all benefit from single payer national health care, that interest is too diffuse and too politically weak to prevail over the powerful, concentrated interests that stand to lose.

There are only two possible solutions to this problem. One is a massive social movement that succeeds in crystallizing that diffuse interest into an effective force. This has happened from time to time in our history, as recently as the 1960s. It's hard for historians and sociologists to nail down the historical circumstances and cultural context in which such things happen, but they do happen. This is called revolutionary change.

The second solution is to try to create incremental change that will restructure the underlying conditions so that the next step is easier to take, and the next step after that, until the vested interests are gradually whittled down and the broader interest has more effective means for expression. This is the Edwards approach: let people under 65 start buying into Medicare, make sure it's a good deal so that more and more people will take it; expand S-CHIP from the other side; and hope that the two of them will end up being the blob that ate the insurance system. Of course, the problem with this is that the insurance companies and the drug companies have this figured out, so they'll fight it just as hard as they will a flat out single payer proposal. That's why Chimpy is so determined to stop S-CHIP expansion, for exactly the reasons he states publicly: it will nibble at private insurance, i.e. donors to Republicans.

So which do you think is more likely to happen? Revolution, or evolution?

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