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The Conservative’s Faustian Fear

Avik Roy has done the unthinkable. In a recent op-ed title he used “conservative’s case” and “universal healthcare” in the same sentence. And bridged these disparate words by the preposition for.

Spoiler alert: Roy has asked Republicans to embrace universal healthcare.

The Twitterverse is abuzz. An angry Gary P. Jackson, a self-affirmed conservative, tweeted:

“there is NEVER a conservative case for Marxism….especially Universal healthcare.”

Stated differently, universal healthcare is the worst form of Marxism except for all other forms of Marxism.

Thus far Roy has not been asked to produce his birth certificate, which is just as well. Roy, a prolific Forbes columnist and a scholar at the Manhattan Institute, was healthcare policy adviser to Mitt Romney. He is not a cheerleader of the Affordable Care Act.

There are things one may disagree with Roy. However, his short treatise, How Medicaid Fails the Poor, was impressive, as it deftly dealt with Medicaid’s structural problems. That a right-of-center policy analyst would write a book with that title is one of the many ironies I am now accustomed to encountering (the other delicious irony was the love of Cadillac health plans by unions).

In The Washington Examiner and National Review Online, Roy urges conservatives to acknowledge and embrace universal healthcare, in no uncertain terms:

“…[conservatives] have to agree that universal coverage is a morally worthy goal.”

The arguments put forward by Roy are pure common sense. No one objects to public education as “socialized education.”  If conservatives are afraid that universal healthcare means big government, government is already heavily involved in healthcare.

And not just Medicare, which a certain tea party placard asked the government to keep its hands off!
The per capita government spending on healthcare in 2010 was $4000; fourth highest in the world, ahead even of that evil bastion of socialized medicine, the UK.

So arguing about government involvement is merely quibbling about the price, not the principle. And to get the right price, i.e. the right level of government, it is imperative that right of center policy analysts and Republican lawmakers are also, not solely, involved in health policy.

But if you start the discussion with “death panels” and verses from Leviticus it is likely that people will tune you out. And US healthcare is the worse for tuning out conservatives. The Affordable Care Act (ACA) would have been more robust if bipartisan. Because it is the nature of conservatives to present a painful dose of reality, the trade-offs and to ask for details that reformers simplify in vanilla statements about ideas that have germinated in their REM sleep.

Healthcare is best served when reality presented by the right meets midway the aspirations of the left.

If more federal involvement does not mean greater access to healthcare, the obverse is surely true: less government involvement does not mean less access.

Perhaps the government is a catalyst for healthcare delivery, but a catalyst whose effectiveness is not dose-dependent.

Roy contends that healthcare can be provided to all and that the government can be shrunk. He uses the delivery model of Singapore and Austria as examples. Without wading too much in to the details, which is not the point here, this surely is worthy of further consideration. Even the most ardent supporters of the ACA concede that the ACA is a temporary stop to something better, and arguably not that scenic lookout on the Trans Canadian highway that one struggles to leave.

We are not there yet. We need to keep moving.

But conservatives have extirpated themselves from the discussion by fearing the “u” word. Universality has nothing to do with whether healthcare is a right or a privilege, that’s sort of irrelevant; mere tardive adolescent musings such as those about free will.

If conservatives are afraid that acknowledging universal healthcare is a Faustian bargain they must realize that they sold their soul to Mephistopheles a long time ago.

The conservative outlets should be praised for publishing Roy’s piece at a time they could be enjoying schadenfreude from ACA’s rickety launch.

The right seems to be taking the gravity of healthcare debacle seriously. It is time to reciprocate.

Saurabh Jha, MD (@RogueRad) is an Assistant Professor of Radiology at the University of Pennsylvania. His scholarly interests include the value of imaging and dealing with uncertainty in clinical decision making. Jha views most problems in medicine as problems of imperfect information. He trained in the UK and migrated to USA for more predictable weather and a larger yard.

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6 replies »

  1. Singapore has massive rules that require forced savings for health care, plus substantial taxes for public hospital funding, plus a strict national fee schedule to help control insurance premiums.

    I have been studying national health systems for 20 years, ever since I read Competing Solutions by Joseph White.

    I have concluded that all successful systems involve the use of coercion,
    Mr Roy may have disguised this but he does not fool me.

  2. Actually, I object to public education as socialized education. Same for public healthcare, incidentally.

  3. Saurabh, you are right about the need for bipartisanship to drive towards least worst system (I’m going to use that line). You are also correct about the abjectly idiotic conservative commentary about death panels. The only peope who say things like that are people who actually have no idea how the current system works, like 99% of politicians and an even greater proportion of media commentators.

    But, if we are going to advocate elimination of vapidity during debate, we will have to be equally vigorous in censuring the moronic “if you like your plan/doctor, you can keep it/him/her” refrain.

    BTW, bipartisanship is a function of great leadership, and great leadership has a sacrificial quality to it, as well as a magnetism that prompts people to follow voluntarily. Haven’t seen much of that anywhere for years and years. And, don’t see it on the horizon either.

  4. You are right Vik, there is no Pareto optimal solution to healthcare, indeed no “solution”. And the red tape limits access of the most vulnerable.

    The least worst system will emerge from the clash of opinions and eventual bipartisanship. Rather than one party writing a regulatory equivalent of Homer’s Iliad and the other party sitting on the side lines sulking and throwing useless comments about death panels.

  5. I live Avik Roy a great deal, but his focus on public education as a universally embraced social good in the US is a straw man. The public education system is broken in many places, particularly in poor inner cities and rural areas. Teachers and administrators are more rhetorically than actually devoted scholastic excellence in a broad swath of the US. The teach-to-the-test mentality is grinding and limiting for many kids, who also must learn to function under the tutelage of mediocre instructors who send home letters and notes that are often unintelligible.

    If we are to use the public education system as a measuring stick, then it is a failure because in only 13 states is the graduation rate greater than 80%, and it is only 70% on average across the country. So, effectively nearly one-third of kids fail to earn a credential that is as basic to formation of an adult skillset as breathing is to living. That failure rate far exceeds the much lamented uninsurance rate that was in such desperate need of remedy that health reform was the only conceivable route.

    The conservative answer to the public education dilemma is, of course, competition by private schools that, particularly, low-income parents are empowered to send their children to by giving them vouchers. But, why limit the power of competition to just poor parents? Why not give parents in affluent suburbs the option to send their kids to private schools and cut their property taxes when they do? The way to make public education better is to make public schools compete for both the kid AND the dollar.

    There are parallels to the healthcare system and they are mostly unfortunate. The healthcare industry, too, is a slave to an ideology that serves its needs more than the needs of its customers: optimize payer mix and maximize reimbursement. Teach-to-the-test is replaced by test-more-and-more to search for disease, treat, and medicate people who needed none of the three.

    The reality that neither conservatives nor liberals want to acknowledge is that there is no perfect system and every system you conceive and design will hurt some class of industry or people. We don’t like pain, and our healthcare system is structured politically in such a way that no one will endure any of it, least of all healthcare industry “thought leaders” and bureaucrats, who, like their education system counterparts, are busily padding their own nests as the society throws ever increasing amounts of money their way, always wondering how, when, or even whether, it is possible to measure value delivered.

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