Why can’t we have nice things? As a self-anointed health policy wonk, I find myself asking this question many times. It seems that every potentially transformative (to use a tired cliché) health care trend must eventually go through a process I’ll call “meme-ification.” And I’ll preface by saying that this applies across the political spectrum.
Take the hobby horse of many progressive reformers – single payer. If you’ve spent any time immersed in health care policy, you’ve probably heard it all: every other advanced country does it, insurance companies (and profits) are evil, health care can’t be a for-profit (evil) industry etcetera.
Of course, if you’ve spent any time immersed in health care policy you probably also understand that attempting to extrapolate lessons from the U.K. (relatively homogeneous, over 250 people per square kilometer, and about 1 homicide per 100,000) to the U.S. (about as diverse as you can imagine, about 35 people per square kilometer, and nearly five homicides per 100,000) is at best, an uphill battle.
Fortunately, this election cycle has offered up real cost estimates of a single payer plan. But even then, when criticism of the unicorn and fairy dust needed to make it work surfaced, advocates simply pivoted back to their usual memes.
Conservatives are just as guilty on this front! High-deductible plans, which will likely be a pillar of future reforms, are a core element of any conservative proposal. And that’s fine. But here too, the “patient as a consumer” mindset has its limits.
Ben Carson’s vision for health care, for instance – a $2,000 per year government contribution to an HSA – leaves much to be desired. Of course, giving people money to spend on out-of-pocket health care expenses – covering deductibles, copays, and everything in between – isn’t a bad idea. Pretending that this is the solution to all of our health care woes is. Just as progressives are guilty of believing in the magic fairy dust of single payer, so too are conservatives for thinking that “consumerism” – at least as advertised – in health care is a panacea. Health care’s skewed distribution – where a small minority are responsible for most of the cost – is instructive here. Leaving a cancer patient with an HSA and saying “good luck” probably isn’t the direction we want to be moving in.
Hiding in the corner, glaring at both of these solutions of course, are the many “well-meaning” regulations. As my colleague Avik Roy pointed out in a recent report, these all stand in the way of more efficient health care arrangements that would deliver better care at lower cost. Serious reformers understand that addressing these challenges is a pre-requisite for improving health care outcomes and cutting costs, with or without HSAs.
Worse still, perhaps more than any other policy area, we’ve turned health care into a meme free-for-all. Maybe this has to do with the two most persistent meta-memes: health care before Obamacare was “free-market,” and universal health care in France, Sweden, or the U.K. is all peaches and cream, and that’s why “everyone else is doing better than us.”
Neither are true. The status quo before the ACA was anything but a free-market, and had enormous problems that made care essentially unobtainable for many – but a $250 billion dollar annual tax exclusion masked that, giving the illusion of “everything working fine.” Similarly, the idea that flipping a magic “universal health care” light switch is realistic (or even desirable) ignores the complexity that makes single-payer so immensely difficult and undesirable.
Real changes to the health care system need more than sound bites, and American voters need someone, at some point, to level with them. Change is hard, compromise between the perfect and the good is inevitable, and we should avoid utopian thinking driven by sloganeering
Yevgeniy Feyman is fellow and deputy director of health policy at the Manhattan Institute.