A new book reportedly suggests that LBJ couldn't have won Congressional approval to create Medicare had he shared good-faith estimates of what it would cost .
That's plausible and raises a series of tough questions, particularly for those of us who are big boosters of transparency. The first is when - or if - Medicare would have been enacted had legislators had good numbers. Another is how things would be different today. It is possible, for instance, that a cheaper program would have been created that did not fuel healthcare inflation and was not now spending enough to poise it on the cusp of bankruptcy.
The question seems relevant today when bloggers complain that (admittedly inevitably imperfect) estimates from the Congressional Budget Office are impeding progress. They argue the fact that CBO never gets things quite right provides justification to ignore the numbers and simply move ahead.
President Johnson didn't have this problem because CBO didn't exist during his term. Indeed, his spending agenda (including both the cost of Great Society social programs and the Vietnam War) created an environment that forced Congressional budget reforms that included the creation of CBO.
What makes this conversation personally painful is trying to reconcile the belief that creating Medicare was a big positive step with a commitment to transparency and fiscal responsibility. If insuring everyone will cost more, we should simply find a palatable way to raise taxes to provide the money needed. Until we can find a tax increase scheme that people can live with, we should delay expanding coverage, which is, of course, quite easy for me to say because I am insured. [ I can understand how those without insurance might view things differently. I probably would were I in their shoes.]
Broader trends suggest not only that the CBO is here to stay, but that it will become more sophisticated and impose greater restrictions on Congressional action. Ultimately, we'll know the price of everything even as we continue to debate the value of a given initiative. That promises a more honest debate, which I think is a good thing coupled to a reluctance to approve needed new spending, which troubles me.
In the health reform area, there are two obvious possible resolutions, but neither will come easily. The simplest is to just raise taxes to finance new spending. The more difficult, subtle and complex one involves linking greater efficiency with expanded coverage, using money saved today by squeezing out unneeded paperwork, tests and procedures to buy services tomorrow for those who are uninsured. If you save a million dollars today, you can spend a million more tomorrow.
This second approach would seem to have a certain disciplined logic on its side, but it violates the basic logic that governs both politics and restaurant meals - distribute the pleasure before asking people to share in the pain of paying for it.
So once again we are asked to select the least uncomfortable of several flawed strategies. Whatever the frustrations of the moment, our political system works slowly and imperfectly. But it is working.
To me, one of the many problems with the debate is mixing together the moral arguments with the fiscal ones.
It's pretty clear that we have to do something to control costs because the current rate of increase is unsustainable. So that's a given. The standard Republican solution boils down to rationing by socio-economic class, which is unacceptable to me. (As a practicing pediatric intensive care doc, I don't want to be part of any more family bankruptcies as a result of what I do.) The standard Democratic solution is a mixture of ignoring the huge cost issues and hand-waving about all the wonderful savings we'll find somewhere to pay for it, which to me is a little disingenuous and just another way of ignoring it. Reform is going to cost -- it's just a question of whose ox is going to be gored.
The moral question of getting all citizens care is a different thing, although it's related to cost in that if we increase coverage without controlling costs we'd bankrupt the system even sooner. I've heard some say we should go that way as a means of forcing cost control. Still, to me universal coverage is the moral thing to do. As I say anytime I get the chance, the notion of healthcare as a privilege, not a right, made sense years ago when we had little in the way of treatments that worked. Now that we do, that older paradigm is both wrong and immoral.
It's astonishing how many senators are unlikely to ratify any single-payer plan, making you wonder if they would willingly cut up their Medicare cards. We could help finance a single-payer system by enacting tort reform & then requiring physicians to contribute the forty percent they would otherwise save on their liability premiums. Just cap the noneconomic damages (pain, suffering, punitives) at $250,000, & the insurance companies would follow suit with lowered premiums, as has been done in Texas & elsewhere. Such caps would not preclude structured settlements for the disabled.
Chris and Howard are both thoughtful doctors who make good points and
obliquely raise an issue for me I may come back to.
it seems to me that we are very bad at defining what is medically
necessary, which is a prerequisite to being able to guarantee care as
a right as Chris (and I) would like to do.
in scores of other areas -- housing, food (food stamps), public
education, transportation, we make such a finding. in our big cities
we generally provide subsidized mass transit while allowing people the
option to spend more and drive big cars. in communities of all sizes,
we have public libraries, but people can still buy first additions or
paperback copies they can annotate as they wish. we promise public
schools that aim to deliver an adequate education, while leaving
richer parents the option of turning to private schools that provide
more extensive -- and often better -- education.
but when it comes to medical care, we don't know where the lines are
beyond saying that people who arrive at emergency rooms in trouble
deserve to be treated. Oregon tried to draw such a line for its
medicaid program and got really beaten up.
it seems to me (wonder whether others concur) if we could define a
modest standard that would keep costs down. for some that might seem
immoral, but it seems no more so than allowing folks to live in
substandard housing (which can create health problems as well).