Soft Sell: Tainted Love

...for your fellow citizens.

MIT professor Jonathan Gruber finds himself in increasingly hot, increasingly deep water as videos of his admissions of public deception and his contempt for either opponents of the PPACA or the public at large (depending on how you elect to interpret his comments) continue to surface. I think the count is somewhere around five now. Instead of commenting on the pillorying (or pointed lack thereof), I want to consider what some of the alternatives would have looked like ca. 2009. At the time, there were many roads to reform. I suspect that the very large, very confusing bill ("we have to pass the bill to know what's in it") emerged as the result of years of planning, plastering, packaging, and preparing by its proponents. A thousands-page document does not spring unbidden overnight nor without considerable input from a substantial constituency.

Suppose instead that civic-minded reformers had pursued other overhauls. Here are a few possibilities:

1. Anarchists' Paradise. A fully free market in medicine. Abolish the FDA, abolish the Department of Health, break the AMA cartel, end medical licensing. Let the market sort it out, an even more extreme laissez-faire approach than what we see for veterinarian services, elective cosmetic surgery, or laser vision correction.
2. Single Payer (A). This is the NHS model, the one lambasted in the conservative media, in which the government both funds and provides health services.
3. Single Payer (B). This is the Baltic model, where there is government funding and provision of health services, but there is no ban on private provision. Private hospitals and clinics can still operate in this model, but patients may not be eligible for subsidies at these clinics.
4. Single Payer (C). This is public funding with private provision. Essentially, this is universal Medicare expansion. This may or may not accompany the reform of severing the link between employment and coverage.
5. Menu Pricing. Medical billing is... confusing for the typical patient. Stories of sticker shock are not uncommon, and it's still something of an industry secret that a lot of the line item pricing on medical bills is part of a negotiation dance between providers and third party payers. Prices contain information so long as buyers and sellers agree about the rules of the negotiation.

Add to the list as you see fit. Now take a moment and consider carefully who the stakeholders are in the status quo medical services game. By way of a large regulatory, industrial, professional, and legislative apparatus, incumbent interests have a great deal to lose should any truly radical reforms stand a chance of passing. Even the pork-laden, special-interest-payoff-ridden PPACA took a heroic effort to wend its way through perhaps the most favorable Congress in the past half century. Do you think—honestly think—that a more disruptive bill would have even gotten out of committee? Medicine isn't euvoluntary: neither voters nor politicians are willing to slay the juggernaut that wields the national scalpel.

In my comet utopia, we'd have some combination of single payer B-C, with transparent prices, low barriers to drug development, few restrictions on practice (with private quality certification), and no link whatsoever between employment and insurance. Insurance would be what it says on the tin, and folks would have free access to health savings accounts. I do not live on a comet. I live in an America flush with transitional gains traps and wealthy interests with a great deal of access to political influence. I cannot imagine a present-day America populated with present-day Americans that could have possibly produced outcomes that would please me or fit what I fancy in my armchair daydreams.

Did Gruber and Pelosi give us a hard sell? Sure, but no other reasonable option could have possibly made the cut. A soft sell just wasn't in the cards, folks.

Man, that video is horrible. I must have missed it on the MTV rotation the first time round. Yikes.