Published November 8, 2017
Editor’s note: Pascal-Emmanuel Gobry, a conservative writer and a fellow at the Ethics and Public Policy Center, is writing a series of columns on uncomfortable truths about health care in America. Some will make conservatives more uncomfortable, others will make progressives more uncomfortable, but most should make everyone uncomfortable.
In my previous columns, I’ve laid out a number of inconvenient truths (to coin a phrase) about the American health-care system: We waste half the money we spend; that half happens to be the most popular part (Medicare and employer-sponsored health insurance); whatever we do, the poor will be worse off. Our problems are also metaphysical, because we aren’t even using the right words to talk about health care and, as postmoderns, we fear death too much and place too much faith in heroic medicine.
But hey, maybe there’s a solution?
No, there isn’t. We’re all doomed.
I’m only slightly exaggerating. I’m what some philosophers disdain as a “solutionist”: someone who believes that, whatever the problem, some great policy fix will make everything better. But when it comes to health care, the simple reality is that nobody knows what to do.
Conservatives have a simple dream when it comes to health care, and that dream has a name, and it is “Singapore.” And it is a beautiful dream. If Milton Friedman and Elon Musk sat down together to design a health-care system, it would probably look like Singapore’s. In outline, it’s very simple to understand: Everybody gets a health savings account, into which a portion of their paycheck is automatically deposited; from that health savings account, they can purchase catastrophic coverage. The elderly get a voucher for their choice of private insurance plans for age-related illnesses. The poor get top-ups to their health savings accounts and a special insurance scheme.
It’s got everything! It works the magic of health-care consumer choice that conservatives keep vaunting, and it really does keep quality up while bringing down prices. There’s just enough government intervention to make sure nobody falls through the cracks and everybody has basic coverage, but otherwise it’s pretty much a market-based system, and it works as magically as Conservative Apologetics 101 tells you market-based systems work.
Which is why conservatives should flee in terror when right-wing health-policy wonks like me start talking about Singapore. Because if there’s one thing conservatives (with their Burkean, Kirkian, Buckleyite deep understanding of the intractable complexity of human affairs and of the importance of culture) should instantly realize, it’s that the idea of importing a system from a highly homogenous, authoritarian, technocratically run urban nation of 5.6 million people to a continent-sized, fractious, ultra-diverse nation of more than 300 million people is a tragic farce. After all, America’s various government bodies and tiers rank from “alarmingly incompetent” to “you could not make this up” and our democratic governance structure virtually guarantees that any perfect-on-paper plan would be instantly captured by special interests.
The Singapore health-care system has lots of devils in its details. It use market competition a lot more than other countries do to keep costs down, true, but it also uses good old-fashioned price controls like every other advanced country. It uses any number of mandates and carrots and sticks to ensure health-care access, and that includes an efficiently run chain of government hospitals that push market prices down. If your plan for keeping health-care prices down in America includes multiplying the VA severalfold (so it can compete in every local market, a slightly more daunting task for the United States than a city-state) while making it run more efficiently than the average private American hospital, you might want to go back to the drawing board.
Not that progressives are having any better luck. Medicare for All, their new toy, is just as laughably impossible. It’s not only that it would cost something on the order of $32 trillion over ten years, according to the nonpartisan Urban Institute’s score of Bernie Sanders’s Medicare for All bill. It’s that it would be impossible to implement. Everyone who now has private insurance will have to be phased into the new awesome Medicare for All system, something that should make blanch anyone who remembers what it took for the government to build a functional website where people could buy plans.
What’s more, while Medicare for All would certainly provide universal coverage, of a sort, it would do nothing to fix the other big problem that single-payer advocates are trying to fix, namely, the crooked way that our system rewards insiders at the expense of patients. Third-party insurance is like a great spell cast by Saruman — it makes everyone mistake the American health-care system for something it is not. Health insurers already provide coverage at the government’s discretion, because they do so on the basis of mandates that themselves are a product of the political process. Taking out the middleman might deprive him of his share, but it’s only a tiny slice of the problem. Frédéric Bastiat famously called government “a great fiction by which everyone lives at everyone else’s expense.” I disagree with his philosophy of government, but he could have been speaking about the U.S. health-care system.
But both these visions have a similar problem, which is practical politics and especially health-care consumers’ aversion to change, which is highly understandable given the emotional import of health. Most Americans who have private health insurance are happy with it. Even if a Singapore-style health-care system could work in the U.S., it would never pass Congress, because Americans would be slitting congressmen’s throats for trying to take their plan away. Medicare for All is the same thing.
Progressives wave off claims that single-payer would be expensive by saying that price controls would bring costs down, as they do in Europe. But Europe’s price controls are sustainable because they locked in the existing cost structure when they were enacted. No European country could democratically pass a law that would reduce physicians’ salaries by two-thirds overnight, or over any period. And this — among many, many other drastic cuts — is what America would need to do to make a Medicare for All system reach Europe-style spending levels. That’s sure to go well.
So what’s left is tinkering around the edges. Some edges are worth tinkering with: Paul Ryan’s obsession with block-granting Medicaid would dramatically improve the health care of the millions of people who need it the most. And there’s something profoundly conservative about tinkering round the edges rather than embarking on a grand reform agenda. The problem is that the rot of the current system goes much too deep. It’s highly unlikely that any amount of tinkering, no matter how judicious (which is not exactly the word you would use for the people, of either party, charged with doing the tinkering), will keep the rot from spreading farther and farther afield until one day the entire country crumbles.
So what do we do about it? The uncomfortable answer is that, really, nobody knows.
— Pascal-Emmanuel Gobry is a fellow at the Ethics and Public Policy Center.