Bipartisan Healthcare Hokum
In which Casey Stengel asks the question and Ray Stevens gives the answers
HEALTH AND HEALTHCARE have occupied center stage in my work for 30 years, but that might not be obvious to the one-third of Bastiat’s Window readers who have subscribed since early October. Since then, most columns have focused on Hamas and its sympathizers and (for emotional breaks from that horror) pleasant topics like music, literature, technology, and culture. Lots more to come on all those topics, but it’s time to return to healthcare. Let me begin by introducing (or reintroducing) readers to my overall take on the subject.
STEVENS AND STENGEL
In 2010, Democrats assured us that the Affordable Care Act (ACA) would, “Clear up that fungus amongus” and that it would be “good for every ailment, includin’ water on the knee.” After the ACA became law, Republicans assured us that their lineup of Repeal-and-Replace bills would “get ridda that runny nose (sniiiff), that naggin' cough (cough), that sneeze (achoo), that wheeze (gasp), and other injurees.” Ooops—my mistake—those are, in fact, lyrics from Ray Stevens’s 1961 novelty hit song. “Jeremiah Peabody's Polyunsaturated Quick-Dissolving Fast-Acting Pleasant-Tasting Green and Purple Pills” (video below).
A year after Stevens recorded his hit, baseball legend Casey Stengel, then managing the spectacularly awful New York Mets, famously asked, “Can’t anybody here play this game?” For many years, I’ve made it my point to ask similar questions about healthcare policy in the United States. To my great pleasure, my words have gotten on the nerves of both Democratic and Republican healthcare experts and policymakers. (And, to be fair and appreciative, other words of mine have been well-received by both sides.)
My principal theme over the past decade has been that would-be health reformers of both parties spend far too much time obsessing over insurance and much too little time considering the structure of healthcare delivery (both technologies and organizations). In addressing this viewpoint, I’ve spent many years delivering a mix of serious research side-by-side with humorous jabs at the shortcomings of partisan reform efforts. Let’s start with the latter and then proceed to the former.
ANSWERING STENGEL
One of my first overt bipartisan blasts appeared in my essay, “Why Both Sides Are Losing the Health Care Debate” (2014). That piece opened with:
“Our Great and Eternal National Health Care Debate calls to mind H.L. Mencken’s description of the prose stylings of Warren G. Harding, America’s much-maligned 29th president: ‘It reminds me of a string of wet sponges; it reminds me of tattered washing on the line; it reminds me of stale bean soup, of college yells, of dogs barking idiotically through endless nights. It is so bad that a sort of grandeur creeps into it. It drags itself out of the dark abysm of pish, and crawls insanely up the topmost pinnacle of posh. It is rumble and bumble. It is flap and doodle. It is balder and dash. … But I grow lyrical.’”
And here are three other routines from my rhetorical rucksack:
“Liberals believe the federal government’s role in healthcare is to interfere with markets and frustrate consumers. Conservatives believe the task of interfering with markets and frustrating consumers is best left to state governments.”
and
“At a dinner I once hosted, a conservative think-tank donor waxed on about the federal government being the ‘800-pound gorilla in the room,’ and that all would be well if we just left healthcare policy to the states. When she finished, I said, yes, the federal government is indeed the 800-pound gorilla, but, unfortunately, each of the 50 states is a 40-pound baboon.”
and
“In the early 1990s, a series of advertisements on American healthcare featured characters called Harry and Louise. But when it comes to healthcare, Republicans and Democrats are really more like Thelma and Louise.”
One of the crown jewels of my career occurred on May 4, 2017. While more of my invective is aimed at healthcare proposals from the left, I’ve never been overwhelmed by the right’s counterproposals. On May 3, 2017, The Hill quoted my criticism of a Republican proposal to boost these high-risk pools (an idea I refer to as “single-payer for sick folks”). The next morning, my phone started buzzing non-stop after then-Minority Leader Nancy Pelosi quoted my comments in her Capitol press conference:
“Robert Graboyes, a healthcare expert at the conservative Mercatus Center, conservative center, said, ‘The amendment at hand focuses on high risk pools, but the $8 billion amount is a pittance. Spread over 5 years, it's a fifth of a pittance.’”
It’s the rare day in May when Former Speaker Pelosi and I are on the same side, but, as they say, all publicity is good publicity. Now, on to my serious research.
FORTRESS AND FRONTIER IN AMERICAN HEALTH CARE
Quips and frivolities aside, most of my healthcare research and writing over the past decade grew out of my 2014 monograph, Fortress and Frontier in American Health Care, whose thesis was summarized in this 4-minute video:
My friend, Jeff Holmes, did a great job of making the video entertaining, so if you have four minutes free, I suspect you’ll enjoy watching. If you’re in a hurry, here’s the text:
“For 70 years, we've languished in a bitter, partisan, unproductive battle over how to ‘fix’ America's healthcare system. Directly or indirectly, both left and right have steered the conversation toward coverage—the number of people with insurance cards—while mostly ignoring quality of care and how much it actually improves health.
To get this debate out of its rut, we need this new goal: ‘To produce better health for more people at lower cost, year after year.’ To start, we have to recognize that the real dispute isn't between left and right—it's between philosophies I call the Fortress and the Frontier. Let's define them.
The Fortress has two goals. First is to imagine all the terrible things that might go wrong in healthcare and prevent any of them from happening. Second is to shield those in the medical industry—doctors, hospitals, insurers, drug and device manufacturers—from potential competitors who might threaten their turf.
The Frontier is different. It understands that big quality improvements and cost reductions don't come without accepting some risk. And it understands that real innovation won't occur unless doctors and hospitals face new competitors—like IBM faced Apple and Western Electric faced BlackBerry. While left and right think of themselves as radically different, both are deep in the Fortress.
To illustrate Fortress and Frontier, let's do a little thought experiment. Get in a time machine. Go back to 1989. Tell your family how healthcare has improved in 25 years: statins, new vaccines, face transplants. They'll appreciate the new technologies but won't be all that surprised. That's the Fortress. Now—and you're still in 1989—tell them what's ahead in IT. [In 2024, we could tell them about iPads, iPhones, VR headsets, Netflix, Google, Amazon, Uber, Twitter/X, ChatGPT, Facebook, Spotify, YouTube, Ring, GPS, drones, autonomous vehicles, email, online banking, video calls, etc.] Tell them how inexpensive these things are. Now, they'll think you're delusional. That's the Frontier.
‘Wait!’ you say, ‘The two industries aren't comparable. Healthcare is life and death, pain, and suffering. Computers? They're harmless. They just sit on your desk.’ Really? On the Internet, you'll find financial fraud, identity theft, predators, violations of privacy, cyberbullies. Cell phones have served as tools of crime and terrorism. Does this make you wish the Internet and cell phones would go away? I doubt it. For an interconnected world and all of the benefits that come with it, we take risks and accept costs. And we allow upstarts in garages to challenge multinationals in skyscrapers.
In 25 years, we've gained near-universal access to information technology. That didn't require a long, vicious Congressional debate. No cumbersome mandates. No one had to ask innovators to innovate, and innovators didn't have to beg bureaucrats for permission to create.
Our challenge now is to move healthcare out of the Fortress and onto the Frontier. To make healthcare as dynamic as IT has been in our lifetime. That means accepting some risks and allowing genius to arise from unknown people in unexpected places.
Make no mistake—enormous changes are coming soon to healthcare: transplantable organs made of your own cells, drugs tailored to your individual DNA, microscopic robots inside your body repairing the genes that threaten your life. Are we willing to move American healthcare to the Frontier so it can lead the way toward these new technologies? Or are we going to remain in the Fortress and let other countries seize the high ground? We have time to choose, but not much. We can spend the next 25 years squabbling over insurance cards, but that won't get us to the real goal: ‘Better health for more people at lower cost, year after year.’”
To sum up the thesis of Fortress and Frontier, Democrats and Republicans argue mostly over the particulars of insurance—single-payer, Medicare for All, Medicaid expansion, Health Savings Accounts (HSAs), employer-sponsored coverage, etc. While the structure of insurance is important, the quest for meaningful healthcare reform is better served by focusing on delivery systems: drug development, provider regulation, professional licensure, scope of practice, certificate of need, telemedicine, therapeutic autonomy, pricing flexibility, etc.
In forthcoming articles, I’ll build on the arguments I raised in Fortress and Frontier in American Health Care. By the way, the monograph is also available on Kindle, but (for copyright reasons), some of the really interesting images are missing from that version.
MY HEALTHCARE ORIGIN STORY?
If asked when my interest in healthcare began, a possible answer is that it was around 1961, when my brother brought home this 45 rpm Ray Stevens record. Its title (at least at the time) was the longest of any hit song in history. As suggested above, I find this song’s lyrics to be at least as persuasive (more so?) as many (most?) of the Democratic and Republican healthcare proposals drifting around Washington.
I do not think that the Democrats care one bit about health outcomes for individuals. What they care about is winning elections. They concluded correctly that pushing legislation that was promised to improve healthcare for Americans would be popular with voters. If there were any adverse consequences from the laws, they could be blamed on right-wing opposition and be touted as reasons for yet more government meddling. This is why they also support gun control legislation. It gets people to the polls to vote for them because more proposals for gun control sends the message that they care about violence. When the laws don't accomplish anything, they return with demands for more.
As for Republicans, they calculate that full-scale opposition to the Democrats' on health care would lose them voters and therefore compromise with the least damaging aspects of the statist agenda.
There is a good deal wrong with the way health care is provided in the US. First I would like to say that insurance doesn’t equal care. I spent an extra year as a fellow learning a sub specialty to treat post cancer and craiofacial patients. The reimbursements became so poor that even if covered I could no longer treat those patients. I would continue to see patients of record and lose money on every treatment. New patients I sent across state lines to the nearest large medical center.
The year my wife and I had our third child I we had only major medical insurance. Each time the older two and then the third one went to the pediatrician she had to take out the check book and pay the fee. This along with the deductible for the delivery added up to what my wife thought was significant out of pocket costs. As I had my own practice and I paid for medical insurance for myself and my staff I calculated that even with the three children and the birth it cost less to keep the major medical than to buy “regular” insurance. We kept the major medical for a few more years until our state outlawed it as junk insurance. That raised the cost for my family and every one of my employees. Instead of raises the next few years employee costs were mostly made up of increasing premiums.