TWB on The problem with Michael Moore's policy ideas

Slate Magazine: (Response to article by Austan Goolsbee --click link for original)

I don't know much about Austan Goolsbee. He describes himself as a "free market type" and as an economic advisor to Barach Obama. He largely agrees with the initial "critique" half of Michael Moore's Sicko, but then savages Moore's policy prescriptions. Some of his points are legitimate, and important: every health care system has to make some decisions about what care to provide, and moving from an existing system to a new one will involve significant transitional complexities that need to be taken into account. Fine. But Goolsbee's use of these fundamentally correct (if hardly novel) insights runs aground on a litter of straw men and Republican-style talking points.

I don't have time or energy to essay a point by point rebuttal of Goolsbee's particulars, but let me try a couple of key issues.

The US spends a far higher percent of GDP on health care than anyone else. The only country that comes close is Canada, and that is far behind. No one contends that the US population would be happy with a health care system funded at the level of Britain's NHS. That argument is a straw man. But if we were able to reduce our expenditures to a percent of GDP akin to Canada's, we could devote hundreds of billions of dollars to making access to reasonable care universal.

Would doctors earn less money under a single payer, universal system? Probably, although the effects would vary by specialty and plan design. Many experts argue that a more salary-based system would (and should) favor primary care providers relative to subspecialists currently highly compensated for performing large numbers of expensive procedures. It is not clear that this should be counted against a universal system. Many think it would improve the mix of physicians and the quality of most patient-physician encounters.

Would drug companies make less money in a universal payer system? Yes, as they do with the VA system, and in most deals they make with large buyers. A moment of silence, please. Would this affect innovation? Perhaps so. It might also affect (downward) marketing expenses for direct to consumer advertising and the variety of thinly veiled bribes to some physicians. Again, should this be counted as a negative? Why?

Malpractice issues? Puh-leez. This is pure talking point drivel. The statistics make clear that in terms of overall health care costs, this is "rounding error" level. In fact, a system in which patients (and jurors) are better treated, less angry with the system, and feel in greater solidarity with fellow patients may well reduce the incidence and the costs of malpractice claims.

Denial of service? Every health care system, absent an infinite budget, will need to "ration" some care in one form or another, whether directly and explicitly, or in a less direct and visible form. The method of rationing may be more or less rational (in something like cost-benefit terms) and more or less fair (allocated by medical need, or by ability to pay). A key truth is that the existing American "non-system" does both these jobs exceptionally poorly, and that tinkering around the edges is unlikely to make a great difference. One responsibility of a system of universal access/coverage will be to make these decisions in a more transparent, fair and accountable fashion. It is not that the current system is not already making these decisions; rather, insurance companies and HMOs are doing so behind closed doors, with little public accountability or sense of fairness. Michael Moore does an especially powerful job of revealing that reality.

A system of universal access to care will not magically do away with all hard choices and difficulties in the health care system. (Britain, France, Canada, Cuba, all counties continue to cope with the challenges of providing and paying for quality health care for their populations, and so will we.) It will provide a new, firmer foundation for a more just and efficient system, in place of the rotting timbers of what we now have. To return to Goolsbee's choice of metaphor, this junker is ready for the trash heap. I hope Barack Obama is not relying too heavily on his counsel.