David Brooks has cultivated an air of “moderation”, so yesterday's downright hysterical column comes as a surprise. Joel has commented on the substance, Dan Kennedy on its intemperate style. I'll just comment on Brooks' unsupported assertion that the Massachusetts plan is “coming apart at the seams.” Good faith criticisms of our new-fangled setup here are most welcome; hysteria, rush-to-judgement and off-with-their-heads condemnation are not. Brooks, unfortunately,indulged in the latter. That's a shame, because in spite of being wrong on facts and tone, he will likely take a few opinions with him.
So, at the risk of boring those of you who have heard this tune already, here goes …
The first thing to understand is that the 2006 law only dealt with access to insurance. It was a rearrangement of health care financing. It provided an insurance exchange, where you can compare plans. Importantly, the law built upon two principles that had been already established in Massachusetts law: Guaranteed issue and community rating. Guaranteed issue means that an insurer has to offer you coverage, regardless of pre-existing conditions. Community rating means that your risk is spread out over the population of folks roughly your age; so your pre-existing condition doesn't make your insurance unaffordable.
So, the results are this: 97% of Massachusetts residents have health insurance. Can any other state sniff that?
No, the 2006 law did not deal with cost control; that was considered too “heavy a lift”, in the parlance of the State House. It did, however, create an enormous incentive to deal with cost control, since it became very expensive for the state to provide subsidies for coverage. Insurers, businesses, and consumers have always been interested in cost control, for obvious reasons; now doctors and hospitals have started to feel pressure to deliver.
The state started the cost-control ball rolling in 2008. And perhaps most importantly, now the state is now re-inventing the whole game, setting up a system for paying for health, not volume of services (“global payment”). This is a big deal, with buy-in from payers and providers; it rolls out in the next five years.
Yes, the state has considered dropping legal immigrants from the subsidy rolls; but that's not a failure of the law, that's due to our enormous budget deficit. (You may have heard of that, Mr. Brooks — 48 other states have the same problem — or worse.)
But the takeaway is this: The Massachusetts health care law is indeed an enormous challenge for the state; but it is not “coming apart at the seams.” In fact, given current efforts, you might say that we're at work pulling the seams together.
Now, on the national level, Congress is considering cost controls:
- Expanding the role of MedPAC in Medicare payments — just added to the House bill due to some productive pressure from — dare I say it? — Blue Dogs! — and directly proving Brooks' thesis wrong.
- The Comparative Effectiveness Institute, which would at least make your health dollar more useful
- The influence of the public plan on the marketplace
- The health insurance exchange, which was a major reason why Ron Wyden's plan was (miraculously!) scored deficit-neutral by CBO.
So in many ways, the US Congress is more on top of cost control than we were here in 2006. Maybe it's not enough. Let's have that discussion, and make a better law. Brooks' hysteria will likely make it harder to get anything done, leaving us with the current system — which has truly been torn apart at the seams. Brooks seems to think that the Democrats should ignore the fact that they were elected for a couple of big reasons — and one of those explicit reasons was to pass universal health care. Get on it.
Update: Jay decides to poke us with a stick, so I will respond. Jay's effort at mind-reading as to the “real reasons” behind the push for universal health care is, well, a paranoid failure. There are indeed people who are wedded to single-payer universal health care, or bust; I'm not one of them, and I suspect most progressives aren't. I don't care whether big-government runs the system, or not, as long as it works. The current private system is a failure; so we pick up from there.
I make no apologies that I favor universal care for humane reasons, for reasons of human dignity. Everyone should be able to go to a doctor when sick. Gosh, is that the secret agenda? All things being equal, I would support it regardless of whether it cost more or not. But in light of the insane amount of waste in our system, and the effect on the economy, we can — must — do this while saving money.