What liberals get wrong about the Republican approach to health insurance
Taylor Williamson

While I’m historically a moderate Republican (drummed out of the party here in California as a RINO), on this particular issue I think the practical reality on the ground has been lost in ideology, by both sides. And that the problem is the decades old political untouchability of the existing medical system (see what happened when Bill Clinton tried).

Conservatives: the market, the entire supply chain, for medical care is opaque and inefficient. When my insurance sends me lots of papers with codes I don’t understand, for services I can barely connect to what day and what building, which were ordered by people I never met, are priced arbitrarily, and my insurance covers or does not cover arbitrary amounts of, meaning that in the end I get bills from a random number generator, I am utterly unable as a consumer to affect the market in the true sense of capitalism. This must be fixed.

While it is possible to fix it the way the automobile market was fixed by competition from Japan, reality is there is no financial way for a competitor to enter the entire US medical supply chain, and there are enough regulatory hurdles (the incumbents would, under pressure, drive to have the competitive physicians and facilities delicensed and their Medicare eligibility revoked) to render such a market entry impossible.

The kind of capitalist, competitive market “fix” which is needed is analogous to what happened in automobiles in the 1970s or computers in the 1990s: a competitor emerged who could sell quality product for less than the current inefficient system cost to deliver a lower quality result. The entire supply chain (and in the case of computers, distribution chain as well) had to be rethreaded, brutally removing costs (and even disintermediating supply chain or distribution chain steps entirely). The insurance companies have not been able to force these inefficiencies out as buyers; the large medical institutions have not been (existentially) incented to force these inefficiencies out; and end consumers have no practical way to control these costs, given that medical services are available only from bloated oligopolies.

Oh, and conservatism has been “borrowed” by a subset of very wealthy people — people with mindsets like the ones at the dinner table my mother grew up at — who simply want to pay less taxes or want the ability to impose negative externalities (ie pollution) on the rest of us with impunity. Throw the bums out or own them, your choice.

Liberals: There is no entitlement to infinite medical care. The % of GDP spent on medical care needs to be contained. That means, bluntly, that the fact that someone has invented a drug or machine or treatment protocol that delivers a better outcome does not entitle anyone to that treatment regardless of cost. Part of the problem we have is that drug makers, machine manufacturers, and medical specialties are incented under the current system to maximize marginal revenue by inventing and justifying ever pricier treatments. This has to stop. We need invention to reduce costs (not to deny treatment, to reduce costs) and we need invention to deliver better outcomes at current costs. I’m willing to let there be concierge medicine that experiments with treatment at any cost, for the ultra rich, in the hope that inventions there (as inventions for space, military, car racing, etc) have trickled into consumer products.

We have death panels today. We have insurers who refuse to approve treatments. We have my mother’s friend’s HMO doctor, who persuaded her (declined to treat) that she did not need a pacemaker, even after repeated ER visits where the teaching-hospital physicians explained her condition and that this was the appropriate treatment. She died in a matter of weeks. We have eligibility criteria and enrollment obstacles for the various state Medicaid programs. In the larger scheme of things, we have the political process between the insurers and the medical industry which chooses what’s covered by standard insurance and what isn’t. So yes, we already have death panels. And in the end we need to ration medical care, if for no other reason than to balance its cost against that of feeding and housing the poor.

So, let’s get going on fixing the cost structure, enduring the pain of correcting an incredible amount of inefficiency hidden by pricing opacity in today’s system, and at the same time let’s get going figuring out what basic healthcare is, how to fund that for everyone, and what concierge care is, and how to take that off the plate for all but the rich.

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