Wednesday, March 24, 2010

Healthcare: a skeptic's guide

Since Sunday night's healthcare vote, we've put up two pro-healthcare reform pieces on this site (by Mad Dr and Pearls N the Hood).  This isn't because our site has any specific stance, it's because we have two writers who happen to feel passionately on the subject, and happen to be pro-reform.  But if you look around the feminist blogosphere, most feminist bloggers and tweeters seem to be taking a "pro" stand (with the exception of arguing reproductive rights shouldn't have been thrown under the bus for us to get there).  On twitter Sunday night into Monday, there was tons of breath-holding (as the final votes were counted) and cheering (once the bill tipped over the threshold) going on among the feminist groups we follow.  Reading all this, you might start to feel that feminism comes as a package deal, complete with liberal political beliefs.  I'm writing this because I don't believe that to be the case, and I don't want our readers who don't share this "belief package" to feel alienated if they don't, either.

There are many reasons one might feel skeptical, or at least less-than euphoric, about the recent healthcare legislation, and none of them make you any less of a feminist.  Let me lay out the spectrum of healthcare skepticism, both for us skeptics and for those who don't get where we're coming from.  You might be skeptical of the healthcare legislation because:
  1. You don't believe in the principle of a social redistribution.  You think the government is for providing basic public services and regulation only, and that people should help others privately if they choose to do so.
  2. You believe in the principle of social redistribution in theory, but you think the government is ill-equipped to do so, or that the government being involved might stifle economic growth, which will lead to less wealth for everyone.
  3. You may or may not believe in the principle of social redistribution, but you think the government should not be involved in regulating healthcare, which should be a private transaction between patients, doctors, and insurers.  You think the government's involvement may be create distortions, inefficiencies, privacy concerns, or other problems.
  4. You think it's fine for the government to be involved in health regulation, but you're not sure this bill focuses on the right things.  You may believe that repealing the tax subsidy for employer-paid health insurance would do more to control costs than the current bill, for example.
  5. You think this bill does the right things, but doesn't do enough of them.  You wanted a more comprehensive bill, and are disappointed because passing this one means less political will for passing stronger reform.
  6. You think what is needed is a total overhaul of the healthcare system, including possibly going to single-payer government run care, and you feel this bill doesn't further that goal.  You may feel this bill takes too many cues from conservative healthcare plans, and helps private enterprise more than public interest.
There, six reasons people may question healthcare reform from across the political spectrum, and not one of them involves wanting little Timmy to die of cancer.  What I'm saying is, there are lots of ways to feel about policies, and they don't make you a good or a bad person, or a good or a bad feminist.  People often call others cold-hearted for saying that a certain number of uninsured individuals is acceptable, but we make these kind of cost and benefit calls in policy all the time.  We set speed limits knowing full well that lower limits are less likely to cause traffic accidents, but unwilling to sacrifice the economic efficiency that comes with swift roadways.

Personally, my skepticism comes from a mixture of reasons three and four.  I'm worried that the government is not the right entity to make decisions about appropriate healthcare, and I also worry that this bill offers several fixes to improve coverage without really addressing soaring costs.  For the first concern (and you should remember, I am pro-choice), I think the Stupak kerfuffle is case in point about why it's worrying for the government to be making care decisions.  This bill strengthens the governments hold on determining what basic healthcare entails and what it doesn't, and the decision to exclude abortion from government-sponsored plans tells me the government cannot make these decisions agnostically.  I think evidence shows the government is not very good at making policy in keeping with cutting-edge science (witness how long it took to change the federal dietary guidelines when it was clear they were out of step with modern nutrition science), and the price for this in the healthcare realm is large.

The second concern doesn't keep me from liking the current bill, but it does give me a sinking feeling about where healthcare is headed, and what the unintended consequences of this legislation will be.  In my opinion, healthcare is unaffordable largely due to our distorted view of what health insurance should be.  Health insurance in the US is not insurance at all, it's a payment transfer system that breaks the link for consumer between how much healthcare they consume and how much they pay.  What I mean by this is that health insurance doesn't just cover unanticipated events (what insurance is designed to do to allow the efficient transfer of risk from one party to another) but rather all health needs.  When someone is very ill, they know that they are consuming a lot of healthcare, and the care they consume is largely non-discretionary.  However, when someone is healthy and simply getting their normal tests, checkups, and prescriptions, not having to internalize how much these things cost can cause over-consumption.  And once again, the government is not very good at setting guidelines.  There has been countless damage done by over-screening for cancer (prostate cancer is one egregious case), that likely never would have occurred if consumers had set the amount of screening with their pocketbook instead of insurance executives and policy-makers with opinion polls and outdated science.  Consumers naturally weigh the costs and benefits of purchases in a way no policymaker has yet been able to replicate.

I believe a driving reason behind the "over-insurance" phenomenon is the tax subsidy that allows employers to compensate employees tax-free if they do so through healthcare.  As a result, including more things in health insurance that employees would spend money on regularly became a way of funneling more tax-free compensation to employees.  Naturally, not only things that constituted true insurable risks would be included, because there were so many other things that could be included and that employees spent money on. If a health insurer spent that money instead, the employer could pay the employee less, and pay the health insurer tax-free.  As a result, we have a system where health insurance isn't insurance at all: Your car insurance doesn't cover oil changes, but your health insurance covers dental cleanings.

So there you have it; I'm skeptical.  I'm not upset about the bill being passed or militantly opposed.  I'm just less than euphoric, because I have concerns.  And that's ok.  I'm still a good person, and I'm still a feminist.  What I'm trying to say (in this now very long post) goes beyond healthcare: I want this blog to always be a safe place for dissenting opinions, even (and especially) those that go against our own.  There are a few things I'll always consider unacceptable (homophobia, sexism, racism, weight bigotry, and religious discrimination are part of the list), but beyond that, no opinion is "taboo" on femonomics.  Celebrating women means celebrating that women are diverse.  So please, join in in the comments!


  1. Coca Colo, I think this is an interesting, well-informed and well-thought-out post that certainly offers a valid and important take on the health care reform. There are indeed reasons why one might be less than euphoric about *this* health care bill (although I personally disagree with 1 and 2, I think the other reasons bring up valid and important considerations). I also think you are right to question whether the government is really the most efficient or knowledgeable actor in making health care decisions for the rest of us.
    However, for me, the euphoria associated with the passage of the bill comes from the fact that it FINALLY addresses some issues faced by some of the poorest and most powerless people in our society by providing them with a basic safety net of health insurance. The expansion of health insurance (although it's unfortunate that, still, not everyone will be insured, and the subsidies may not be large enough) will serve to make sure that people don't go bankrupt when they get sick (or don't forgo necessary treatment because they can't afford it). This is huge! I think this article: makes this point well by talking about how this bill is the first in many decades to address the growing wealth inequality in the US. Now, there might be concerns with how well this reform will be executed or whether there are loopholes... But just the mere fact that this (yes, imperfect) legislation passed, I think, is something to celebrate. And that's my (perhaps traditionally liberal) opinion!

  2. Agreed this is a good post.

    The No. 1 reason I prefer the bill to the status quo is that it will prevent the scenario where one gets a catastrophic & expensive illness and can't get insurance. Starting from a state of nature, I expect we would all want this kind of social insurance always and forever, and this bill gets us closer to that ideal. This dominates most other concerns for me and makes me cautiously optimistic about the bill.

    Now this comes at what cost? My No. 1 concern is what negative effects the bill will have on medical innovation. This falls into your No. 3, but to be clear -- the kind of distortions I'm concerned about are not relative price changes and little triangles between supply and demand curves, but rather the treatments and medicines that might never be around to save lives if government stifles innovation. Too much policy gets made based on a static view of the world that completely ignores the dynamics of creativity and invention, and that does worry me.

    One more thought on innovation that's mostly unrelated to health care but truer to the theme of this blog -- imagine telling someone in the 70s, after Title IX passed, that in the year 2010, millions of households would have several networks that show sports 24 hours a day, and one of them would freely televise every game of a 64-team women's college basketball tournament. I imagine most people would not have believed you. Government policy can change the world in ways you might not dream are possible, for better or worse, and the long run needs more attention than it's been getting, beyond just CBO budget forecasts.

  3. My primary gripe with healthcare reform in the US has been the need to go after big packages. Pretty much everyone agreed that pre-existing condition exclusions had to go, and that consensus has existed for quite a while. Why couldn't a small piece of legislation have been passed decades ago to accomplish just that(*note). It seems that politicians' egos require that they attach themselves to big projects, that to pass necessitate tons of shady compromises, instead of making incremental positive change.

    *note: pre-existing conditions are slightly tricky, in that when insurers must price everyone the same, and where health insurance is not required, the pool of insured can enter a death spiral see Wikipedia -


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