Tyler Cowen on me on Medicaid Wars

Tyler Cowen responds to my post about his NYT piece. Go read it to catch up.

Let me start by saying that I’m going to be as dispassionate as possible here, because it’s too easy to let emotions get in the way.

Yesterday, I was “annoyed”. That was not entirely directed at Cowen, but at the ideas that often permeate our discussion of health care policy. Krugman refers to them as “zombie ideas“, and I think that’s a pretty good description. Some of those ideas were, by my reading (yes, I read it, carefully, many times), strongly implied by Cowen’s NYT column. In his post, where he has more space to do so, he explains how and why they aren’t. Nuances matter. At the same time, many more people will have read his column than his post. So many won’t read the nuances.

I did not, as Cowen writes, dispute his main argument. That’s because I don’t or can’t necessarily disagree with most of his points. He gives an accurate description of Medicaid itself. He talks about his belief that Americans will someday vote to rebel against Medicaid.  He says Republicans might try to take it apart. Then he gets into a number of paths we could take to alter the Medicaid expansion. He ends with what he thinks is the “most positive path”, which seems to be a subsidized and mandated catastrophic plan with a free market for everything else.

None of that is “wrong”; it’s opinion. That’s not what annoyed me, so I didn’t write about it. As I am one of those people who do want conservative engagement with policy, I welcomed the above.

What bothered me were the little snippets of information along the way supporting his assertions. It’s the little ideas that many “assume” are true. It’s the justifications (often without evidence) that reinforce the ideas that annoyed me, and that’s what I wrote about.

I’m not going to do a line by line rebuttal to Cowen, because I’m not sure that will be productive. I’d rather shed some light than turn up the heat.

-I read in Cowen’s piece the idea that single payer systems lead to longer lines. I dispute this. Doctor shortages and an underfunded systems lead to wait times. We always point to Canada, but their wait times (overblown) are because they keep the budget down. You can have a single payer system and no wait time problem (see Medicare). So when you drop in that line, yes, it bothers me. But the larger point is that any increase in patient coverage without increasing the doctor supply will potentially lead to longer wait times. It doesn’t matter if the coverage comes from Medicaid, Medicare, or private insurance.

-I read in Cowen’s piece the idea that Medicaid has never been popular. What does that mean? Does he mean Republican governors don’t like it? I agree. Does he mean there will be a political battle over it? Sure. But those are not traditional meanings of “unpopular”. The very piece Cowen cites from Ezra Klein says this:

Medicaid is a bigger program than Medicare, serving more than 50 million people, to Medicare’s 48 million. Nor does it poll substantially worse. A recent Kaiser tracking poll found that 88 percent of Americans wanted either no reduction or small reductions in Medicare funding. At 83 percent, Medicaid was close on its heels.

I don’t see that as “unpopular”. It doesn’t imply it ever has been.

-I read in Cowen’s piece the idea that docs don’t accept Medicaid. In support of this in his post, he cites a personal experience in northern Virginia. I don’t dispute his experience. But I can give plenty of anecdotes with private insurance as well. What we care about are data. There’s a doctor shortage in the US, period. Lots of doctors aren’t taking new patients, period. Medicaid isn’t the worst offender here.

Moreover, this issue is all about reimbursement. Medicaid gives too little. It doesn’t make me an ACA “apologist” to note that the law tries to fix that. It might work.

-I read at the end of Cowen’s piece a preference for a more free market system on top of catastrophic insurance. I see no evidence for why that would be superior on cost control grounds, though the market does offer more choice. On cost control, I see it as trying to move in the opposite direction of nearly every other country, and they are cheaperuniversal, and often just as good.

Bottom line – I did use the word “annoyed”, but it was directed at everyone who uses memes like these to support their arguments. They’re the equivalent of “all insurance companies are evil” and “the pharmaceutical companies just want to make money and screw you”. I went out of my way to praise Tyler Cowen in general, and to be polite. “Annoyed” was a reaction to what I wrote about – to these “zombie ideas”. I think we could make our arguments without resorting to them. I wish everyone (including Cowen) would stop using them and stick to facts. Thus, the title of my first post.


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