My question to Mark Pauly

I asked the final question put to Mark Pauly after his plenary talk yesterday.

My question (paraphrased): Almost without exception, when I hear health economists describe their preferred health reform, it is rarely exactly the ACA, but it often has many similar features. Yet the health economics community is not uniformly pro-ACA. Should we be?

Pauly’s answer (paraphrased): It’s not our role to endorse legislation, and I have never done so. We should remain unencumbered in our ability and willingness to comment about the strengths and weaknesses of any proposal.

I think this is a good answer, and it is consistent with my own behavior, yet I still feel a little uncomfortable. In asking this question, I had in mind a slightly different one: could there ever be anything important enough to warrant putting aside the standard academic equipoise? (“On the one hand …, yet on the other …”) If so, what? Could making substantial progress on the problems of the cost and quality of and access to health care be in that category? Is it or should it be relevant that a failure of this health reform, like all comprehensive attempts in the past, likely means at least another decade or two before it is attempted again?

I imagine a European colleague pulling me aside at the ASHE conference and asking, “Why can’t you American health economists figure out how to provide coverage for all your country’s citizens? What’s wrong with you?” I really do think it is a national embarrassment, or should be, that we are the wealthiest country on the planet, spend vastly more on health care than any other, and yet have enormous disparities in access. How we tolerate this, and for so long, is astonishing to me. What is wrong with us indeed!

Is there ever a time when we just say, “Enough!” not just individually, but collectively? Sometimes it seems like madness that we do not.

And yet (go ahead, groan), even if one can reasonably disagree with Pauly, he’s not wrong. Health care is so political and today’s American political environment is so fierce and unforgiving —  toxic, even — that it is dangerous to yoke oneself or a community to legislation. Doing so would alter one’s relationship with it and to the party that promoted it, as well as with the one that opposed. That way danger lies. I respect those of my profession who are willing and able to take such risks. Most of them are tenured. Many of the rest of us are not. This matters, and we all know it.

So, I find myself conflicted. Facing the choice between madness and danger, I’ve tried to slide between, to be constructive without being partisan, to be honest without the hubris that I know best. I don’t. But, being honest, you don’t either. There is no such thing.

For three years, on this blog, I’ve written that the ACA or something like it is better than no reform but is neither ideal reform nor the end of reform. I’ve written about the important problems the ACA would start to address and about its limitations. I’m as pleased by the law as I am disappointed, and I’ve expressed that. This seems to be consistent with Pauly’s way, but I am less certain than he is that it is the right way. It is the safe way, and hence the appropriate position for the stewardship of the community. It’s the right view from the podium. But I still wonder, does madness ever trump danger? Do we sleep well in the academic bunker?

(Pauly’s talk, about the longstanding shortcomings of the private health insurance industry, was excellent. I believe it may appear in print in the future, but I didn’t quite catch where or when.)


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