• The perfect and the good, benefits and harms

    A good friend of mine listened to a recent talk on health care reform from a well-known political figure, and was telling me about it. This figure disapproves of the Affordable Care Act, and was explaining why it needed to be repealed. His most salient point was that companies exist which would drop health insurance for their employees since the penalty would be less expensive than providing the insurance.

    I don’t think this argument is factually incorrect. And so I agreed that he was likely right in his assertion.

    Too often, however, when I agree that those I am arguing with have a point, they throw up their arms in victory and think they’ve “won”.* I don’t understand this mentality. If we want to be totally honest, yes, companies exist which will do this. There are likely some large companies that are giving their employees bad insurance, or none at all, and they won’t want to be faced with the new costs. Companies likely exist who will drop some employees to part-time in order to avoid having to pay for either insurance or the penalty. Companies likely exist who will find loopholes to get under the cap of a “large business”.

    Some bad things will happen to some people under the law. When did we become a country of people who only expect that purely positive things ever happen?

    When I hear that companies will drop insurance, I nod and say that their employees will go to the exchanges. When I hear that this will increase the cost of the law because of increased subsidies, I nod and say yes, I think it’s worth it. I say that because I live in the real world where sometimes good things cost money.

    When Medicare was put in place, I’m sure people and businesses didn’t like the Medicare tax. They adjusted. When social security was put in place, I’m sure they felt the same way about the social security tax. Whenever we do something good (or even bad), we all pay for it somehow. If you don’t believe that’s so, you’re in denial.

    So if tens of millions of people get insurance who did not have it before, if tens of millions of people with chronic diseases are assured they will always be able to get insurance, if tens of millions of people are given financial help to buy insurance, if tens of millions of seniors have an easier time buying drugs, if millions of young adults can get on family policies, if millions of people are protected from annual or lifetime caps, and if some steps are taken to try and curb costs, then I can live with covering the cost difference between the subsidies these employees will receive in the exchanges and the penalties companies will pay for sending them there when they drop coverage.

    Of course there will be some negative outcome from the Affordable care Act. But if you think any negative consequences means we should do nothing, then we might as well close up shop now. This type of magical thinking is killing our discourse.

    I can find fault with your plan, and you can find fault with mine. That can’t be the end of the discussion; it has to be the beginning. For me, it’s not that negative consequences don’t exist, it’s that the benefits outweigh them. You may be able to find a salient flaw in the law, but if all you’ve got is repeal, then you need to convince me that this flaw is worse than doing nothing. I can come up with reams of data to show that our health care system costs too much, covers far too few people, and is shockingly lacking in quality. I think that health care reform under the Affordable Care Act is far from ideal, but I also believe it does more good than harm.

    You can’t just talk about the bad stuff. You need to explain why the bad stuff overwhelms the good stuff. Otherwise, you’re just letting the perfect be the enemy of the good.

    *My friend did not do this, of course

    UPDATE: Julie Rovner reports that Employers May Not Rush To Drop Health Coverage After All. This still doesn’t change my main point.

    • I agree that the status quo is unacceptable. But, this begs the question of cost. Yes, good and important things cost money. But, didn’t the President argue in the run up to the bill at the rising cost of health care was creating an unsustainable burden on the taxpayer.

      The President and the Dems, then used transparent budget tricks and gimicks to receive a positive scoring from the CBO. They then used the CBO score to claim that the law “would bend the cost of health care down. (see 6 years of benefits and ten years of revenue; double counting of the $500 Billion in Medicare cuts and of course the CLASS program)

      The public saw through this and the majority of Americans were against the bill. When has a massive piece of public legislation ever been passed in this country that didn’t have majority support?

      I represent some of the finest not for profit hospitals in the NY Metro area. This bill (especially the millions that are going to be thrown into Medicaid) will devastate these institutions. The regulatory and compliance costs of the PPACA are already creating a financial crunch!

      We need health care reform. The PPACA is a fatally flawed bill. It must be repealed and we need to start over! If we do not, we are following a pattern of this administration. Taking a bad situation and making it worse.

      • @PJK
        A next step would be for the House to actually mark up Rep. Ryan’s Patients’ Choice Act and proposals for Medicare and Medicaid reform. Then the alternatives can see the bright lights of CBO and we could decide what to do.

      • We all know that a great many compromises were made to pass the ACA. It certainly can be improved.
        However, the standard right wing attack always starts with “repeal the entire bill and start over”. Perhaps they are cynically aware that after repeal, it will be impossible to pass a new comprehensive ACA.
        It would be a much better approach to fix the problems with the current bill but that would require some constructive effort and bipartisan cooperation and would certainly not earn any political points on the Republican side. It’s much easier to just say “repeal the act”.
        I’m sure the Democrats would be interested in constructive improvements to the ACA. They have already suspended the CLASS provisions because they were fatally flawed (by design?).

      • As a representative of “finest not for profit hospitals in the NY Metro area.” can you tell us what, if any, strategies they’ve considered for fixing ACA from their point of view and how important you think it is to significantly (i.e. by tens of millions) decrease the number of people without insurance?

    • I want to extend PJK’s point. Of course, we should weigh the costs and benefits of these proposals and choose the option where the benefits most outweigh the costs. However, I don’t think anyone–ANYONE–has an accurate idea of the costs and benefits of a bill as far-reaching as this health care bill. With that much uncertainty, each side will grab whatever information that supports their opinions.

      • But that’s true of anything. The future is always unknown.

        This blog serves are a testament to the amount of research and thought describing the positives (and negatives) about health care reform. You can’t just say that no one knows anything.

        Make a constructive argument, backed by date or evidence, as to how the negatives outweigh the positives.

    • “You may be able to find a salient flaw in the law, but if all you’ve got is repeal, then you need to convince me that this flaw is worse than doing nothing.”

      1. Worse on which dimension?

      2. Nothing isn’t the only alternative, and it’s not clear that legislation is the only means to bring about a non-nothing outcome.

      3. Does anyone believe that CBO projections count as “data”? As John K Galbraith said once, “The function of economic forecasting is to make astrology look respectable.” Even if you ignore the garbage-in, garbage out problem of the bogus assumptions that Congress forces them to plug into their models – it’s not clear that the models themselves are good enough to call their predictions “data.”

      4. Nassim Taleb and others have often made the case that a bad or inaccurate map/prediction is significantly more dangerous than having no map/prediction at all.

      With no snark or disrespect intended, this post in particular seems a bit like someone in the days of the four humors claiming “If you can come up with a better theory than “The Four Humors,” for understanding physiology, *then* I’ll stop bleeding the patient.

      “Health Care” is an enormously complex enterprise. How about more Sextus Empiricus and less Plato if we really want to make sure that we’re doing more harm than good.

      The Rand study, the Oregon Medicaid Study, and discrete, disaggregated studies of clinical efficacy are all we have to go on, and that’s not much. Hence it’s quite defensible to argue for more experimentation before we go for the heroic cure.

      • While I am sure that most people who post on this blog are sympathetic to the idea of doing more research, how long do you think we can delay major changes to the health care system to do this research and what makes you think the a working majority of policy makers will pay attention to the results?

    • edit… “Not doing more harm than good.”