• Who are these mythical liberals who don’t care about costs?

    I have a lot of respect and admiration for Zeke Emanuel. I really, really do. But when I read his Opinionator piece this weekend, I went away a little annoyed:

    WHEN it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act passed under President Obama is to finally erase the moral stain of the United States’ being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world’s most expensive health care system — what about cost control? For many liberals, that just sounds like a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.

    But liberals are wrong to ignore costs. The more we spend on health care, the less we can spend on other things we value. If liberals care about middle-class salaries, public education and other state-funded services, then they need to care about controlling health care costs every bit as much as conservatives do.

    Who are these mythical liberals who “ignore costs”? I will bet all the money in my pocket right now that when President Obama gives the State of the Union speech next week he devotes massive amounts of time to reducing spending. When the ACA was passed, it did not contain all the cost-controls I’d like, but it did contain more than any other recently passed legislation. I hear liberals talk about “bending the curve” so much I think it’s lost meaning.

    I also think that most of the “liberal” experts talk about this all the time. Find me a single well-respected wonk in the blogosphere who isn’t concerned about costs. I did a two week series on health care costs!

    It makes for an interesting straw man, but I think Emanuel is making the wrong argument by arguing against these cost-ignorant liberals. It isn’t that conservatives want to cut costs and liberals don’t. It’s that they want to do it in different ways. Conservatives usually* want to rely on the market and individuals (those at the bottom of the health care system) to be responsible for driving costs down. Liberals usually* want to rely on experts and government (those at the top of the health care system) to be responsible for driving costs down. We can debate those competing schools of thought, and how they might or might not work, without resorting to believing that only one side cares.

    On a side note, explain to me how Medicare Part D – passed by a “conservative” government – controls costs at all.

    *Note that exceptions abound, and this is an overly simplistic description. I think the broad brush strokes are pretty accurate, though.

    • Aaron, I’m worried that you’re mistaking your corner of the academic/technocratic wing of the liberal establishment for the whole thing.

      My liberal friends without a science background focus the argument mostly on: covering the uninsured, protecting the most vulnerable (kids/ppl with preconditions/etc.) and the establishment of a public option or single-payer.

      To these people, the offering of coverage IS the battle. They have no idea how to implement cost reductions, and don’t fully understand the shift that’s going on between intuitive vs. Evidence-Based medicine. They would care, but all they’ve been hearing about in the media when healthcare comes up is the establishment of insurance. The health system itself is just too complicated, so they don’t think about it.

      The reason it feels like a straw-man argument is that Zeke’s blog is mostly read by people like you who are familiar with these issues, and we HAVE been thinking/talking about cost control. But the message that needs to be imparted on the less involved liberals: the struggle to provide healthcare to Americans will be decades long and providing “insurance” to everyone is nowhere close to the end of the story.

      We need people to know about FFS, Capitation, ACOs, NNT, QALYs, all of these things… because outside of the directly involved, most advocates of providing healthcare haven’t even heard about them!

      • Perhaps. But I’d want to see data on the numbers of people who want to increase access but don’t care about spending. I bet they are equivalent to the number of “conservatives” who want to cut costs and don’t care about access or quality. I think those people are rare, as well.

        I also don’t think Emanuel is only talking to the general public in his piece. I think he imagines he’s talking to policitians and policymakers as well. They DO recognize that spending is a problem.

        If he’s not targeting those people, I think he could have made that point more clearly, and in a better location than the NYT blogs…

    • I’m going to second Will. I do have liberal friends outside of health policy who tend to downplay costs. My impression is consistent with this: non-health policy liberal commentators seem to me to not be as concerned with cost, figuring that we can tax people, push costs onto providers, or get rid of the really wasteful procedures, or reduce use of ER care, etc.

      While I think that Dr. Emmanuel has a point about some liberals, my impression is that conservatives who -are- in health policy are much more prone to magical thinking about individual choice and how that’ll bring costs down. As Will says, liberal technocrats need to bring the message about cost control to other liberals. But on the conservative side, Heritage has disowned the individual mandate and is feeding the public junk about magical solutions for our health policy problems – disgraceful, imo.

    • I believe that Emmanuel also conveniently leaves out that health reform probably would have never happened had meaningful cost-control measures been included in the legislation. If he is simply concluding that since the PPACA was created by liberals, and the PPACA does not include strong cost-control measures, therefore liberals do not care about costs, he’s wrong. Lets not forget that it barely passed as it was and only got support from certain groups because it wouldn’t cut into their profits too much (or at all). Lack of cost-control measures were a consequence of political realities, not political ideology. In one of Oberlander’s more recent articles (Journal of Health Politics, Policy and Law, 2011), he suggested that an underlying strategy to health reform could have been to first get everyone in the system and go from there to address costs (I am greatly paraphrasing, and I hope more or less accurately). I agree with Oberlander’s argument. Perhaps some like Emmanuel are only focusing on what PPACA does not do while ignoring the context. I’ll add that it was bizarre of him to only focus on liberals when there are plenty of examples of conservatives’ own disregard for cost and the burden of our expensive health system (like Aaron said, see Medicare Part D). Perhaps he was only giving himself room for a follow-up piece?

    • People like Aaron who seriously understand the economics of health care are correct in that they care about costs; other “liberals” do not care about costs do not understand the economics of health. They think that if somehow government is involved, costs don’t matter.

      The great tragedy of the ACA is that it did little or nothing to introduce any type of cost control into the system. Costs go up primarily because that is how income to the health care system goes up. Cost control will occur only when fee for service is eliminated from the system, something any first year econ student knows.

      The post also misconstrues to some extent the Conservative position. The main drive of Conservatives is to reduce the costs borne by government in health care and increase the costs borne by individuals, so that taxes can be cut and government spending reduced. Their idea that individuals can control costs through a market system is simply a false rationale for reducing government expenditures.

      Once government is out of the picture Conservatives really don’t care if costs go up, down or stay the same. After all, 99% or so of the Conservatives in office or who have served in office have government provided health care insurance with relatively small employee contributions.

    • Essentially everyone on the left who writes about health care is concerned about costs. I suspect that some on the left who are not interested in the details of health care do not care that much. They are not going to write policy. They are also bombarded pretty regularly with news about rising health care costs. I think this is probably a pretty small group. I think it more likely that they end up defending the ACA because it covers more people and talk less about the cost issue.


    • Perhaps it’s an Emanuel family trait to misconstrue or falsify what actual liberals or progressives say in order to reinforce their standing as Very Serious People. Is he just ignoring everything that, say, Paul Krugman has written about health care costs and sustainability? Does he even know who Dean Baker is? C’mon man. It’s not liberals’ fault that the US spends much more per capita than other nations in spite of non-universal coverage, with mediocre health outcomes to boot.

      If liberals and progressives put first priority on coverage, that’s because the US lags other developed nations in assuring access to care. As the Dartmouth Atlas work demonstrates, in health care supply tends to drive demand in an extremely non-transparent environment. Spending is high because prices are high and utilization is unconstrained by any requirements to show actual benefit from a new treatment or procedure or drug. And both parties are happy to finance their campaigns with large contributions from every interest group that wants its revenue streams protected.

    • Downplaying medical costs is common among liberals who don’t know much about health care economics, which is around 95% of liberals. I’ve been arguing about health care costs with fellow liberals (at first mostly on liberal blogs like Daily Kos) for nearly 10 years, and particularly before HC reform passed it was almost impossible to find a liberal who thought we needed to do anything about costs other than go to a single payer system.

      The liberal line about costs was generally that they are driven by insurers’ high profits and administrative expenses (most of which seemingly consisted of executive salaries). Remove that, and problem solved. I had dozens and dozens of debates with people who argued this way, and reflexively defended doctors, dismissed utilization controls as unseemly, rejected the idea of supply-driven care and actually embraced the fact (when I pointed it out) that providers here are paid twice what the are in other nations. The belief was that doctors are worth it, and people were glad docs were making $150k to $500k, and that this wasn’t a big part of the problem. Again, I’m a liberal so this isn’t an attempt to demagogue, but it was my experience.

      Fun fact, I did a poll back around 2007 on Daily Kos of what people thought the average profit margin for insurers was. Most respondents thought it was higher than 25%, when the reality was less than 5%. this matches, by the way, results that Wellpoint got when they did a statistically valid survey on the same topic around 2009. So liberals were not outliers. Nobody understood the real sources of our higher costs; well, a quite small proportion of people did, and do.

      One of the biggest benefits of the ACA is that it is changing this dynamic.

      And you know, if insurance profits were as high as people thought they were, they would have been right to argue that single payer should be the main focus to control costs.