Judge Health Reform on Care it Delivers to People, Not Subsidies it Passes to Private Insurers

There's a lot I object to in Hendrik Hertzberg's judgment
of those opposed to the Senate health bill as "pathetic." His entire
piece revolves around the claim that bill critics are committing a
pathetic fallacy: attributing to an inanimate object-Congress-animate
actions-passing the bill.

The pathetic fallacy is a category
mistake. It's the false attribution of human feelings, thoughts, or
intentions to inanimate objects, or to living entities that cannot
possibly have such feelings, thoughts, or intentions-cruel seas,
dancing leaves, hot air that "wants" to rise.

Yet most critics have been very specific about the people (Harry
Reid for his inability to enforce party discipline, Rahm and others for
prioritizing deals with the industry over cost containment, Joe
Lieberman for being Joe Lieberman) who have made this bill what it is.
It is Hertzberg's fallacy, not critics', to suggest that this bill got
so bad because of an inanimate object called "the system." Indeed,
suggesting the end result of the actions of a small group of fully
deliberate beings is not the product of human will serves as a neat
excuse for those who want to obscure the process and decisions that
resulted in this bill.

Hertzberg also curiously invokes the defeat of Kennedy's Medicare
efforts in the Senate (after which, two years later, the bill passed)
to argue we are faced with a choice between the status quo or this
bill. The history of prior reforms can and has been used as a double
edged sword in this debate, so I'm not arguing that the lesson offers
us any real insight into the fate of health care if we do or don't pass
this bill. But used as he is doing, doesn't it suggest the possibility
that, if this bill were to fail, it might not be
several generations until we tried again, it might be passed in the
near future? (Not that I necessarily believe this would get easier in
two years, I just think it is a very inapt use of the example.)

But reading the piece finally got me to read another piece that bill
champions have repeatedly pointed to to celebrate the bill: a post
by University of Chicago Health Policy Professor Harold Pollack,
comparing the subsidies included in this program with the subsidies
offered in just about all other support for the poor.

By 2019 when the reforms are fully implemented, the Senate bill would provide about $196 billion per year down the income scale in subsidies to low-income and working Americans.

Even policy wonks have trouble getting their heads around such a big number.
With due allowance for the back-of-the-envelope nature of this
calculation, $196 billion exceeds the combined total of federal
spending on Food Stamps and other nutrition assistance programs, the
Earned Income Tax Credit, Head Start, TANF cash payments to single
mothers and their children, all the National Institutes of Health, and
the Department of Housing and Urban Development. (I admit to some
uncertainty about that last one. We may have to leave HUD behind...)

(Pollack has a worthwhile, thoughtful expansion of his stance on the bill here.)

Now, I don't contest Pollack's numbers. Nor do I underestimate the magnitude of this amount of subsidies.

But there's a flip side to that magnitude, one which, IMO, is not worth celebrating.

First, a significant number of the recipients of these very generous subsidies aren't going to see them in tangible form. For
those getting subsidized premiums, the biggest immediate benefit will
be yearly check-ups, if they have access to a doctor (experts expect
there will be access issues in the years after the subsidies start). If
MA is any indication, though, many won't actually be getting health care beyond that check-up; they still won't be able to afford it. And for those who will go into debt before they get any out-of-pocket subsidies, I suspect those subsidies won't feel all that generous.

Now compare that to the other tangible things the subsidies Pollack
lists give people: real cash for single mothers, tax credits for the
working poor, and food stamps that function as cash in many stores
(which, shockingly, serve as the sole source of income
for 6 million Americans). These other subsidies give people income,
cash to spend on food, affordable housing. Real, tangible benefits. The
thing they lack.

Shouldn't the program be measured by what tangible benefits it
provides-how many get health care-rather than how many subsidies the
insurance companies get?

Then there's the issue of scale that Pollack's post displays. We are
providing the poor food, shelter, and income. All for less money than
it is taking to provide an admittedly much larger group of people
insurance (but not necessarily care). Do we have our priorities in
order? Doesn't the sheer scale of these subsidies constitute a flashing
warning sign about the relative cost of health insurance (but not care)
that this reform institutionalizes?

And therein lies the real risk. As many many people have pointed
out, subsidies-particularly subsidies to the poor-often fall prey to
political pressure. Particularly given the number of conservative
Democrats who are itching to cut back on other programs supporting the
needy, should we really be crowing about the success of this program by
how dependent it is on subsidies-by how big a target it establishes for
deficit hawks to go after?

I'm sympathetic to both Hertzberg's and Pollack's argument that we
have an opportunity to get millions care that they don't have, even as
they acknowledge the imperfections of the bill.

But isn't it a sign of the bill's problems that bill champions have
to point to the subsidies the bill will provide, rather than the actual
health care it gives?