Thirty Million Uninsured

How many times did we hear during the health care debate in 2009 that thirty million people in the United States don’t have health insurance? Every time I heard that statistic, I asked, So what? What is the breakdown? How many of that thirty million don’t want health insurance? How many of that thirty million don’t care one way or another? How may would like to have insurance if they could get it, but aren’t that concerned about going without? Lastly, how many people don’t have health insurance, and wish strongly that they could obtain it?

Interestingly, the people who cited the statistic did not show any interest in questions like that. The number was enough. For advocates the size of the number mattered: the more Americans uninsured, the more urgent the need for reform. You can beat down the opposition if you repeat a number like that often enough.

The advocates for reform never did address the so what question, but after their triumph in early 2010 they began to reveal their thinking a little more candidly. You saw more references to the Massachusetts plan after the bill passed. Massachusetts originated the idea of an individual mandate to achieve nearly universal coverage in 2007. The reformers held up the Massachusetts plan as their model in 2010. Look what Massachusetts achieved with their health care reform: we can accomplish the same thing all across the nation.

I live in Massachusetts. I can tell you that RomneyCare is not a model for the rest of the country. It has not achieved what its advocates said it would achieve. Neither does it have any prospect of success. Yet people look to this plan as a reform model for all the other states. Why would that be?

I want to say something that reveals my prejudices, but I’m not sure that’s helpful. The fundamentals of the Massachusetts plan come from the mind of a pointy-headed professor at MIT. Whenever I learn that a professor conceives something that’s supposed to work in the real world, I know it’s destined for failure. I used to be a professor. Professors don’t have any idea about the real world. That’s why they’re professors. That’s my prejudice, based on my experience as a professor. People who teach at academic institutions do a lot of good work, but devising reform plans that change real institutions for the better is not something academics do well.

I heard the reasoning behind the Massachusetts plan on the radio not long ago. The simple-mindedness of the reasoning dismayed me somewhat. Ordinarily I like simple explanations and simple reasoning. It’s elegant and rapidly carries you from premises, through connections and reasons to conclusions. Simple reasoning won’t do for health care reform, though. It just won’t.

The main goal and motivation for health care reform in Massachusetts was to cut costs. Health care was too expensive for everyone: for individual patients, for taxpayers, for the state government, for the insurance carriers, and of course for health care providers as well. Everyone involved stood to gain from making health care in Massachusetts more efficient and therefore less costly. The state government in particular stood to gain a great deal, as its outlay for health care expenses greatly exceeded its resources.

The professor at MIT reasoned this way. If you want to pay for an expensive health care system, you have to expand the number of people who pay to support it. High quality health care, after all, is a collective good. If you have too many free riders, the cost becomes unbearable for the people who actually pay. That’s how professors reason. They think in terms of collective goods. If you see health care as a collective good, you have to solve the free rider problem in order to make the system work for all participants. To solve the free rider problem, you have to force people to participate. Thus the individual mandate.

How does an individual mandate contribute to lower costs? If you bring all parties together in a health insurance exchange, the purchasers of health insurance have more bargaining power than they do under the current system. Therefore they can keep prices lower, or at least keep them from rising so rapidly. That’s the reasoning. Universal coverage means greater bargaining power.

I don’t want to criticize the Massachusetts plan or the reasoning that underpins it here. I did that at length in another article. I do want to point to the intellectual dishonesty of that statistic we heard so often. When you cite a number – or any piece of evidence, for that matter – so often that it becomes a cornerstone of your argument, you owe your listeners an explanation. You can’t cite your argument over and over, and presume that its significance is self-evident. You have to answer the so what question.

Advocates of health care reform would difficulty were they to explain why thirty million uninsured is a significant number. They would have to break the number down to see why people are uninsured, whether they want to be uninsured, or whether they even care. Advocates of health care reform take the desirability of universal coverage as a given. That’s obvious enough. Once you take universal coverage as your goal, however, you can’t use the number of uninsured to show why the goal is desirable. That begs the question.

Here’s why. If you reason forward from the number of uninsured, you would include analysis of people who are insured as well. If you reason backward from the desirability of universal coverage, you would compare systems that have an individual mandate, or some other means to ensure universal participation, with those that don’t. If you do both, though – if thirty million uninsured becomes your reason for advocating universal coverage – you bypass all analysis and comparison. Your argument is self-contained because you don’t look at anything else. If thirty million uninsured is a bad thing, then of course universal coverage is a good remedy.

Here’s where we rest. Honesty leads to the truth. Dishonesty leads to disaster. When lawmakers and leaders say they will make health care less expensive for employers and for individuals, but enact a plan that does nothing of the sort, that’s dishonest. When lawmakers and leaders say they will make health care more rational and efficient, easier for all participants to understand and navigate, they ought to do so. If they enact legislation that instead makes health care more complicated and costly, that’s dishonest.

The dishonesty started with the initial statistic of thirty million uninsured. Health care reform advocates didn’t appear to care that much why thirty million people lacked health insurance. Yet they made that high number their rhetorical centerpiece. Advocates wanted universal coverage, no questions asked. You want to know why thirty million is unacceptably high, why we should have an individual mandate to bring the number to zero? Don’t answer questions like that. Honesty won’t get you anywhere.

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