Tuesday, April 7, 2009

Health Care Policy

Economist's View: "When it Comes to Healthcare, the U.S., Britain and Canada are Hurting": "'save-the-rustbelt', a commenter at Mark Thoma's Economist View, criticizes Ezra Klein, a young progressive pundit with an interest in health care policy: 'Most of the people driving health care reform, including Klein, know nothing about the nuts-and-bolts of the health care system and how it operates . . .'"

Klein has made himself more than fairly expert on the subject of health care policy, which has become its own cottage industry with its own esoterica, as a nation waits in frustration for humane rationality to have a hearing.

The actual administration of health care is so vast in its scope, no one -- literally no person anywhere -- is expert in the usual sense of being able to relate the high abstractions of policy to the operational details. And, health care policy, on the level Klein observes as a journalist, no one even tries any more: the policy proposals and outlines of policy entrepreneurs in Washington and academia are purely heuristic. That's not Klein's fault -- it is just the way things are. If we are going to have reform, it is by adopting a policy heuristic, and then elaborating a new organization from the consequences, which consequences will be almost entirely unforeseen by the policymakers. At best, one hopes that some kind of change at the top creates the kind of chaos down below, where local scope is sufficiently smaller, that there really are experts, and those local experts can leverage the chaos of changing institutional reform to cause something better to emerge.

I think some policy heuristics are better than others, but, obviously, lots of players in the political process are so stupid and have so much ill-will, that the political "debate" is completely pointless. The agenda can be controlled by the opposition of the right-wing and the "centrists", both of whom are strangers to reason.

It is a general problem, I suppose, of interest group politics, and of the domination of the state, by a reactionary plutocracy.

It is part of the zeitgeist of our moment, that this problem of teh stupid is emerging into such pure relief, as the shape of American politics.

We can see it in the economics of the stimulus, where winners of the Nobel Memorial Prize, demonstrate that they are incapable of passing Econ 101 at a community college, in order to give political cover for the stupidest, obstructionist elements of the Republican Party.

And, we see it in the Administration's advocacy of pointless giveaways to the banksters.

As far as health care is concerned, the shape of a health care policy reform almost doesn't matter. At the level of a Congressional enactment, all that is important is that the reform be sweeping enough to change the game and create the chaos necessary to make space for new organization and institutions to begin to emerge. It doesn't have to be sensible; it doesn't have to "work" in the sense of creating anything sustainable or functional -- it would almost be better if initial reform just accelerated the entropy of the existing system, bringing on a more acute failure, and undermining the interest groups that prevent rational policy choice.

If the "rational" choice is "irrational" policy to destroy an interest group blockade, it almost doesn't matter, if anyone doing health care policy knows how the system works. We know that, in important ways, the system doesn't work, and reforming it requires policy that further undermines it, before we will have any chance of substituting a better system.

In a topsy-turvy world, in which the "best" health policy proposals are judged good, to the extent to which they are fundamentally subversive, and politically palatable only to the extent that the hired guns of existing interests do not fully understand how subversive they are, Ezra is actually a pretty good guide. But, don't expect any map of Alice's world beyond the Looking Glass, or Ezra's health care policy universe, to have a lot of lines drawn with a straight-edge.

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