When it comes to the health care policy proposals under discussion in Washington and across the country, it seems almost everyone finds something to dislike.
Libertarians and healthy young people don’t want government to force people to buy insurance. People on Medicare Advantage plans don’t want to give up the bonus subsidy these plans currently get. Medicare beneficiaries in general don’t want any reduction in benefits. Labor unions don’t want a tax on high-benefit insurance plans. Abortion opponents don’t want one cent of public money to cross-subsidize abortions. Ditto for those concerned about illegal immigration.
Doctors don’t want government dictating payments for specific procedures or limits on their discretion to prescribe treatment. Insurance companies don’t want to lose their hegemony in health care financing and administration.
Pharmaceutical and medical device manufacturers don’t want to be taxed and don’t want government to dictate which devices or medications are preferred or the allowable prices at which they are sold.
Consumers don’t want limits on coverage for pre-existing conditions, on their choice of providers, or on the procedures that their coverage must pay for. Attorneys don’t want new limits on malpractice suits. People in their 50s don’t want to pay more for insurance than those in their 20s. Thin people don’t want to have to pay as much as fat people.
But opponents should take a lesson from Polish history before they press their points too stridently.
In 1596, the Kingdom of Poland and the Grand Duchy of Lithuania formed a confederation that incorporated aspects of modern constitutional government. There were monarchs, but these were elected by the Sjem, a parliament of nobles that could impose broad constraints on actions by the king.
The confederation exhibited admirable precedents of freedom of religion and expression, but failings in its internal organization led to its eventual destruction.
The rules of the Sjem gave veto power to any single member of the assembly. This “liberum veto” was exercised very little for the first 150 years of the confederation’s existence. But in the 1700s, use of the veto became commonplace, creating successive political deadlocks that stymied effective responses to both internal and external challenges. Despite reforms in the 1760s, the individual veto power contributed to the 1795 dismemberment of Poland by Russia, Prussia and Austria. Poland re-emerged as an independent nation only after the Paris Peace Conference at the end of World War I.
The U.S. Constitution was drafted just before Poland disappeared. The authors of the Constitution were conservative men who wanted to make dramatic change difficult but not impossible. They did not want any majority to be able to ride roughshod over the wishes of the minority. Yet, they were aware of the danger of letting opponents of change have too much power.
The resulting Constitution, supplemented by House and Senate rules including the need for 60 Senate votes to overcome a filibuster, makes change more difficult than in other industrialized countries.
In the health care debate, each group has a position it considers legitimate and important. So did the Polish nobles who increasingly called out “Nie pozwalam” (“I don’t allow it”) in the Sjem over the 1700s. We may end up with the same sort of deadlock of policy paralysis that helped scuttle Poland as an independent nation.
Such special-interest considerations are widespread in both parties. There are demagogues in both. But while the Obama and the Democratic majorities in both houses want some bill to pass, many Republicans think blocking all Democratic proposals is an opportunity to “break” the Obama administration and pave the way for a Republican resurgence in 2010 and 2012.
They should be careful about what they wish for, particularly in waving the bloody shirt of “they are going to take away your Medicare,” to rouse the over-60 cohort. Medicare’s funding is unsustainable, with or without any of the proposed changes before Congress right now. Its financial problems are going to come to a head in the next five to eight years.
Either benefits will have to be cut or Medicare tax rates increased sharply, regardless of which party controls the White House or the Congress. Measures like commissions of experts to determine the most cost-effective treatment protocols are one way to cut outlays. Ridiculing these or treatment-option counseling sessions for the elderly as “death panels” is going to come back to bite any future reform in the rear.
People concerned about these issues or any other need to think deeply about how important their concerns are relative to the costs of perpetuating the existing system. Those focusing on electoral tactics need to think about how short-term advantage may affect their party in the long run.
Different interest groups may success in defending their particular position, but the net outcome will be that resolving fundamental problems in U.S. health care just gets kicked a fw years down the road.
The cost to our society and economy from the failings of the existing system will continue to fester.
Moreover, the passions inflamed by special-interest groups in scuttling current initiatives will make it even harder to consider important possible reforms the next time around.
© 2009 Edward Lotterman
Chanarambie Consulting, Inc.