This is not an alternative universe nor did you misread the title. I'm a bit behind on my magazines, but I recently finished David Goldhill's "How American Health Care Killed My Father" in the September issue of Atlantic Monthly. It's a wonderful essay--and I disagree with much of it.
Goldhill is a Democrat. I take him at his word, but this is an argument made by a businessman, by a grieving son, and by a man who would have been a Republican in 1977 or even 1987. It is precisely the sort of contribution conservatives should make to the health care debate. Why do I say that?
First, Goldhill's perspective reflects what I would regard as a truly conservative balance between individual responsibility and structural forces. On the one hand, people need to behave better and they need to engage in prevention. In many ways, they should carry responsibility for their health and for their health care in ways that they now do not do. On the other hand, Goldhill argues that the system offers perverse incentives; people are encouraged to behave badly and, given those incentives, they're likely to do so.
Second, Goldhill approaches this problem as a businessman. Rather than beginning with vacuous abstractions about family values, he turns to empirical fact (hospitals kill inordinate numbers of people) and best business practices (why has our health care system utterly "missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?").
This is an approach that reflects the case study method of the best business schools. How do we define the problem? What are best practices available? Why does this instance not use those practices and how might we go about encouraging said practices? This represents the empirical logic of a Hume or even a Burke--know what's going on and look for modest, existing, useful solutions.
Third, he believes deeply in the concept of "moral hazard"--that we will become less likely to do the right thing when someone else covers this cost or takes the consequences. Thus, government intervention in a general sense is highly problematic in a free market economy; if some have no "moral hazard" that deeply distorts the system of incentives that should produce good behavior.
There's much more that I could cite, but I think you can get the flavor of the essay from these three factors. This is a sophisticated, powerful argument that maintains an extension of the present system to more people, the incremental approach favored by President Obama, is highly flawed.
What might we do? Restore logic to the system through the rational subject. Goldhill assumes a rational agent, able to review health care possibilities and make the best choices. This information gathering, logical American would be subject to risk, but would also understand the choices available to mitigate it. This agent, then, would be able to make the "right" choices, thus bringing market forces to bear to discipline an industry that seems utterly to lack them.
I disagree strongly with this perspective for a couple of reasons, both of which Paul Krugman has articulated at one time or another.
First, if the entire market is distorted for whatever reason, such as the housing market prior to the Crash, then even a logical individual agent can do nothing; we'll do all the due diligence possible, but the bubble will continue and its explosion will cause terrible damage. My comparative shopping does no good when the whole market for housing is screwed up.
Second, people are not rational animals when it comes to health care. We may decide with some care that the heating system for the seats is not necessary for a car destined to live in Champaign/Urbana, Illinois, but our beloved is damn well going to get every ounce of health care available. Heck, our dogs are going to get every possible treatment. Death disrupts logic.
You'll note, dear reader, that Goldhill has an argument that I can and do engage. Even if I do not accept all of his points, I accept some (the quality control stuff is crucial) and I debate the rest. I can do so because Goldhill lives in the currently existing United States of America, understands the role of facts in public debate, and is interested in creating a health care system that does not kill more fathers.
This is the kind of contribution that key representatives of the Republican Party and the conservative leadership should be making. It is based on clearly conservative values and principles; it rests on a nice understanding of the market. Instead, we get Joe Wilson and Glenn Beck and Rush Limbaugh.
I hope there will come a time when real conservatives decide to take back their party and movement. Until then, we are the worse for their absence.