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©1998 by Patrick J. Shanahan
The View From the Ground
9/4/98
Political Solutions vs. Trade-Offs:
Thinking Through the Managed Care Debate
Anyone who wants to talk intelligently in the debate over the future of Managed Care and HMOs needs to start by reading Dr. Thomas Sowell's "The Vision of the Anointed" . The gist of the book is that many in the arena of public policy and politics ("The Anointed" ) approach issues in a manner which is utterly divorced from the real-world effects of their actions. In many cases a "crisis" is declared to prod voters into action. A political "solution" is then proposed to solve the crisis. The solution is implemented to great fanfare, only to do nothing to make the situation better, and oftentimes making it worse.
The flaw is that almost nothing in life is solvable through categorical political "solutions" . All political actions involve "trade-offs" . To create a new "right" or a benefit for one person is by necessity to impose a burden or cost on another. Intelligent debate must therefore seek to understand these trade-offs before leaping to a solution.
Neat theory. But how does it apply to managed care? The current debate over managed care in Minnesota is a case study in the "Vision of the Anointed" .
First, a crisis is required. Since there is nothing even remotely resembling a health care crisis in Minnesota, one has simply been declared to exist through the clever use of propaganda and demagoguery. For anyone who was alive and paying health insurance premiums in the 1970 & 80s this "crisis" is clearly bunk. Almost all of the available facts point to a continuing improvement in healthcare over the past 15 years. Quality of care is up, cost increases are down, access is wider, proactive "preventative" programs seek to keep people healthier, continuity and coordination of care are miles ahead of where they were, and member satisfaction rates have remained, at least in Minnesota, remarkably high. The evolution of Managed Care systems played a significant role in bringing about these improvements.
What makes this a case study in The Vision of the Anointed is that the "crisis" was not declared by real people who are HMO members. Over 94% of Minnesota HMO members are satisfied with their health plans. This crisis was manufactured by politicians looking for a "hook" issue and organizations with a vested interest in undoing many of the accomplishments of managed care. But, having declared a crisis, the Anointed's "solutions" inevitably pour forth. Although there are many ideas about ways to stop evil HMOs from killing little old ladies, the noisiest are coming from Governor wannabe Mark Dayton. His solution is breathtakingly simple: As Governor he would force HMOs to pay for members to see any provider they choose. There. Crisis solved. You can all go home now.
From the viewpoint of the anointed this all makes perfect sense: the solution is painless to all except HMOs, and we don't care about them. But if you look at the idea in terms of trade-offs, it become dirtier. Virtually all HMOs allow for coverage outside the plan for treatment that is not available within the plan. Where they dig in their heels is when the same care is available within the plan, because it is usually available at a significantly lower cost. If the rules were changed tomorrow and HMOs are forced to pay for any provider, the trade-offs are clear:
The cost of forcing expanded choice for a few will be transferred to the backs of those who can't afford to pay more for insurance, the very same people who don't have lobbying organizations or a loud political voice to protect them. I'm willing to wager that you won't be seeing their stories on the 10:00 news.
As long as people get sick and hurt they will need help getting better, but sometimes people don't get better. The sort of tragedy that simply tears your heart out is the everyday domain of health care providers and insurers. It happened before HMOs. It happens with HMOs. It will happen after HMOs. It's part of the tragedy of the human condition. It is understandable that those affected by such tragedies will desperately ask "Why?" , and "Could something more have been done?" And sometimes, rarely, something more could have been done. And we must learn from those situations. But to use human tragedy as a political prop, as a stick with which to beat up organizations dedicated to helping people get better is deplorable. To pretend that forcing political "solutions" on HMOs will fix anything requires that one throw common sense out the window and put on the blinders of the Anointed.