Obamacare

RomneyCare: Health Security Theater?

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The TSA gave us lines at the airport. RomneyCare gave us lines at the doctor.

Former Massachusetts Governor and current GOP presidential wannabe Mitt Romney is set to give a big speech on health care this afternoon: Judging by the op-ed he published in yesterday's USA Today, he won't spend much time talking about his role in passing RomneyCare, the state-based health program that served as the model for ObamaCare. I'd like to see him disown the program entirely, but if he'd rather defend it, he might look to The New Republic's Jonathan Cohn, who consistently does a better job of defending RomneyCare than Mitt Romney does. 

Today, Cohn responds to what is perhaps The Wall Street Journal editorial board's most brutal attack yet on the state-based system that paved the way for ObamaCare. You should read the Journal's takedown of the plan Romney signed into law, and you should read Cohn's defense: Side by side, they provide a handy way to compare the cases for and against the law. 

The Journal makes the case that it's a broken, unaffordable system that, rather than encouraging "personal responsibility" (as Romney argued), has put most of its beneficiaries on the public dole without getting rid of the burden on emergency rooms or solving the problem of uncompensated care: Emergency room usage went up by 9 percent between 2004 and 2008, and state spending on uncompensated hospital care rose between 2008 and 2010. 

In a previous defense of the system, Cohn admitted that the "big flaw" in the system is that "it hasn't controlled the rising cost of medical care," though he says the authors of the plan weren't really trying, and that they're now working on getting its finances in order. This time, he zeroes in on the Journal's argument—similar to the one I made earlier this week—that the only thing that's worked about RomneyCare is that it has increased the percentage of the state's population with health insurance coverage. Here's Cohn:

But the most revealing sentence in the Journal editorial is this one:

"The only good news we can find is that the uninsured rate has dropped to 2% today from 6% in 2006." Yes, and the only good news in foreign policy lately is that American forces finally killed Osama Bin Laden.

In turn, I would say that the last line quoted above is the most revealing sentence in Cohn's post: As far as I can tell, he's suggesting that expanding the Bay State's insurance coverage, like taking out bin Laden, was a considerable victory that should not be dismissed or underweighted in any overall assessment; in particular, expanding coverage during a recession should be seen as a major achievement.

I think the comparison works, but not in Cohn's favor: Taking out Bin Laden was a success. But it took far too long, cost far too much, and involved a massive, needless sacrifice of Americans' civil liberties. America created an expensive new security agency, nationalized airport security, and spent almost $1.3 trillion (and counting) and countless lives on two ill-advised wars. As Cato's Christopher Preble told me last week, much of what we've done, and much of the cost we incurred, in our post-9/11 war on terror has been not merely wasteful but actively counterproductive. Taking out Bin Laden was a real, and necessary, victory. But it's exceedingly difficult to defend the expensive, poorly thought out, roundabout methods that eventually led us to him. 

The push to expand health insurance via mandates and public subsidies isn't perfectly analogous, but there are more than a few similarities. Analyst Bruce Schneier likes to talk about "security theater," his term for when governments spend a lot of money on showy countermeasures that primarily increase the feeling of security without actually enhancing it. Government-implemented expansions of health insurance, which is not the same as access to health care, work much the same way: Health insurance certainly makes people feel secure in their health. But when it takes longer and longer to see a doctor, and fewer practices are taking new patients, how real is that security?

As we've seen with the introduction of Medicare, which didn't cause any significant drop in seniors' mortality during its first decade, and with Medicaid, whose beneficiaries frequently do worse on many health measures and whose administrators admit to having no evidence that it works, the health benefits of carrying insurance are not as strong as one might think. Nor, as we've seen with emergency room crowding—which, as the Journal notes, has recent in recent years in Massachusetts despite Romney's claim that RomneyCare would address the problem—does expanding insurance coverage solve the public policy problems it's supposedly intended to fix. Government-driven expansions of health insurance are arguably a form of security theater for health safety: Call it Health Security Theater. 

Meanwhile, focusing on expanding health insurance coverage continues our national emphasis on trying to help people's lives by giving them greater and greater amounts of medical treatment. But as economist Robin Hanson has noted over and over again, the relationship between health and medicine is surprisingly weak. A large amount of medical care is probably what Hanson calls "heroic medicine": doing more primarily to be seen to do more

When politicians push to expand health insurance on the public dime, they're engaged in a sort of political version of Hanson's heroic medicine: doing something to be seen to do something in hopes that it will look like they care. But much of it ends up looking a lot like Health Security Theater, primarily increasing the "sense" of health security through expensive and highly visible acts. America's decade-long experiment with security theater hasn't solved many of the problems it was supposed to solve, but it has cost us a lot of time, personal liberty, and money. The early evidence from RomneyCare suggests that our experiment with Health Security Theater may well turn out the same. 

Here's my response to Cohn's 2009 defense of RomneyCare. 

NEXT: Ron Paul: Less Lonely These Days

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  1. I’m just going to say it: No nomination, no presidency for Mitt. He’s got an “L” tattooed on his forehead.

    1. I’m guessing the “L” doesn’t stand for libertarian.

      1. You are correct, sir.

        1. Am I missing something here? L stands for…what, loser? Seems pretty cheesy if so.

        2. Am I missing something here? L stands for…what, loser? Seems pretty cheesy if so.

        3. Am I missing something here? L stands for…what, loser? Seems pretty cheesy if so.

  2. The policy discussion is interesting but sidesteps the fundamental point here:

    Whatever else you say about Romneycare, its centerpiece is an individual mandate that forces people to buy health insurance.

    Romney can bob and weave on what he’d change now and what he’d do different, but when he was actually sitting in the governor’s chair he sat down to think of a way to reform health care and he said, “Let’s have an individual mandate.” And then he got that passed and signed it into law.

    I don’t care if he disowns it now. He can’t be trusted if he ever found that acceptable.

    1. I don’t care if he disowns it now. He can’t be trusted if he ever found that acceptable.

      This was my exact thought, yesterday, when I was listening to a local right-wing pundit attempt to defend Romney. The dipshit actually tried to argue that the Democrats were to blame for Romneycare, because the final version wasn’t what Romney wanted.

      1. My advice to the GOP: Throw him out, right now. Don’t try to reconcile what can’t be reconciled. Otherwise, 100% socialized healthcare will be on your platform.

        1. We don’t care, as long as its not being instituted by a colored person.

          1. It’s simpler than that. The GOP hates socialism except when instituted or maintained by. . .the GOP.

  3. Typo: “Nor, as we’ve seen with emergency room crowding?which, as the Journal notes, has RECENT in recent years in Massachusetts despite Romney’s claim that RomneyCare would address the problem?does expanding insurance coverage solve the public policy problems it’s supposedly intended to fix”.

  4. “Health Security Theater”….

    Why, that is just…..beautiful…(sniffs)..

    Also, in case you can’t read the entire WSJ piece, here’s the last two paragraphs that essentially sink any chance of Romney living this down-

    For a potential President whose core argument is that he knows how to revive free market economic growth, this amounts to a fatal flaw. Presidents lead by offering a vision for the country rooted in certain principles, not by promising a technocracy that runs on “data.” Mr. Romney’s highest principle seems to be faith in his own expertise.

    More immediately for his Republican candidacy, the debate over ObamaCare and the larger entitlement state may be the central question of the 2012 election. On that question, Mr. Romney is compromised and not credible. If he does not change his message, he might as well try to knock off Joe Biden and get on the Obama ticket.

  5. “”The only good news we can find is that the uninsured rate has dropped to 2% today from 6% in 2006.”
    Yes, and the only good news in foreign policy lately is that American forces finally killed Osama Bin Laden.”

    What the fuck happened to our schools that anyone could mistake this for coherent (much less publishable) thinking?

  6. America created an expensive new security agency, nationalized airport security, and spent almost $1.3 trillion (and counting) and countless lives on two ill-advised wars.

    While I am in entire agreement with the sentiment, I note the rhetorical oddity of pairing “$1.3 trillion” and “countless lives.” I mean, we didn’t kill a trillion people, so presumably we can count that high?

    More substantively:

    The coverage/cost thing is absolutely key, and shows a consistent failure in libertarian messaging. Anyone can see that America does not have a crisis in “getting people health care.” We may, arguably, be worse at it than we should be. But we do not have a crisis. People are not dying in the streets. Our life expectancy is pretty good. Medical outcomes are, you know, okay. All of that could be better — there are countries which outperform us, and there’s at least a reasonable argument that’s because their health care systems are better — but they aren’t awful. The number of uninsured sounds high, but it turns out that that doesn’t correspond to terribly health outcomes for the vast majority of them.

    Where we do have a crisis is in costs. We spend twice as much as comparable countries. Three times as much as some of them. It’s a huge, huge, huge amount of money. If we could reduce our health care spending to be just 1.5x what France’s is (in terms of percent of GDP), without compromising our quality of care, it would be an enormous boon to everyone in the nation.

    But it’s easy to point at human tragedy and say, “We must act to prevent this,” and numbers are boring. It feels crass and heartless to say, “We have to contain costs” when the other side is saying, “We have to HELP this critically ill person.” This is a problem libertarians always have. All kinds of good libertarian policy get trumped by someone saying that the opposing policy will save lives, and convincing people to do a pure benefit analysis instead of a cost/benefit analysis.

    I wish I knew a good rhetorical frame to argue the reverse. I think it’s a major hurdle in convincing people of libertarian politics. There are a lot of people out there who like the idea of our policies, but find the “this will SAVE LIVES” argument ultimately more persuasive.

  7. The true test of Tea Party co-option by the establishment republicans will be their reaction to Romney.

    If they don’t fight him tooth and claw in the primaries, and (if it comes to that) refuse to vote for him in the general, then they have been co-opted.

    1. A difference that makes no difference is no difference.

  8. “Cohn admitted that the “big flaw” in the system is that “it hasn’t controlled the rising cost”

    Funny, my plan to feed the homeless by providing them all unlimited access to the Dennys “all you can eat buffet” failed for the same reason.

    I love the argument that their healthcare system is a huge success except for the part that they can’t afford it. As if extending care and giving away free stuff was the hard part. The hard part is paying for these well intentioned programs.

    Obama’s plan is just as fatally flawed. And even if it were to bring down the cost of Medicare, it’s going to cause private insurance to sky rocket. (In some cases already has) thanks to the unlimited liability to insurers.

    I seriously wonder if anyone in the administration or congress understand simple economics.

    1. What’s to understand? Just print money!

  9. So Romney is a “New Republic” style Republican.

    1. He’s just a two bit opportunist.

      Not to mention dead politically.

  10. I’m intrigued by the Robin Hanson guy who Suderman cites, who seems to argue that medical treatment on average doesn’t do anything. Love to see him explain that to the Type I diabetics in my family. I’m sure they’d all have been fine w/o their insulin.

    Then again, Robin Hanson believes in cyronics — actually is a customer of one of the firms.

    So be be clear, Suderman is asking us to believe the argument that medical treatment doesn’t improve health outcomes from a guy who thinks he can have his head frozen in a vat of liquid nitrogen and live forever.

    Seriously, Peter? Seriously???

  11. The other problem with bragging about increasing the number of people who have medical insurance is that insurance only helps if there is adequate access to medical care. Who cares if everyone is insured, if everyone can’t get care?

    Since RomneyCare went into effect, accessibility appears to have declined, e.g. providers not accepting new patients, amount of time needed to wait before getting an appointment increasing, etc.

    IIRC, a Boston Globe article pointed out a year or so ago (maybe a little longer than that; link not handy) that MA has the highest per capita ratio of primary care providers to patients in the USA, but it has among the longest wait times to see a doc in the country. Square that circle.

  12. From a libertarian point of view there is nothing to like about RomneyCare. But he can defend it from a constitutional conservative standpoint by saying the following:
    1. There is no authority for the federal government to run health care, but the 10th ammendment does give states the right to do so if they choose.
    2. He was the governor of a liberal state where the people were clambering for universal health care so that is what he enacted, but it isn’t the right solution for most other states. He can say he would have preferred a strictly free market solution but that wasn’t possible in a state that is 90% liberal.
    3. Every state should be free to regulate health care as they see fit and the competition of ideas will allow the best solutions to spread and the worst to die out.

    I still won’t vote for him, but from a strategic point of view he might get by with that.

  13. like taking out bin Laden, was a considerable victory that should not be dismissed or underweighted in any overall assessment; in particular, expanding coverage during a recession should be seen as a major achievement.

    I think the comparison works, but not in Cohn’s favor: Taking out Bin Laden was a success. But it took far too long, cost far too much, and involved a massive, needless sacrifice of Americans’ civil liberties.

    Why the complicated, heavily nuanced analysis?

    Providing coverage costs nothing. It merely need be declared by legislative fiat. *Poof!* Thou art covered!

    It’s the provision of actual healthcare which is the hard part, and is arguably not happening– which could explain the increase in emergency room visits for routine care, longer waiting times and increased medical costs: Supply and demand.

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