What I've learned from health care debates

Health care has been a big debating issue in the United States for much longer than I can remember, and this year it's consumed even more public discourse bandwidth than usual. Rare is the day I hear or read no arguments about health care, and I don't even seek them out. Observing these discussions, I've learned nothing about health care but quite a bit about debate.

There's very little rationality to be found in these conflicts, which tend to devolve into emotional, ideological shouting matches. Rather, there's typically a couple grains of rationality, but no more; participants seem to refuse to think critically about every aspect of the situation. As a result, there's a lot of talking past one another, and even less gets accomplished than in regular political arguments, which don't accomplish much.

My low-res description of these health care debates breaks the debaters into two sides: "pro-market" and "anti-market," depending upon their preferred means of health care delivery. (Others argue on behalf of whatever configuration happens to obtain in their own country, but that appears to be little more than sublimated nationalism.) The labels represent not extreme ends of a spectrum — practically nobody in the mainstream plumps for thoroughgoing privatization or nationalization — but humps of a bimodal graph. Here are the lessons I've taken from their debates:

If you profess to be for or against a concept, know more about that concept than its name. There are sound reasons to condemn socialism if you know what socialism is. If you don't, there aren't. The same goes for free markets, where capitalism's war of all against all and redness in tooth and claw have sunk into the realm of desperate rhetorical cliché. And don't forget the important question of whether what you're talking about actually is socialism or a free market, which brings me to implore you...

Do not confuse abstractions with realities, and vice versa. Neither straight-on socialism nor pure free markets really exist in the United States, so it's not exactly a rich field for examples of either. Some anti-market debaters hold up the U.S.'s ad hoc health care structure as an example of what's wrong with free health care markets, but few of its observable mechanisms suggest anything like a truly libertarian free market. It's similarly misleading to invoke the "socialism" of a Sweden or a Finland or what have you while leaving "socialism" undefined. I tend to agree with Paul Graham on this count:

I think the fundamental question is not whether the government pays for schools or medicine, but whether you allow people to get rich.

[ ... ]

Any country that makes this choice ends up losing net, because new technology tends to be developed by people trying to make their fortunes. It's too much work for anyone to do for ordinary wages. Smart people might work on sexy projects like fighter planes and space rockets for ordinary wages, but semiconductors or light bulbs or the plumbing of e-commerce probably have to be developed by entrepreneurs. Life in the Soviet Union would have been even poorer if they hadn't had American technologies to copy.

Finland is sometimes given as an example of a prosperous socialist country, but apparently the combined top tax rate is 55%, only 5% higher than in California. So if they seem that much more socialist than the US, it is probably simply because they don't spend so much on their military.

Americans on the anti-market side also display a persistent drift between, say, Sweden itself and their idea of Sweden. A professor of mine once said to his class that Sweden "offers free medical care to its citizens, of the highest quality." I think he made more empirical (and empirically testable) claims in that statement than he realized. We have much to learn from northern Europe, but an unacceptable amount of anti-market people's claims about the region have passed, unchecked, into cant.

Watch your analogies. Sweden is often the x in a common anti-market lament: "x developed country has universal health care, so why doesn't the United States?" (France also pops up as x, though its system isn't quite what's normally thought of as "universal health care.") As any analogy, this one presumes that its subjects are comparable. But are the tiny, near-homogeneous nation and the gigantic, ultradiverse, relatively ahistorical superstate really alike on any meaningful dimension? A U.S.-France comparison is vaguely ludicrous; a U.S.-Sweden becomes highly abstract almost immediately.

The idea of "American exceptionalism" gets dismissed as jingoistic nonsense, but it's not the idea that America is exceptionally awesome; it's the idea that America is, by the standards of the world's nation-states, starkly, observably different. (Which could mean worse, if you're into that.) You should take as much care recommending the transplantation of one country's institutions to America as you would recommending the transplantation of one species' organs into another.

Your great data are not convincing. If you find yourself winging histograms at your interlocutor, the campaign for heart and mind is probably lost, no matter how much they support your point. I realize, data wonks, that this isn't how you think it should be, but cast back in your memory to the no doubt countless times you've seen someone — anyone — convinced that way. Your only hope is to perform your conversions in an extra-debate setting, where all participants aren't primed to shield their ideological identities as they would their scrota.

That said, most of the data I see wielded doesn't actually address opponents' concerns. Numbers about spending won't matter to someone who cares only about quality, numbers about insurance coverage won't matter to someone who cares only about delivery speed and numbers about R&D won't matter to someone who cares only about universality.

We do not live in a morality play. The useless concept of desert sees a lot of action in health care debates. Depending upon which accusatory screeds you read, anti-marketers believe that everyone everywhere deserves health care and pro-marketers believe that people only deserve the health care they can pay for. While I doubt that many on either side actually hold those explicit beliefs, that's not my point: desert is so objectively unrootable that discussions about it don't devolve into shouting matches, they effectively begin as shouting matches. Claim that a group does or does not deserve health care and your evidence necessarily amounts to nothing more than "says me." The rebuttal will be no better.

Your tragedies are anecdotes. It's hardly rare for a health care debate to feature sob stories presented as support. Hell, even Malcolm Gladwell did it in the New Yorker. But are someone's uninsured grandmother's death from an untreated gum infection or a freeloader cousin's overuse of the emergency room relevant data points to a discussion of public policy? Maybe if the public consists of five people. Otherwise this anecdotal strategy is a naked stab at emotion, terribly intellectually insulting to those you try to use it on. If the debate is about your cousin or grandmother, fine. If it's not, leave them out of it.

You do not have the hand of god. The first of the four horsemen of futility frequents health care debates like they were singles bars. "Should the United States have single-payer health care?" and "Should the United States had a totally free health care market?" are questions at such a distance from reality as to not be worth asking. If two omnipotent superbeings who actually possess the power to instantiate these conditions by pure will are the ones debating, different story. But brother, we ain't omnipotent superbeings. (My recommendation, not that you asked for one, is to discuss possible changes at the margin instead.)

Don't appeal to your imagination. The second horseman has a taste for the health care speakeasy as well. He goes in for more pedestrian stuff, though: made-up disaster scenarios, libertopias, the aforementioned fantasy Swedens.

Begin debating at step one, not step ten. The most offputting characteristic of health care debates is their tendency to skip important establishing steps. As a result, foundational questions such as "Why do you regard health care as different from other consumer goods like food or water?" are never addressed, rendering the conflict insoluble. The key with any discussions of this kind is to begin from a common set of premises, however basic; otherwise, you'll never identify the real nature of the disagreement.

Comments

[Isak]

About data not being convincing - I think you are making a mistake here. I don't think you can judge the efficacy of presenting data by just seeing if people changed their mind right away. You have to look at how their confidence for a proposition change.

For example, say you have someone who is currently in favor of socialized health care, and is 90% confident that it is desirable. If you present him with some data that detracts from socialized health care, even if it change his mind completely - if it just lowers his confidence in socialized health care - your exhibit may have been pretty worthwhile. To the extent any public policy discussion is worthwhile, that is.

Now, if you think that data does not affect peoples probabilities at all (or very little), then you must have a pretty low opinion of people in general.

Btw, in general, you have some good points in this post, but in some segments I think you overplayed the "Hah, look at these silly extremists - The truth is in the middle" card.

[buy soma]

What can we expect for our future? If Obama's planning to do the same thing with our countries health care system, it will be a great risk because the population in our country is to large compared to Canada. If republican's are trying to sabotage the future of this country then I cannot expect more.

[Soft Cialis]

Why has Obama chosen the health insurance companies to demonize? He really doesn't talk about why health care its self is so expensive.