I worry that today’s equivalent of Robert McNamara is Peter Orszag, who I fear is poised to do for our health care system what McNamara did for Vietnam.
I suspect this is a bit overheated, but the fact that Arnold’s book, Crisis of Abundance: Rethinking How We Pay for Health Care, is so outstanding makes this tough to simply dismiss.
Anyway, my similar but less dramatically stated worry, which I expressed in my latest column for The Week, is that the reforms currently on offer take the form they do because of Democratic dreams of a single-payer system, but such reforms, once they make contact with political reality, will likely produce a U.S. system that is even more of an convoluted, unsustainable mess. I think Princeton’s Paul Starr is spot on about the politics:
Some supporters favor this approach [i.e., a new “insurance exchange” offering a “public plan”] because they see it as a step toward single-payer, which is exactly what the opponents fear. Squeezed by the public plan, providers might raise prices for patients insured by private plans, sending those plans into a death spiral.
But a Congress that is not about to adopt single-payer is unlikely to adopt a Trojan horse for single-payer. Some compromise proposals — such as Sen. Charles Schumer’s — offer a second model, calling for a “level playing field” between private insurers and the public plan, including limits on the latter’s ability to flex its purchasing muscle. But tight controls on its bargaining power might doom it entirely if it faces severe adverse selection.
Here’s the delicate political problem: Depending on the rules, the entire system could tip one way or the other. Unconstrained, the public plan could drive private insurers out of business, setting off a political backlash not just from the industry but from much of the public. Over-constrained, the public plan could go into a death spiral itself as it becomes a dumping ground for high-risk enrollees, its rates rise, and it loses its appeal to the public at large. Creating a fair system of public-private competition — giving the public plan just enough power to offset its likely higher risks — wouldn’t be easy even if it were up to neutral experts, which it isn’t.
FUBAR, as McNamara’s pawns would say.