Where's the Beef?

In today's New York Times, David Brooks complains that neither Bush nor Kerry really talks about the issues confronting us. Here's his evidence:

"John Kerry and the Democrats spent their convention talking about broad values like unity and military service and almost no time talking about specific proposals. And if you peek in at a Bush campaign event, it's like a traveling road show of proper emotions. Bush will remind the crowd of the feelings we all experienced on Sept. 11. Then there will be several paragraphs on the importance of loving thy neighbor, and several minutes spent reciting the accomplishments of Term 1.

No offense, but where's the beef?"

I haven't spent a lot of time listening to Bush's and Kerry's speeches in their entirety, but I'm willing to assume that Brooks is right to say that they don't contain many specifics. But are their speeches really the place to look for a detailed exposition of their policy proposals? Might one not, in addition, check out, oh, I don't know, their web sites? Offhand, I'd think so; but this idea doesn't seem to have occurred to Brooks. Suppose you went to the policy section of John Kerry's web site. You would find quite a variety of policy proposals, many of which are extremely interesting and substantive. His health care plan, for instance, includes a proposal to cover most of the costs of catastrophic illnesses, which is (in my view) a very interesting way to lower the cost of private insurance both for businesses and individuals. His proposal to let people buy into the Congressional health care plan is less innovative, but would be a very significant change nonetheless. He has a whole raft of smaller-bore proposals for cutting costs and upgrading the technology used for things like record-keeping; while these are the sorts of technical proposals that only a health-care policy wonk would find interesting, they are (collectively) very important nonetheless, and would in my opinion be a great improvement over the status quo. And there are lots of other pieces to the policy which are also quite significant.

I've used Kerry's health care policy as an example; I could go on to cite his other policies, or Bush's, but you get the idea: there are significant policy proposals out there, and the only reason Brooks doesn't notice this is that he has inexplicably focussed on the candidates' speeches rather than their position papers. However, I wouldn't pick on Brooks if this problem were confined to his editorial. But it's not: during this election cycle the media has ignored policy almost completely (with the exception of Iraq, which is in some ways the least informative policy question to look at, since what either candidate does in Iraq will almost certainly depend on what happens there between now and January, that is, on factors we cannot really predict.) During the democratic primaries, for instance, I heard over and over that the major candidates all had basically the same sets of policies. This was just not true. They had major differences on tax policy, health care, and foreign policy. Moreover, some candidates had very interesting proposals that were unique to them. Here's one that I bet few of you ever heard of: Wes Clark's proposal for a civilian reserve.

Basically, it would have worked as follows: people over 18 would have the opportunity to volunteer for the Civilian Reserve. If they did so, they would list their various skills, languages, etc. Then they could be called on to serve (except for 'grave national emergencies', they could decline, so it would be doubly voluntary.) As with the military reserve, they would receive a small stipend, health insurance, and have their job waiting for them on their return. The tasks they might perform could include emergency response (imagine if, after 9/11, there had been a database of people with, say, EMT skills who could be called up, rather than having first responders from all over descending at random, or if we could use civilians with relevant skills instead of the national guard to do support work for firefighters during big forest fires), fixing schools and the like in this country, doing development work abroad, providing language skills when needed, and so forth. And it wouldn't have required a vast new bureaucracy: the idea was to do most of the work with a database and existing organizations. Just the sort of idea that might occur to a general who had been reflecting on the number of tasks the army is asked to do for which its members are not specifically trained, and who was trying to come up with a better alternative.

Personally, I thought this was a great idea. But even if you disagree, it was surely both novel and substantive. And yet it got zero coverage. Instead, we were treated to endless speculation on such pointless questions as: whether Howard Dean had the nomination sewn up, whether Hillary Clinton would jump in at the last minute, etc., etc., and whenever issues other than Iraq came up, we were assured that there were no real differences between the candidates. My conclusion: the press is completely failing to fulfill one of its key functions: informing us about the genuine differences between the candidates on issues of enormous importance. And when I read them not just talking about other things, like polls, but actually bemoaning the candidates' supposed lack of policy proposals, it's enough to make me despair.

Instead of despairing, however, I just resolve to read all those policies myself, and to try to tell as many people as I can about what they actually say. If the press won't do their job, we will just have to do it for them. (Speaking as someone who was politically active before the web came into existence, and who therefore spent lots of time trying to figure out how to obtain various candidates' position papers, I think the fact that they are now available to anyone with an internet connection is an unbelievably wonderful development -- even better than the fact that it's possible to see candidates' speeches even if you were not actually present, and even if you missed them on TV.)

Comments

[Sebastian Holsclaw]

The question is of focus. Politicians use their speeches to focus on what they believe is important--in an abstract sense and/or (but more often or) in the sense of what they think will get them votes. If the latter they tend to focus on such things when they are in power so as to get votes the next time. So the speeches are important. Position papers? What is their history? I suspect it isn't as damaging to reverse your position from one expressed in a position paper, so it would seem that they are even less trustworthy indicators of what a politician will do than the material found in speeches. Not that I'm thrilled with Kerry's foreign policy position papers anyway.

[Moe Lane]

Nice post, hilzoy.

Does anyone else find it amusing that if there's a single sentence that everybody in the blogosphere would agree upon, it'd probably be some variant of "Jeebus, but the press bites"? :)

[hilzoy]

Sebastian -- politicians don't always use their speeches to focus on what they think is important, beyond the level of "talking about health care". In particular, I don't think that the level of detail in their speeches necessarily reflects the amount of detail they (a) think is important, or (b) are willing to provide, so much as the level of detail they think their audience would be interested in. For this reason I think that Brooks' specific complaint -- that the speeches don't contain policy proposals so much as support for laudable goals -- is misguided, since the position papers are the right place to look for those proposals; and his more general complaint -- that the speeches show that the candidates don't have adequate policy proposals -- is downright wrong.

It might have been a mistake for me to set this as my startup page after I agreed to sign on -- I see it so much more often, and then I have to check the comments, and then I have to respond...

[Dave Schuler]

Moe, isn't the blogosphere an alternative press? Of course the blogosphere is dissatisfied with the press. If we weren't, we wouldn't be here.

Taking hilzoy's example of health care, whenever Mr. Kerry says that health care is a right my blood runs cold. To mean anything at all the assertion that health care is a right means it must be available at least to some at below market costs. This in turn means that its purchase must be subsidized. In the long run is there any way for this to work without price controls?

[hilzoy]

Dave: Sure there is. First, note that it will not need to be subsidized for everyone, only for those who can't afford the market price (presumably, the market price for health insurance, not for health care directly.) We already do subsidize health insurance for those who can't afford it, through Medicaid, CHIPS, and the like. This has not yet led to the introduction of price caps.

Second, subsidized health insurance for those who can't afford it does give the government an interest in keeping health care costs down. But there are lots of ways to try to do this without price controls. One could try to rein in drug costs by granting the government the right to bargain for its bulk purchases, by requiring the use of generics when they're just as good, by reinstating the ban on direct-to-patient marketing of prescription drugs (since each and every one of those ads you see on TV adds to the drug's price), etc. One could try to bring down hospital costs by providing incentives to upgrade hospital technology so that doctors don't spend time writing everything out longhand. And so on, and so forth.

Besides which, if everyone had health insurance, that would probably bring costs down all by itself. Under the current system, patients who can't afford medical care get it via emergency rooms, and the cost of this is passed on to consumers. We all end up paying for their care through higher insurance premiums. But this is not just a dreadful way for them to get medical care; it's also more costly than just insuring them, since it leads people without insurance to delay getting treatment until they have a genuine emergency, even when they could have dealt with their medical problem at much less cost earlier on. This is both worse for them and worse for the rest of us, who pay for it.

[Dave Schuler]

hilzoy:

Although drug costs are a fast-rising component of health care costs, it's one of the smaller components. The big components are physician salaries and hospital costs (of which a significant component are salaries). And I'm skeptical that universal coverage will in and of itself reduce costs. The worldwide experience is that it leads to over-utilization.

I don't believe that any serious control of costs can be achieved in health care without controlling salaries.

I have lots and lots of problems with our health care system, the most important of which is I think it's immoral. But asserting health care as a right does not help, IMO. The formulation I'd rather see is that we're a rich society and we can afford to extend such a benefit to our people. This would avoid conflation of such benefits with rights like freedom of speech or of the press. The rights extended by the Bill of Rights don't conflict with property rights but defining goods as rights does.

[JKC]

"I don't believe that any serious control of costs can be achieved in health care without controlling salaries."

Brilliant. There's already a serious nursing shortage, as well as a looming shortage of primary care physicians. And your answer, Dave, is to cap salaries.

That'll help.

[Dave Schuler]

JKC:

It's not my answer. I don't have an answer. I don't have the precise figures at my fingertips but IIRC the cost factors in health care are (in this order): salaries, non-salary hospital costs, administration, and presciption drugs with salaries and hospital costs accounting for well over 50% of the total. Administrative costs are about twice Canada's so even if you go to a single payer system the savings are in low double digits—around 14%. Prescription drugs account for, what, 8% of the total? Not a lot of optimization there, either. So you're left with salaries and non-salary hospital costs. That's where cost savings must come from.

[hilzoy]

Dave: you have raised two problems that are, I think, distinct. The first is whether, if one wants to say that health insurance should be available to those who can't afford it, one should call it a right. That's a long and complicated question (what is a right, anyways? Did Kerry intend to enter into this question of political theory, or just to say that health insurance should, as a matter of justice, be available to all? Etc.)

The second is whether we could make health insurance available to those who can't afford it without capping salaries. (Note that this problem remains even if we don't call it a right.) Here I think the answer is 'yes'. Explaining why would be long and complicated, but briefly: there are significant savings to be gained from changing utilization patterns (which does not have to mean depriving people of needed services; see my discussion of care for the uninsured above), taking steps to lower administrative costs (ours were actually just over three times Canada's in 1999, per capita*), savings in prescription drugs, and so forth. Note that lowering administration costs would partially address hospital costs: in 1999, administrative and clerical staff made up 27.3% of staff in "health care settings" (this does not include insurance company personnel*.) There are lots of ways to cut health care costs. For various reasons, including JKC's, I don't think that caps on physicians' salaries are the best way.

*Source: 'Costs of Health Care Administration in the United States and Canada', NEJM Volume 349:768-775

[Dave Schuler]

hilzoy, I hope you don't think I've hijacked this thread by focussing on health care. This is precisely the kind of discussion that I wish there were more of rather than discussing Mr. Kerry's Viet Nam service record.

I don't think we differ on objectives. I agree with the objective of affordable health care for everyone. But we need not appeal to justice. An appeal to mercy is more appropriate, IMO. I'm skeptical about characterizing anything that requires transfer payments as a right. Heretofore we've characterized such things as benefits and I think that's appropriate.

Health care is an expensive benefit. According to the stats that I've read we've already got trillions in unfunded Medicare and Medicaid liabilities. I would be thrilled if we could support that level of expense and even expand it to everyone who needs help based on marginal efficiencies. I'm skeptical that that can be achieved but I could be persuaded.

As I said in my original comment I've got lots and lots of problems with our current health care system and the most important problem is that it's immoral. Our health care system is raising health care costs worldwide (not just here) and, IMO, that's immoral.

[JKC]

Dave & hilzoy:

Actually, controlling salaries isn't without merit. I just think it has some serious problems:

1) The average debt load of graduating physicians is in the neighborhood of $100,000. That kind of debt makes better-paying subspecialty medicine a smart financial bet. It does nothing, sadly, to address a growing shortage of primary care physicians, especially in underserved and rural areas. We need to fix the cost of medical education (and higher education in general.)

2) I suspect that some of the increases in salary are market forces at work- if you're short nurses, you have to pay more to attract and keep the ones available.

3) Technology gets some of the blame. All of those wonderful diagnostic tools at our disposal (e.g. CT, MRI, PET imaging, etc.) as well as life-saving technologies running the gamut from dialysis to radiation therapy cost buckets of money, both for the equipment and for the personnel to operate and maintain it.

I wish I had some answers. Dave's point about the rise in health care costs being "immoral" is phrased differently from how I look at it, but has a great deal of validity nonetheless.

[Moe Lane]

"1) The average debt load of graduating physicians is in the neighborhood of $100,000."

I admit to some interest in precisely why it costs so much to go to medical school. If anyone's got a breakdown of typical costs, I for one wouldn't mind perusing it...

[Dave Schuler]

The most obvious reason is teacher salaries.
Aren't most of their teachers also MD's?

[Dave Schuler]

Moe, I haven't come up with any proof positive yet but the Harvard operating expenses tend to support my intuition. Note that the salaries and employee benefits for the medical school are more than a third of the total expenses and three times the salaries and employee benefits of the law school.

[hilzoy]

Yes, but bear in mind that salaries are not just faculty salaries. Also, different disciplines have different policies as regards faculty appointments. I think med schools give many more courtesy faculty appointments than most other schools.(E.g., to doctors affiliated with their teaching hospitals.)

[JKC]

Dave, you should know that the faculty at medical colleges most often see patients as part of their job; much of their contact with students comes during clinical rotations (aka clerkships). Lectures to 1st and 2nd year medical students are generally carved out of patient care time.

[bleh]

I would be very interested to hear (directly or indirectly) from any health economists who have studied the incentives and efficiencies of single-PAYER systems. Offhand, it seems to me that such systems would combine the efficiencies of administrative centralization with the (mostly) salutary incentives of market-driven operations, and obvious market failures (e.g., "redlining") could be corrected politically.

Plainly, our current system of financing health care -- which is something of a historical accident -- is a disaster. The multiple vast and unproductive administrative systems (insurance companies, claims handlers in doctors' offices, etc.) seems to me an obvious cause of at least some of our outsized administrative costs, and the (now rapidly crumbling) linkage between private employment and health care provision creates material and deleterious distortions in the labor market.

And equally plainly, the 40-some-odd-million people without any but emergency health care coverage are a serious economic burden (quite apart from being a moral catastrophe), e.g., because of their lost productivity due to delayed or inadequate care and their misuse and overuse of emergency facilities.

(And this really is a much more interesting topic than Brooks's snivelling.)

[Haven]

Dave,

Do you believe economic benefits in society are immoral like killing an innocent or stealing or is it immoral like farting in an elevator filled with strangers or cussing out one’s elders?

[Phil]

"Economics benefits in society?" Any phrase vague enough to encompass both me being in a profit-sharing plan at work and me stealing your wallet, you might want to narrow down a bit.

[Phil]

"Economic benefits in society?" A phrase broad enough to encompass me getting health insurance from my employer, me being in a profit-sharing plan and me stealing your wallet might be worth narrowing down just a little bit.

[Dave Schuler]

Haven:

Do you believe economic benefits in society are immoral like killing an innocent or stealing or is it immoral like farting in an elevator filled with strangers or cussing out one’s elders?

There's a worldwide market in health care just as in automobiles and oil. Here in the U. S. we pay vastly more than elsewhere in the world. Our willingness and ability to pay allows us effectively to outbid other countries. To use a vastly oversimplified example a system that increases health care costs for people dying of dysentery in Bangladesh so we don't have to wait to get our sniffles treated is immoral.

[John Kelsey]

So, our health care system seems to have several different effects on those of poor countries, right? On one side, we bid away medical students and nurses from poor countries. On another side, we invest a lot in research that benefits everyone.

I'll admit that I'm deeply skeptical that the shape of the US health care system has any substantial impact on how many kids die of dysentary in Bangladesh, though. The ways you reduce those deaths are very low-tech, stuff like clean water supplies, proper sewers, vaccines, and occasionally, that salt/sugar/water mixture that keeps you from dying of an electrolyte imbalance. I just don't see how any of that is affected by how our doctors get paid.

--John

[Dave Schuler]

hilzoy:

The second trackback I've made to this post is my response to the skepticism that was expressed to my observations about the immorality of the U. S. health care system.