Can you cook the books by using more accurate statistics?
That’s the question hanging over the Obama administration, now that the Census bureau has decided to change the way it assesses the number of Americans without insurance in the middle of the Obamacare rollout.
The basic problem the Census has been struggling with is how, exactly, to define “Americans without insurance.” If you ask your survey respondents “Do you currently have health insurance?” the percentage answering “No” will be a lot lower than the number of people who would say “No” to “Have you been uninsured at any point in the last year?” If you change your question to “Were you uninsured for all of last year?” the “Nos” will plunge accordingly.
The Census’s Continuing Population Survey has struggled for years with the phrasing of this question, and, when compared to other surveys of insurance coverage, has persistently overestimated the number of Americans without insurance. However, its numbers have still been commonly used, since CPS is the only survey that produces state-by-state insurance numbers across the nation.
The Census bureau did the right thing and has been investigating how to improve the accuracy of their numbers. Yuval Levin describes one of the error checks the CPS ran, and the surprising results.
In 2000, for instance, the CPS supplement introduced a simple verification question: If people had answered “no” when presented with a list of possible options for different kinds of insurance coverage on the questionnaire, then the interviewer, rather than just note them as uninsured, would say “So does this mean I should record you as uninsured?” They found that an amazing 8 percent of respondents answered “no,” and only in the wake of this verification question (which, for those who answered in the negative, was followed again by a list of insurance options) reported that they were in fact insured.
The CPS has finally found a new question, that they trust to produce reliable data, but, since they’re switching over just as Obamacare goes into effect, the methodological change may obscure the effects of Obama’s signature legislation. As reported in the New York Times:
In the test last year, the percentage of people without health insurance was 10.6 percent when interviewers used the new questionnaire, compared with 12.5 percent using the old version. Researchers said that they had found a similar pattern in the data for different age, race and ethnic groups.
But Ezra Klein of Vox isn’t worried that the changes in the survey will make it impossible to measure the impact of the Affordable Care Act. According to Klein, the CPS changed their methodology just in time.
Politics aside, there’s a technocratic logic to this timing. The Census Bureau’s change begins with data for 2013 — meaning it starts before Obamacare does. By making the switch in 2013, there’ll be a baseline to compare obamacare to, and that baseline won’t fall apart in year two or three or four.
Unfortunately, a baseline data point is a lot less valuable than a baseline trend. The test for Obamacare isn’t just if it brings the numbers of the uninsured down, but if the new policies cause more people to sign up faster than historical data would predict. The 2013 datapoint may be a baseline measurement of coverage, but it can’t serve as a baseline for the changing trend of coverage.
The ideal solution might have been to run both questions, the old and the new, in parallel on the CPS for a period of five to 10 years. Instead of posing the improved question to all respondents, the Census employees could randomize assignments, so that a third to a half of all those surveyed answered the old, biased question, while the rest answered the new, improved question. Read More…
The front page article in the New York Times (“Selling a Poison by the Barrel: Liquid Nicotine for E-Cigarettes“) didn’t mince words. The bad science reporting that followed this hyperbolic headline is a much graver threat to public health than e-cigarettes themselves. The sensationalization of science and public health coverage occludes real dangers and gives consumers an excuse to ignore serious warnings as just more of the typical hype.
Electronic cigarettes, increasingly popular as a substitute for normal cigarettes, allow smokers to consume nicotine by inhaling it in a vapor. In contrast to traditional cigarettes, e-cigarettes contain fewer carcinogens, since the nicotine is delivered without incinerating paper, tar, and other materials used to treat and bind tobacco leaves.
The NYT article doesn’t dispute the comparative safety of e-cigarettes when smoked, but is concerned about the concentrated liquid nicotine, and the dangers of drinking or spilling it before it is smoked. If a user drinks the liquid in e-cigarettes, it is poisonous, and it is much more dangerous to children, if they drink the nicotine or pour it all over themselves, where it can be absorbed through the skin.
However, this danger isn’t enough to justify the hyperbolic headline. As far back as Paracelsus in the 15th century, doctors have known that it’s the dose that makes the poison. If the NYT were looking for other examples of dangerous chemicals lurking in the home, there’d be no reason to default to the bleach and the antifreeze; Tylenol would fit the bill.
Acetaminophen, the active ingredient in Tylenol, is safe at regular doses, but life-threatening. For a patient taking extra-strength Tylenol, just two additional pills per day over the recommended maximum is enough to wind up in the hospital. Arguably, liquid nicotine is less risky than Tylenol, since an adult isn’t in danger from a casual error. There’s no danger of miscalculating the dosage in normal use, just drinking something that wasn’t meant to be swallowed.
Or maybe e-cigarettes are more like compact fluorescent lights (CFLs). These efficient lightbulbs contain mercury, so, although they’re perfectly safe on a day to day basis, they’re hazardous if they break, and require special cleanup. A customer should address a liquid nicotine spill about as carefully as they would a shattered CFL.
Tylenol and CFLs haven’t been banned as a result of their dangers. The solution has been child resistant packaging, better warning labels, and consumer education. The NYT might have done better to spike this cover story, and give e-cigarettes the same practical safety guide they offered for CFLs in 2009. Frontloading an article with scaremongering is irresponsible and may alienate the most relevant readers: e-cigarette users.
Sensationalism may make better traffic, but it, too, is toxic at high doses.
Today’s Supreme Court oral argument, in the case of Hobby Lobby Stores, Inc. and Conestoga Wood Specialties Corp. v. Sebelius, is correctly understood to pit defenders of religious liberty against those who believe that the government has a compelling interest in requiring employers to provide contraception, abortifacients, and sterilization services through their healthcare policies. In significant part, the case hinges on whether the companies—privately held businesses whose owners are unquestionably deeply religious individuals, and who run their businesses informed by those views—can be considered “persons” under the Religious Freedom Restoration Act. I, like many Christians, hope their case prevails.
But while the businesses are often characterized as “family-owned businesses,” each is a national business with hundreds of employees and multi-state operations. Hobby Lobby is by far the larger chain, with 640 stores that employs 28,000 individuals. While it has religiously-themed goods, plays Christian music, and closes on Sundays, in most respects it is identifiably a “big-box” store that can usually be found in major retail corridors, surrounded by acres of concrete and provisioned largely by merchandise made in China. While it is a “family-owned” business, it is hardly a mom-and-pop shop.
The dominant narrative—religious liberty against state-mandated contraception—altogether ignores the economic nature of the case, and the deeper connections between the economy in which Hobby Lobby successfully and eagerly engages and a society that embraces contraception, abortion, sterilization, and, altogether, infertility. Largely ignored is the fact Hobby Lobby is a significant player in a global economy that has separated markets from morality. Even as it is a Christian-themed brand, it operates in a decisively “secular” economic world. It is almost wholly disembedded from any particular community; its model, like that of all major box stores, is to benefit from economies of scale through standardization and aggressive price-cutting, relying on cheap overseas producers and retail settings that are devoid of any particular cultural or local distinction. The setting where one finds Hobby Lobby near us—on Grape Road in nearby Mishawaka—is about as profane imaginable a place on earth, accessible by six lanes of concrete roads where there is a heavy concentration of large chain retailers, where it anchors a sensory-deadening row of retail store fronts that border acres of cracked and barren pavement, awash in discarded plastic bags and crumpled fast food wrappers. On the rare occasion that I enter the store, even amid the Chinese mass-produced crosses and the piped in Christian music, under the endless florescent lighting and displays carefully-managed to optimize impulse buying, I am hardly moved to a state of piety, prayer, and thanksgiving. I am, like everyone else, looking for the least chintzy item at the cheapest price.
Hobby Lobby—like every chain store of its kind—participates in an economy that is no longer “religious” or even “moral.” That is, it participates in an economy that arose based on the rejection of the subordination of markets embedded within, and subject to, social and moral structures. This “Great Transformation” was detailed and described with great acuity by Karl Polanyi in his masterful 1944 book of that title. He described a sea change of economic practice that took place especially beginning in the 19th-century, but whose theoretical groundwork had been laid already in the 17th- and 18th-centuries by thinkers like Thomas Hobbes, John Locke, and Adam Smith. As he succinctly described this “transformation,” previous economic arrangements in which markets were “embedded” within moral and social structures, practices, and customs were replaced by ones in which markets were liberated from those contexts, and shorn of controlling moral and religious norms and ends. “Ultimately that is why the control of the economic system by the market is of overwhelming consequence to the whole organization of society: it means no less than the running of society as an adjunct to the market. Instead of economy being embedded in social relations, social relations are embedded in the economic system.” Read More…
“Off with Obamacare’s head!”
Such was the battle cry at the first day at CPAC, woven into nearly every speech, from Ted Cruz’s opening remarks at 9AM to the afternoon panels, regardless of whether the topic at hand was healthcare-related or not. Repeated demands were made to repeal or abolish Obamacare, each new iteration met with enthusiastic applause. Obamacare was criticized, attacked, and ridiculed with palpable glee. Speculation abounded about what would happen when Obamacare collapsed under its own weight. But few solutions were offered to replace a defenestrated Obamacare, which will cost Republicans with potential voters in the midterms, and in 2016.
CPAC is not known to be a breeding ground for policy initiatives, but that doesn’t mean that it can’t or shouldn’t be. Try as Republicans might, they have been thus far unsuccessful in their attempts to repeal Obamacare, leaving them with only one viable alternative: reform. In an environment like CPAC, words like reform aren’t “sticky” or in line with the talking points drilled into participants’ heads. But it is necessary, and may even be crucial to our health care system having a fighting chance of recovery. The health care system is in desperate need of overhaul, and Republicans should be leading the charge of how to fix it, not simply pointing out that Democrats broke it most recently. Senator John Barrasso from Wyoming, who had a career as an orthopedic surgeon before becoming a politician, stressed the additional burden placed on patients on having to travel farther to see doctors on a government mandated health insurance program. “Obamacare is patient, heal yourself,” Senator Barrasso said, indicating that it will be harder for seniors to get to hospitals and receive the consistent care they need. “They’re aren’t enough people to take care of the patients, and it’s actually making things worse.”
The silver lining to the grim prognosis is that there is, at last, Republican legislation surfacing. The Coburn, Burr, and Hatch plan is one example of such legislation. The bill takes practical measures to reform Medicaid by allowing patients to keep their own health care plan, reforms medical malpractice law, and allows patients to make their own choices when it comes to their own health care plans, as opposed to government regulations dictating what providers are available to them.
CPAC may be about hitting those talking points, but it can also be a meeting of minds and the beginning of substantive conversations that could put a derailed healthcare system back on track. Republicans need to act quickly, though. Time is running out, and the final phases of Obamacare implementation are on the horizon.
The Congressional Budget Office (CBO) has run the math on Obamacare again and has calculated that, due to the health care reforms, the size of the American workforce will decrease by two million full-time jobs in 2017, when all provisions of the law are in place.
- Great news! Workers aren’t chained to a job as the only viable way to get health insurance.
- Terrible news! It encouraged people to stop working and depend on government subsidies.
- Ambiguous news! It probably depends a lot on whether workers are choosing prudently.
We live in a time when statistics are easy to come by, but their interpretation is far more complex. For one thing, the CBO didn’t find that two million people will quit their full-time jobs. They summed up the total person-hours by which we’ll cut back, so, it could just as well be the result of four million people cutting their hours from full-time to half-time. Or ten million people shifting to a four day workweek.
But even if we’d nailed down the effect more precisely, our course of action wouldn’t be clear. The CBO and other government agencies have picked up the statistical tools of epidemiologists and big data groups like Facebook, but the outcomes they’re tracking aren’t as clear cut as whether mumps cases are going up or down or which ad produces the most clickthroughs.
It’s not as immediately obvious whether the CBO calculations are good news or bad news. If we learned that, as a result of Obamacare, two million people needed to find work in order to manage their health care costs, or that four million needed to increase their hours, we might interpret that as a poor outcome. Or, if regulations were prompting employers to fire two million workers or slash their hours (as we worried when businesses realized that cutting workers hours exempted them from providing benefits) the loss of these workers might look like bad news. After all, then people’s desire to work would be frustrated.
But the judgment of the CBO is that the reduction in labor will be mostly voluntary as workers will be the ones choosing to resign or reduce hours; it won’t be bosses forcing layoffs. The mere fact that a shift is voluntary, though, is not enough to tell us if it is desirable. Soft paternalist policies (the mandate itself being a case in point) are meant to put a thumb on the scale when citizens make choices, although the actual choice of whether to buy health insurance or pay a fine is technically up to the individual.
When nudges are at work, people seldom connect their choice with the regulatory constraint that informed it, so CBO actuaries may know the causes of their choices better than they do. Thus, it’s harder to rely on feedback from voters about how a law is affecting their lives. So, how are we to judge the merits of the change?
It’s tempting to amass more numbers. If a decline of two million jobs isn’t enough to make a normative claim, we could track the impact of the voluntary exodus using psychological surveys to track the prevalence of depression, or we could do a longitudinal study to discover the impact these choices had on the educational attainment of the children of these families, or we could use our modeling tools in a manner closer to their original use and look at health outcomes.
But we’re really bottoming out at a moral claim, that can’t be supported by facts and figures alone.
Is access to health care more or less important than making sure people are secured by their own labor, instead of a subsidy? What benefits does employment offer, besides the ability to purchase necessities and luxuries?
Politicians should make their cases explicitly based on the values their policies serve, without hiding behind purely empirical organizations to hint at their argument for them.
On CNN’s State of the Union Sunday, economist Douglas Holtz-Eakin made a funny about the GOP’s (relatively speaking) decent showing among voters right now: “Republicans have tried something new: they made a budget deal and they’re not shutting [down] the government.” After saying this, Holtz-Eakin initially kept a straight face. His bottom lip quivered. Laughter ensued.
Republicans made a budget deal and didn’t shut down the government.
The public craves, now as ever, two things: stability and widely shared prosperity. Promising the latter is fine; actually providing it is best. Denying the former is fatal.
Alas, there’s reason to believe the GOP’s recognition of the primacy of stability is merely temporary.
The party may simply be lying in wait until the next kulturkampf over Obamacare.
Dave Weigel reports at Slate:
One of the bullet points that convinced most House Republicans to back [the budget] bill was “hey, let’s shut up about everything except Obamacare.” (I’m paraphrasing.)
Later in 2014, with Republicans largely focused on winning Senate races, what will they want out of Congress? A chance to codify their problems with Obamacare, and exploit whatever delays to the law the president is making in his executive decisions. The overwhelming acceptance of this deal suggests that Republicans aren’t really obsessed with passing entitlement reform, but they are obsessed with dismantling Obamacare, and they think their biggest mistake in 2013 was using the wrong leverage (the CR) to achieve that.
If true, Republicans are grossly miscalculating.
The truth is, polling on Obamacare is not starkly different than it was two years ago. And recall that, in October, during the shutdown, the needle moved toward approval of Obamacare not because it was working well (obviously), but because Republicans shut down the government over it.
The numbers on Obamacare fell to earth again largely because of the “If you like your plan, you can keep it” imbroglio. In other words, Obamacare suffers most when people feel like it’s going to disrupt their lives. Hence the seeming paradox that’s not really a paradox: the law itself is unpopular, and so is the idea of repealing it.
Disruption is the common denominator.
A wise party would learn from this. A wise party would not be salivating over the next opportunity to destabilize the government, spook markets, and upset stability-craving voters. A wise party would seek to either constructively improve or offer a serious alternative to the law, or else take the public’s hint and simply keep its head down and do its job.
But wisdom is in short supply.
And we’re probably still looking at a clown show.
Ariel Levy’s story of miscarriage ran last week in the New Yorker and exploded across the country, receiving a resoundingly positive reaction from empathetic readers. When the Dish picked up her story, their readers also responded with an outpouring of comments describing the grief and pain of miscarriage. This bursting forth has opened a door, shedding new light on a previously unseen grief. Melissa Lafsky Wall explained the reaction Monday in her piece “Giving Voice to the Silent Sorrow”:
I never heard of the “silent sorrow” until a few months later. Learning that a phrase existed for women who’ve miscarried made me even sadder. Its presence means that there are untold armies of women marching grimly through life, carrying their silent sorrow like a wound patched up with duct tape, and no one even knows what they’re suffering. Pain will always accompany losing a pregnancy. But silence — that part is optional.
Earlier this year, I had the opportunity to interview a mother who lost three children to miscarriage. This is her story. My hope (and hers) is that it will keep the conversation going, and help other grieving mothers know that they are not alone, and that every lost child counts.
Mike and Katie sped along a country road in Fruitland, Idaho. The local hospital was on the other side of the Snake River in Ontario, Oregon—thankfully, only minutes away. It was only a few days after Katie’s 20th birthday, four months after their marriage in an old Idaho schoolhouse.
Katie prayed frantically. “I don’t care if this baby is handicapped, I don’t care if this baby doesn’t have an arm or leg,” she thought. “I just want this baby. I want this baby alive.”
She remembered how happy they had been when they found out she was pregnant, only five weeks after their August wedding. The following months were gloriously normal. Katie had terrible morning sickness, and puked on the side of the road during a Thanksgiving vacation.
But in December, she began bleeding. She thought to herself, “Maybe the doctors can stop it… maybe the baby can still live…”
But the baby was gone. Friends told them helpfully, “It’s just your first baby, you’ll have another one.” Others said, “You weren’t very far along, it’ll be better the next time.” Katie smarted under their words. Her arms hung limp and empty, aching for her child.
Katie had three normal, smooth pregnancies between 2002 and 2006: the three boys, Braden, Nathan, and Ian, were healthy and boisterous.
When Ian was eight months old, Katie found out she was pregnant with her fifth baby. At 19 weeks, the family went in for an ultrasound. Everything was fine. Katie had begun to feel her baby’s little kicks. She hoped it was a girl.
All signs point to Gov. Chris Christie cruising to reelection in New Jersey tonight.
This is one of those times when personal bias is well nigh overwhelming: Christie—an authentic, half-Italian, New Jerseyan Bruce Springsteen uberfanatic, and a strong conservative by any reasonable standard—is about to rocket to the top tier of 2016 presidential contenders.
Judging by a spate of recent posts and on-the-ground reports, Business Insider’s Josh Barro is an unabashed fan of Christie as well. He even brushes aside the one serious reservation I have about the governor: his proclivity for in-your-face confrontations—in a word, “bullying”:
Christie’s confrontational personality can appeal to all sorts of electorates so long as he trains his anger in the right places.
When Christie yelled at that teacher yesterday about how education spending levels will “never be enough” for New Jersey’s teachers’ unions, he was doing so in a state that spent $19,291 per pupil on K-12 education last year — more than any state except New York and Vermont and 74% more than the national average. … So long as Christie keeps training his anger in the right place, Christie will be O.K. What national liberal reporters don’t get is that “towards teachers” can be the right place, politically and substantively, to train that anger.
This is true as far as it goes.
Which I fear is not actually very far.
Back in 2010, I wrote this at U.S. News:
In the short term, the example of New Jersey’s Gov. Chris Christie is instructive. He has maintained popularity while aggressively pushing an agenda of fiscal austerity. How does he do it? Simple: In teachers unions and state-government employees, Christie has found a juicy, isolatable adversary. This works on the state level, where things like pensions and teacher benefits are significant sources of budget shortfalls—unlike on the national level, where middle-class entitlements are the big driver.
The lesson is this: To the extent that “government” is a sectional entity—an interest group consisting of people who have not had to “sacrifice like the rest of us”—Republicans will find that cutting it is politically popular. To that extent that “government” is Grandma and Grandpa in Boca Raton, Republicans will need to tread carefully and—it’s possible to do both—honestly.
Zoom in on “juicy, isolatable adversary.”
At the presidential level, teachers aren’t going to cut it. Neither are employees of the federal government, whose salaries account for about 5 percent of total federal spending.
Is Chris Christie going to yell at senior citizens about Medicare?
Is he going to yell at beneficiaries of food stamps?
Is he going to yell at families on Medicaid or CHIP?
Is he going to yell at farmers about agribusiness subsidies?
If Christie is a wise and disciplined campaigner, I find it hard to believe he’d do any of those things. And given his recent disparagement of the GOP’s “libertarian strain” in the context of the debate over the national security state, I can’t see Christie getting up in the grill of a Pentagon contractor, either.
Teachers and public-sector employees who don’t want to pay as much for their healthcare as most of the rest of us do are the “right targets” when you’re arguing about state budgets. In fact, they are ridiculously easy targets. They are to Chris Christie what southern reactionaries are to Sacha Baron Cohen.
But I ask Josh: who are the analogously easy marks when you’re talking about the federal budget, and do you honestly think it will do Chris Christie any good to get in their faces?
Josh Barro has a helpful post on why health insurance is different from other insurance products, such as homeowner’s or flood insurance.
The hardy perennial of problematic insurance analogies, though, is the one that’s supposed to make the case for expanding catastrophic health insurance and calling it a day. I first encountered it in some Cato Institute literature at college in the mid-’90s and came across it again a couple days ago:
Conservatives love catastrophic health insurance. Indeed we believe non-catastrophic health “insurance” is an oxymoron. It’s prepaid health care. Would you buy auto insurance for an oil change or tune up or new tires?
This one has bothered me in an inchoate, can’t-quite-explain-why sense for years. I wondered if the people who use it think beyond its superficial logic. So I decided finally to parse it.
Here’s why I think the analogy is lousy:
First and foremost, when I hear “catastrophic” car insurance, I don’t think of anything that happens in the mechanic’s garage, like rotating tires. I think of a collision with another car. When I got my first set of wheels in 1993—as it happens, an ’84 Ford Tempo that leaked oil profusely—I had the choice of buying “liability” insurance and opting out of “collision”: that is, in the event of an accident in which I was at fault, my plan would cover the damage to the other car but not my own. In my case, this was a decision that made itself: If I wrecked the Tempo, almost beyond repair as it was, its next and final home would be the scrap heap.
Equally obviously, we do not get to decide whether to insure our bodies only in the case of collisions with other bodies.
Which segues into my next point: Unlike 1984 Ford Tempos, we don’t send people to the scrap heap if they’re old, infirm, or otherwise financially inconvenient. We don’t “trade in” people. Indeed we spend an astonishing amount of money on the human equivalent of problem-plagued cars. You may have read recently of a startling fact: Half the population accounts for a trivial amount of our total healthcare expenditures, while a scant five percent spends half the total amount.
If you want to press the cars/people insurance analogy, you have to acknowledge the fact that, while we don’t put in an insurance claim every 5-7,000 miles, neither do we try to resuscitate 1984 Ford Tempos, or keep them on the road until 2084.
In the same sense that the writer (Scott Sumner) whose passage I quote above mocks the idea that maternity care is a “catastrophe,” is old age any more or less a “catastrophe”?
Moreover, there is this business of “preventative maintenance.” Are humans and cars even remotely analogous from this angle?
I’m calling b.s.
No, I don’t use insurance to pay for tuneups and oil changes. But what is the closest approximation, in the realm of healthcare, to tuneups and oil changes? The implication is that the routine checkup—the annual physical exam—is the closest approximation. But is it?
To my lights, oil changes and tuneups and tire rotations are more akin to proper diet and exercise than they are to a visit to the doctor’s office. These are the things we do to keep our bodies in good general health. We don’t consume professional medical services to do that—we go to the produce section and hit the treadmill.
Wait a minute, you say; what about the similarity of, say, mileage service intervals (it’s time you had your radiator flushed) and age-based disease screening (you’re 40 years old now; we don’t have to worry about your testicles so much as your prostate gland).
Well, what about that? What’s the worst a mechanic is going to find? That the car you paid $35,000 for is going to require an unforeseen $3,000 repair? As I argued a moment ago, when it comes to cars, you get to weigh the cost of fixing it against its overall, and annually depreciating, value.
If a car is diagnosed with, say, juvenile diabetes, you can cut your losses. And, unlike babies, if it’s disabled when it comes out of the factory, it either doesn’t reach the showroom or … there’s this thing called a warranty: it gets fixed at the manufacturer’s expense.
I could go on, but I’ll conclude with this last thought. I realize cars have become more and more dependent on onboard electronics, but I grew up around plenty of guys who could change their own oil and tires. And while we can self-examine for signs of certain types of cancer, we can’t be our own doctors.
It’s helpful to step back and remind ourselves why we ask doctors to perform “preventative maintenance” on our bodies. If diseases are caught early, they’re often cheaper to treat or cure. If we stay in good physical shape, we reduce the chances of developing many diseases in the first place. When we preventatively maintain our cars, however, we are merely forestalling problems that we would have to pay out-of-pocket for anyway. If you don’t change your oil, your car insurance plan isn’t going to cover the cost of fixing a seized engine.
Maybe it’s time conservatives retired this car insurance analogy. Surely someone took out a life insurance policy on it!
Often discussed in different sections of the newspaper or the blogosphere, the twin crises of health care and higher education are extraordinary in their similarities. Both are regarded as necessary goods for human flourishing whose costs are spiraling out of control. Both rely on a professional class that is becoming more specialized, losing the generalist who once cared for the “whole person.” Both have seen expanding intervention by the central government which has sought to provide access to the lower and middle classes. Both are believed by many conservatives to be properly reformed by means of market-based solutions. Both are the subject of intense contemporary political debate.
And both were once almost exclusively the province of the Church, and, indeed, can trace their institutional origins—hospitals and universities—as part of the Church’s charitable ministry.
This latter fact, it seems to me, sheds bright light on the common roots of the contemporary crisis of each area. The dominant voices in the debate in both areas—health and education—cleave closely to the contemporary party lines. On the Right, the case is made that a competitive market model will solve the ills of both health care and education. By allowing prices to be driven by supply and demand, and the motivations of the primary actors—doctors and professoriate, on the one hand, patients and students, on the other—to be largely self-interested, the market will resolve how best to allocate the relatively limited access to the best health care and the best institutions of higher education. On the Left, it is believed that the State should rest a heavy hand on the scales of the market, enforcing widespread access, suppressing costs (or providing subsidies), and forcing providers to conform to state-mandated expectations and standards.
Yet there is something fundamentally amiss with making provision of health and higher education contingent on market models and profit calculus, as both seem to be goods that are not subject to the same kind of calculus as automobiles and bubble gum. The very idea that doctors and teachers are or ought to act out of the motivations of self-interest, and provide services to their “consumers,” seems fundamentally contradictory to the kind of work and social role performed by each. The decline of the “generalist” in each sphere is indicative of a deeper crisis of the willingness to act on behalf of a broader conception of the good intrinsic to each profession and on behalf of the person being served, in favor of the specialization encouraged by modern canons of efficiency, productivity, profit, and rationalization.
At the same time, the State is rightly suspected of being unable to fundamentally improve or even maintain the quality of either sphere. It is doubtless the case that it can assure access by the heavy hand of threats, but many rightly worry that, as a consequence, the quality of care and education will deteriorate as a result. The State takes on the ersatz role of “generalist,” seemingly concerned for the good of the whole. It can only pursue that good by seeking to control pricing and access while influencing the ways “care” is provided, but it fails necessarily in caring for the vision of the whole that the actors of the professions are no longer willing or able to perform.
The debate as currently constituted represents a pincer movement aimed ultimately at the re-definition of each area—as we have seen in so many areas of contemporary life. While superficially opposites, proponents of each position in fact share a fundamental hostility to the original presuppositions that had informed the foundation of both institutions—the corporal works of charity central to the Church’s earthly mission.
In fact, it seems increasingly evident that practices such as health care and education are likely to fail when wholly uninformed by their original motivation of religious charity. Neither functions especially well based on the profit-motive or guided by large-scale national welfare policies. As the failure of the market model in each area becomes evident, the demands for the second—government intervention and control—have quickly followed. That both are reaching crises at the same time is hardly coincidental: both benefitted for a long time from the “social capital” accumulated as Church institutions, a legacy of cultures and practices that persisted for a long time even after the practitioners had ceased to embrace them. However, in both cases, the social capital is now depleted, and each now operates on a nonsensical combination of self-interested market motivations and taxation and threat-based national welfare policy. Neither is a fitting motivation or model for either sphere.