Depending on your personal opinion of David Brooks' style of punditry, you consider him reasonable conservatism's model, or its mascot. I side with the former. I don't like what he thinks so much as how he thinks. So I want to take seriously his six Big Reasons to oppose health care. Unfortunately, they're just not very good. Here we go:
The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you've got a cold. But if you've got cancer, you want surgery, not nasal spray.
If this bill passes, you'll have 500 experts in Washington trying to hold down costs and 300 million Americans with the same old incentives to get more and more care. The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve.
On its own, this argument against the bill doesn't hold up. Of course this is an incremental bill. Brooks knows better than anybody than you can't reinvent the wheel in Washington, especially when this particular health care wheel makes up 16% of our economy. This bill isn't perfect, but social policies like Social Security always started small and were refined through the decades. If the thing Brooks wants more than anything is to hold down costs, what's the deal with bashing 500 medical experts in Washington trying to hold down costs? Verdict: Thumbs down.
The second reason to oppose this bill is that, according to the chief actuary for Medicare, it will cause national health care spending to increase faster. Health care spending is already zooming past 17 percent of G.D.P. to 22 percent and beyond. If these pressures mount even faster, health care will squeeze out everything else, especially on the state level. We'll shovel more money into insurance companies and you can kiss goodbye programs like expanded preschool that would have a bigger social impact.
Third, if passed, the bill sets up a politically unsustainable situation. Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform.
This country has reduced health inflation in short bursts, but it has not sustained cost control over the long term because the deep flaws in the system produce horrific political pressures that gut restraint.
Brooks might be right. The Democrats have struggled with how to balance cost-cutting and subsidies to offset the new demand for health care, and this will be a tight rope to walk. But the CBO projected that government health care subsidies and the excise tax would actually help bring down the cost of health care for families in the next few years. Subsidies could cut premium costs by more than 50 percent for more than 50 percent of the individual market. In the larger employer-insurance market, the excise tax on expensive plans is projected to push employers to provide their workers with less expensive plans, which would send more money home in wages. And yet, that last sentence is dead on. Look no further than the Medicare "doctor fix" to understand how difficult it is for Congress to implement long-term cost control. Verdict: Thumbs sideways.
Fourth, you can't centrally regulate 17 percent of the U.S. economy without a raft of unintended consequences.
Hard to respond to this. Do I believe in the law of unintended consequences? Yes, I do! But let's get real. This bill would make it illegal for companies turn away a customer for a preexisting condition; or charge you a different sum for the same amount of insurance; or take away your health care when you get too sick. If Brooks objects to those regulations, then he should speak out. It's somewhat cowardly, or at the very least way too vague, to pretend that Murphy's Law is a specific argument against a policy. Verdict: Thumbs down.
Fifth, it will slow innovation. Government regulators don't do well with disruptive new technologies.
The Times' David Leonhardt recently made the opposite point: "If Health Care Reform Fails, America's Innovation Gap Will Grow." He argues that by our employer-based insurance system forces some would-be entrepreneurs to choose companies they don't fit in because the firms offer more affordable health coverage than the private market. But it's hard to know how much the Democrats' plan will fix this problem. It's true that the health bill offers subsidies and creates exchanges that presumably make it easier for those on the individual market to compare policies and pick the one that suits their needs (and presumably gives insurance companies incentives to bring down prices when more people join the exchange market). But it's also true that both the House and Senate plans work to preserve our employer-based system. Ultimately, this reform does very little to employer-based insurance. It applies an excise tax on expensive plans (which might get watered down) and then it builds a system of subsidies and programs around it. Verdict: Thumbs sideways.
Sixth, if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we'll never come back to the spinach.
And thus the argument dissolves into soggy metaphor. Reason number six has two big problems. First it's theoretically wrong. Just look at Massachusetts, where they're eating plenty of spinach (that means debating health care costs!) years before they scarfed down their dessert (metaphor for passing universal health care!). Second it's substantively wrong. There are actually quite a few cost-controlling "vegetables" in this health care jambalaya. As Brooks himself writes earlier in the piece:
The authors have thrown in a million little ideas in an effort to reduce health care inflation -- improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research...They are not fundamentally disrupting the status quo, but they are experimenting with dozens of gradual programs that might bend the cost curve.
David Brooks is having his spinach and eating it, too. Or something. Verdict: Thumbs down.
So this piece just doesn't fly for me. That's two thumbs sideways and four down. For a weighty conservative critique of health care, go read Reihan Salam.