If I were a Democrat…
First, I would not cite evidence about how Western European countries spend less on health and are healthier than U.S. citizens. This data set, if you take it seriously, also implies that the marginal product of more health care, adjusting for income and a few other variables, is zero. Expanding health care would not be important. Now I believe this is an incorrect conclusion, but that is what shows up in this data. We should not invoke this data selectively.
Second, I would recognize that American policy generally works (or doesn’t work) by building upon existing institutions. The most likely form of national health care — for better or worse — would extend a version of Medicare to more people. This would not lower health care costs, whether in gross or quality-adjusted terms. Keep in mind that negotiating price reductions does not per se lower real resource costs at all.
I would disaggregate health care systems and see where we could do the most good:
1. Step up R&D subsidies through the NIH and our university system, both high quality institutions. Their autonomy and micro-fiefdoms provide a good framework for risk-taking and innovation. The returns to medical R&D are extremely high. Furthermore the case for market failure, based on the inability to capture the full social gains from a new idea, is simple.
2. Redo the Medicare drug bill so that people can understand it (even I can’t, nor does my mother), and so more people benefit. If need be, we can do this in budget-neutral fashion. The Bush plan is a mess.
3. Invest in local public health systems. Preventive care is important, especially for the poor. Price can be an obstacle but often the relevant constraints are behavioral in nature. Public health care systems should be easy and inviting, and they have to become part of life routines. Government can be part of the solution. Strong local public health care also will improve surveillance and later surge capacity if a pandemic comes along; this added benefit is significant.
4. Borrow a page from the libertarian litany about the FDA.
5. Institute prizes for successful vaccines. We have been discouraging vaccine production when we should be encouraging it; Michael Kremer has some intriguing proposals.
All those options are doable. All would save lives. None are fiscal disasters. They offer something for both rich and poor. They lay out a positive and constructive role for government, while keeping room for the private sector. None raise the prospect of excess bureaucracy or discourage innovation. None rest on the questionable belief that government as single supplier or payer would improve efficiency. And they are all areas where the Republicans are dropping the ball.
I would cut talk of national health insurance. I would cease obsessing over the number of "40 million uninsured," however good a debating point it may be. Many of these people are either linked to immigration or get decent medical coverage in any case. I would admit that we cannot take care of everyone and that we face tough trade-offs.
Hmmm…these counterfactuals are fun. What should I try next? Pretending I am a Republican? But for now, it is back to normal life…and so we return to your regularly scheduled programming. But comments are open, in case Kevin Drum’s readers wish to pretend they are libertarians…