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President Obama, faced with declining poll numbers for himself and his agenda, must now relaunch his sputtering health care plan. So he held a press conference on Tuesday, and hosted a low-rated ABC News infomercial on Wednesday. In other words, he has his work cut out for him--especially since he is pursuing a health care agenda that flies in the teeth of what the American people really want. But Republicans should not be complacent, because if they are ever restored to agenda-setting power, it is likely that their policy platform will also run into a public-opinion buzzsaw.
The debate over health care has so consumed Washington wonks that few of them noticed the news from the Heartland over the weekend, news that demolished two central premises of the Obama health care plan: first, the idea that health care expenditures can be pushed down, and second, the idea that any sort of "fair" policy --"fair" as defined by the government is possible.
Inside the Beltway, health care combatants, right and left, were so busy wrangling over the minutiae of Medicaid rebates and insurance cooperatives, to say nothing of explosive controversies over "revenue enhancements," such as a Value Added Tax. And so these busy policy warriors barely looked up to see what happened on Saturday: the announcement that Steve Jobs, the grand guru of both Apple and Pixar, had undergone a liver transplant.
But after a few days, the impact of Jobs' self-financed and self-initiated medical plan became clear to liberal supporters of national health insurance. And so on Tuesday, The New York Times, that reliable champion of all liberal causes, ran a critical story under the headline, "A Transplant That Is Raising Many Questions." And while The Times stipulated that Jobs didn't do anything illegal, the newspaper sniffed, "It might not seem fair." Indeed. If Jobs can do his own thing, then what's to stop everybody from doing his or her own thing? And where would that leave grand plans for government supervision over life-and-death issues?
A lifelong resident of California, the 54-year-old Jobs temporarily relocated to Tennessee to receive his transplant. Observers estimate that Jobs spent hundreds of thousands of dollars for the actual transplant and associated treatment and chemotherapy, and perhaps millions more in donations to "expedite" the process. In the words of Jeremy Shane, a veteran observer of health care issues, "The father of the iPod and iTunes is now the poster child of iWantToLiveAtAnyPrice consumerism." And why shouldn't he? This is America, land of the free. Jobs is a billionaire, earning his money fair and square; why shouldn't he be able to spend millions on his own survival?
But the larger lesson for all of us is this: If people have the money, if they get the chance, they will spend more on health care, and happily so. And so the scientific sky is the limit for transplants, bionic body parts, you name it. In the words of Jim Woodhill, a St. Louis-based software entrepreneur active in the health care debate, "People want a war against serious diseases. And war is expensive."
Woodhill notes that health care is what economists call a "superior good." That is, a superior good is something people consume more of as their income rises, such as, say, caviar, Beverly Hills mansions, or better health care. (Potatoes, by contrast, are an example of an "inferior good"; people consume fewer spuds, and other low-cost foods, as their income rises.)
Indeed, according to a new survey from the Pew Research Center for the People & the Press, more Americans (40 percent) think that we are spending too little on health care than think we are spending too much (38 percent).
Yet the political elites have a much different vision for health care, putting them at odds with the American people.
The left, which has dominated policy debate over health care for a century, is locked in to the vision of a European-style centralized health care system, requiring forced equality in the name of "solidarity." And so, for example, Britain's National Health Service (NHS) has long fought against the practice of "top up" payments --individuals supplementing their NHS benefits with additional health care purchased with their own funds. Slowly, and with great reluctance, the NHS has yielded to public pressure and is allowing such supplements. That's a defeat for solidarity, to be sure, but it's a big victory for liberty.
Meanwhile, here in the US, liberal-left think tanks share the old Euro vision: Everybody should get some, but nobody should get too much. The Center for American Progress (CAP), for example, makes clear in the "Where We Stand on Health Care" section of its Web site that "controlling costs" is right up there with "expanding coverage" as a top priority.
Interestingly, the liberal argument is mirrored on the right: Conservative think tanks agree that we are spending too much on health care. The Heritage Foundation, to name one, doesn't share CAP's affection for European-style regimentation, but its experts --and the donors who pay the experts -- do have a fear of higher health care costs, which could lead to greater expenses for both business and the taxpayers. And so on its Web site, Heritage specifies "lower costs for Americans" as a major objective.
So while CAP and Heritage might not agree on the means, they do agree on the ends controlling health care costs. And so it's little wonder that this consensus on cost-control has trickled up to the top, to the White House, where Barack Obama wants to enact a "bipartisan" health plan, if at all possible. The president laid out his policy vision to the American Medical Association on June 15, declaring it, "One essential step on our journey is to control the spiraling cost of health care in America." Obama continued, "Today, we are spending over $2 trillion a year on health care --almost 50 percent more per person than the next most costly nation."
To the elites-- left, right, and White House -- such spending is a terrible thing and needs to be restrained. But as we have seen, the American people don't agree. And as an aside, we can only imagine that the slim plurality of Americans who told the Pew Research Center that we should spend more on health care would be a thumping majority if such a view weren't so contrary to "respectable" elite opinion.Ordinary Americans, lacking think tanks and bully pulpits to speak for them, might be shy about telling pollsters their true opinion, knowing that their political opinion is deemed politically incorrect by the experts. But when the crunch comes, in terms of their own budgets and their own personal choices, folks are willing to spend whatever it takes for the health care they want. And as for the wealthy, such as Steve Jobs, they don't need think tanks to plead their case; they just write a check and do what they wish.
But now an even larger crunch is coming: the clash between the elite and the people over national health care policy. The Obama administration, and Democrats in Congress, are pushing hard for a bill that will control costs, which is not what most people want. And Democratic denials notwithstanding, it's not hard to see that rationing is part of their plan, as part of an overall effort at both supply- and demand-reduction.
But the public is resisting. Support for ambitious "reform," of the kind put forward by liberal Washington wonks, is already wilting; the same Pew Research Center found that just 41 percent of Americans today think the health care system needs to be "completely rebuilt," compared to 55 percent who thought so in 1993. And of course, back then, "ClintonCare" was defeated. So what will happen this time around? Stay tuned. But Democrats are nervous.
The basic issues are these: Health care is a superior good. If people have more money, they will spend more of it on health care. Steve Jobs points the way to a longer-lived, but costly, future.
In the words of health expert Shane:
"Bravo to Steve Jobs for pursuing the best treatment that American medicine can provide. We talk about a desire for better health care -- which for each person is really about genetics, diet, lifestyle, and environment -- when what really counts is the ability to access the best medical treatments, which are a function of technology, physician skill, and hospital care."
And, of course, money. Obviously, the rich will never allow themselves to be herded into a health care system that prohibits "top ups." And so the question: Will the near-rich allow themselves to be so herded? And how about the wannabe-rich? And the downright not-rich? And those who merely want to live? Most likely, all but the hardest of hardcore left-wing ideologues will rebel against government-run healthcare, sooner or later.
As Jim Woodhill sees it, the health care elite has the wrong intellectual model in its head when it comes to health care: a vision of managing scarcity. If, as he says, health is war, then that war will require a kind of national mobilization that will not be cheap. But if such a mobilization is what people want, then it will be popular. A vote-getter, as they say in Washington.
Of course, death cannot be defeated in the end. So does that mean endlessly escalating costs in a war that can't be won? Woodhill's argument is that productive life can be greatly extended through what he calls "serious medicine" that is, one battle, one breakthrough, at a time. And when that happens, just as in warfare, technological advances can make victory both easier and cheaper. As an illustration, Woodhill cites the case of President Dwight Eisenhower, who suffered a massive heart attack on September 24, 1955. The doctors' prescription for the 64-year-old patient was simple and minimal: bed rest. As important as Ike was, there wasn't anything else that doctors back then could do for him, even if his good health was a vital national security concern in that Cold War era. But the minimalist medical status quo soon changed; by the 1970s, open heart surgery was common. Such procedures were, of course, hugely expensive, but they were effective and popular.
But since then, further advances have greatly reduced the cost of heart disease. Using a bit of business jargon, Woodhill calls it "getting to the right side of the experience curve," that is, getting over the hump of higher costs to a declining slope of expenses and difficulty. Robots can now do some minimally invasive heart surgery, through a much smaller incision into the chest -- good news for patients, and for payers. Also, stents allow doctors to clear cardiac blockages by remote control. Down the road somewhere, nanobots might be able to perform the "roto-rooter" function on a routine basis.
The upfront cost of such nanobot technology will be huge, of course, but if the technology could be mass produced, costs would fall to widget levels. It's in the nature of mass production that the prototype of anything is fantastically expensive, whereas the latest unit rolling off an assembly line is terrifically cheap. The challenge is to support the initial investment, allowing for a long-term payoff in terms of both health care improvement and cost-crash.
And that's just medical machinery. Wonders have also been wrought by pharmaceuticals that cost billions to develop, obviating surgery altogether. What else can we look forward to, in terms of more drugs, or stem cells, or particle beams or some completely new kind of breakthrough?
But we'll never find out what new medical miracles are possible under the current intellectual-political reign of the elites, for whom "controlling costs" is the agreed-upon goal. Yes, such high-tech breakthroughs might cut costs in the long run, but all too often, politics operates in the short run. And in that short run, health-care-crats will be looking to cut, so as to make the overall cost of a national health care plan appear as low as possible. More deeply, the guiding vision of regulated, regimented one-size-fits-all scarcity, which animates the left, does not allow much enthusiasm for "heroic medicine."
But hold on a second here. The elites don't get to decide these questions; here in America, the people rule. And that popular reality spells trouble for the Obama agenda in 2009. Moreover, public opinion will prove to be an obstacle for any politician or party, from the right as well as the left, that pushes an agenda the voters don't want.
The American people haven't found their voice yet, but when they do, they will endorse a health care system where expenditures rise, not fall. They will support an overall "war" on the maladies they fear and dread. The only question is, How long will it be before the political elites accommodate the public's wish?
But in the meantime, Steve Jobs, paying for his costly but successful treatment, is pointing the way to the healthy future Americans actually want.
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