It's Not Possible To Have A Rational Debate About Healthcare In The Political Arena

The genius of the private property/free exchange system (aka "capitalism") is that nobody other than the people who make things or provide services needs to know all the complexities of how the things are made or the services provided.  Least of all government bureaucrats.  An automobile may be a very complex thing to make, but to buy one all you need to know is how much it costs and whether you like this particular model better than the alternatives.  But then you get into the things provided by the government, which in recent times have come to include healthcare as Exhibit A.  Now all of a sudden government bureaucrats are supposed to know everything about how to provide care for heart conditions or diabetes or dementia or whatever in a cost effective way, and also simultaneously without ever putting anyone at financial risk.  And equally the public is now required to know enough about healthcare policy to participate in a political debate and to figure out whose proposals to support in the next election.

Frankly, it's just not possible for our political system -- or indeed for any conceivable political system -- to have a rational debate on such a complex subject.  Political actors need to appeal to marginal, often poorly-informed voters who pay attention sporadically if at all.  In the best case, debate on a complex issue gets condensed into slogans and epithets that almost always fail to capture the significant arguments.

And boy, are we a long way from the best case!  Looking over what prominent Democrats have had to say recently about Republican efforts to restructure Obamacare, you could be forgiven if you came to the conclusion that that entire side of the debate consists of accusing the Republicans of being murderers.  Am I exaggerating?  Let's take some examples:

Hillary Clinton, June 23 (tweet):  "Forget death panels. If Republicans pass this bill, they're the death party." 

Bernie Sanders, June 23 (tweet):  "Let us be clear and this is not trying to be overly dramatic: Thousands of people will die if the Republican health care bill becomes law."

Elizabeth Warren, May 4 (tweet):  "Families will go bankrupt.  People will die."

And it's not confined to the party's headline septuagenarians.  Bob Unruh at had a big roundup of quotes on May 9, including the following:

Washington Post headline:  “Repealing the Affordable Care Act will kill more than 43,000 people annually.”

DNC Chair Tom Perez:  “Trump and Republicans will own every preventable death, every untreated illness and every bankruptcy that American families will be forced to bear if this bill becomes law."

Kurt Eichenwald (senior Newsweek writer):  “I hope every GOPr who voted 4 Trumpcare sees a family member get long term condition, lose insurance & die.”

Think Progress:  “Approximately 17,000 people could die in 2018 who otherwise would have lived if a House Republican health proposal endorsed by the Trump administration becomes law."

You could go on with this literally as long as you want.  My reaction is, is this really the best they've got?  By the way, you won't be surprised to learn that these numbers for supposed excess deaths do not come from counting up anyone who can actually be individually identified.  Rather, they are based on statistical output of advocacy-driven observational studies.  Is there any reality to this at all?

Well, we're now a good three years into the full implementation of Obamacare.  Surely by now there should be some good statistics out there showing that Americans have become healthier, or that longevity has improved, or something like that, right?  Actually, it's the opposite.  James Freeman of the Wall Street Journal notes the lack of evidentiary support for health improvements from Obamacare in his Best of the Web column yesterday, "Why Didn't Obamacare Make Us Healthier?"    Freeman quotes from a December 8, 2016 New York Times article:

American life expectancy is in decline for the first time since 1993, when H.I.V.-related deaths were at their peak. But this time, researchers can’t identify a single problem driving the drop, and are instead pointing to a number of factors, from heart disease to suicides, that have caused a greater number of deaths.  A study on mortality rates released on Thursday by the National Center for Health Statistics showed that Americans could expect to live for 78.8 years in 2015, a decrease of 0.1 from the year before. The overall death rate increased 1.2 percent — that’s about 86,212 more deaths than those recorded in 2014.

Attributing those 86,000 excess deaths to the advent of Obamacare is just as fair as the use of flaky observational studies by Clinton, Sanders, Warren, et al.  But don't expect any apology from them.

If you want a more detailed scholarly analysis, Oren Cass had a long piece for the Manhattan Institute back in February, anticipating the barrage of unsupported "death" claims, titled "Will Repealing Obamacare Kill People?"   He makes a number of good points, although nothing with the punch of "People will die!!!!!"  Long excerpt from the abstract:

Studies showing positive effects from health-insurance coverage focus on private insurance, not Medicaid.

  • In Oregon, researchers studied the effects of expanding Medicaid coverage and found no improvement in health outcomes. Numerous other studies support this finding for specific conditions and procedures, for Medicaid expansions and for public health spending generally.
  • Where studies do find that Medicaid has a positive effect, it is for pregnant women and young children— groups whose coverage was not expanded by the ACA.

A statistical claim that the ACA saves large numbers of lives should be supported by evidence that it has reduced mortality rates; yet the opposite occurred.

  • In 2015, age-adjusted mortality rose and life expectancy declined in the United States for the first time since the early 1990s.
  • Nor is it the case that states adopting the ACA’s optional Medicaid expansion performed better than those rejecting it; to the contrary, mortality in 2015 rose more in Medicaid expansion states.
  • Despite implementation of the ACA, there were 80,000 more deaths in 2015 than had mortality continued to decline during 2014–15 at the same rate as during 2000–2013.

And even these two rebuttals don't get to the most important issue in my view, which is simply that socialism doesn't work.  To discuss repeal of Obamacare in terms of excess deaths or lack thereof supposedly directly attributable to presence or absence of "insurance" coverage is implicitly to accept the basic socialist fallacy.  That fallacy is this:  We know that the government, by passing out money or handing out or mandating benefits, can make any one person or small group of people better off; therefore, it follows that the government can make everybody better off by indiscriminately handing out money and benefits to all.  In the context of Obamacare, ignoring the socialist fallacy leads to ignoring the downside to the people of the trillions of dollars of additional expenditures for marginal if any health benefits.  It means ignoring the downside of further concentration of power in Washington.  It means ignoring the distortions and inefficiencies that a Washington-controlled system injects into healthcare markets.  It means ignoring the likelihood of decreased innovation in the healthcare system as providers figure out that their time is better devoted to gaming government payment systems and regulations than to developing better methods of care.

None of these things can really be directly measured.  We can't really say that x thousand additional people will die, nor that everyone will be y dollars worse off.  All we can do is look to places like the Soviet Union, Venezuela or Cuba to see how the socialist model gradually undermines the productive and innovative capacity of society, not the least in the healthcare area.