Monday, 10 August 2009

Myth versus reality

This evening’s exercise in compare and contrast.

The textbook public policy process (seriously, whip open any book with "Public Policy" in the title, or any college intro to American government text that covers policy, and you'll see this or a paraphrase):

  1. Define the problem.
  2. Propose alternative solutions.
  3. Promulgate some specific solution as law.
  4. Implement the solution.
  5. Figure out if it works. Rinse and repeat if necessary.

The health care reform process thus far:

  1. The problem is defined, sort of. “Health care is broken and/or really expensive.” I mean, seriously, nobody has even defined the problem in any more specific way that remotely relates to the bills being proposed. Textbook stage 1 problem statements would resemble “Americans have to fill out ridiculous amounts of paperwork every time they get within 300 feet of a doctor” or “People treat emergency rooms like places they should go when there isn’t an actual emergency situation.”
  2. Instead of considering policy alternatives, throw a lot of stuff that is largely unrelated except having something to do with “health care” into a giant, opaque bill. Actually, several of them. Several of which manage to solve problems that nobody has identified, like “older Americans will be forced to see a counselor every five years so they can have a depressing conversation about dying” without giving an explanation of either how this is a good idea or how it saves anyone money. Although it does solve the problem “how can various rent-seeking groups get all of the population to use their services on a regular basis?” which isn’t really a health care problem, but I digress.
  3. Yell and scream a lot about how everyone is trying to murder their political opponents, old people, and/or key Democratic voting blocs, and particularly about how people are being unpatriotic by yelling and screaming at each other.

Thus, I conclude that the policy process model is actually prescriptive, not descriptive. No wonder nobody asked me to teach policy again in the fall. (I lack faith that stages 4 and 5 will correspond to the official versions either, should we see those.)

Chris’s probably silly (and completely non-libertarian, which is an under-appreciated asset for potential policy solutions in D.C.) health care plan:

  • Allow anyone who wants it to be covered by Medicaid. Make everyone over the current Medicaid eligibility thresholds who chooses to enroll pay for it using some formula scribbled in the margins of a draft copy of this post. Every time someone who doesn’t have insurance shows up at an emergency room, they get a stern talking to about signing up for Medicaid or something else while they’re sitting on their butt anyway during triage. People who do this for minor ailments get the stern talking to several times before they are seen so they get the point, and a brochure stapled to the crap they leave with. People who continue to show up without insurance for minor ailments get escalated to meet Mike Tyson and then receive immediate treatment (for Tyson, not the minor ailments).
  • Allow anyone who loses his or her job to buy into COBRA until becoming employed by an employer offering health care or becoming eligible for public assistance through Medic*. Throw money at people receiving unemployment benefits to buy in.

Voila. Everyone who wants it can now afford insurance and has access to it. That was two paragraphs. We can put that in legislature-ese and make that a 30-page bill. The rest of the nonsense is about “cost control” which isn’t going to happen in practice, since we can’t compare costs to counterfactual reality (the world without “cost control” or other worlds with different “cost control”). This crap is going to be ridiculously expensive no matter what, and whatever costs we might be able to control (doctors using two little band-aids instead of one big one, prescribing the Really Awesome Cholesterol Drug instead of the Not Quite So Awesome Cholesterol Drug That Doesn’t Work But Is Cheaper In Theory, throwing people in the Really Fancy Scanner rather than just having them sit on some film and swallow some U-238) are rounding errors in that.

Besides, Hugo’s paying so who cares?


Any views expressed in these comments are solely those of their authors; they do not reflect the views of the authors of Signifying Nothing, unless attributed to one of us.

What I teach in my intro classes is that Easton’s Systems Theory model is inaccurate in that it posits needs on the input side and policy as the output. In fact it’s interest group pressure morphing into laws as outputs—and the laws themselves are seen as the end of the cycle (or as victories unto themselves), with little regard for whatsoever as to whether the perceived problem is actually solved…

[Permalink] 2. Matthew Stinson wrote @ Mon, 10 Aug 2009, 10:47 pm CDT:

In short: rational policymaking is generally subjugated to political goals. It’d be interesting to see how this fact of American politics plays out in a comparative context.


Err… Didn’t Kingdon cover all this in 1984 already?

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