Friday, January 13, 2017

Ferociously fragmented, frenetic chaos

Buster Keaton in The Navigator (1924).
Well, Brooks has been looking at problems that are several different kinds of problem at once, like house-hunting, which is emotionally, psychologically, cognitively, and even morally difficult, or Trump advisor Stephen Bannon's neo-fascist (Brooks coyly calls the philosophy "populist ethno-nationalist") critique of the post–World War II order, which is simultaneously moral, religious, economic, political and racial.

Now he's looking at the problem of devising a Republican replacement for the Affordable Care Act, and specifically the question whether market incentives "work" in health care, which is both economic and psychological:

This is really two questions. The economic one: Would market mechanisms improve quality and reduce costs? The psychological one: Do people want the extra cognitive burden of shopping for health care, or would they rather offload those decisions to someone else?
Really, it isn't two questions, in the sense that the incentives will only function if the consumers are incentivized: improvements in quality and cost won't happen unless shoppers are willing to shop.

I think the weak point here is the implication that the Affordable Care Act doesn't use market incentives, which shows that he still, six years after its passage, hasn't found out what's in it. The ACA is an overhaul of the health care system that is entirely based on market incentives!

That is, other than the heritage of socialist programs of the Veterans Administration, Medicare, and Medicaid, the latter expanded by the ACA, which are regarded as sacrosanct by the entire population, the Act retains a system of health insurance issued by private companies in competition with each other and care supplied by private health care providers in competition with each other, using pure market means:
The Patient Protection and Affordable Care Act (ACA) has 3 main objectives: (1) to reform the private insurance market—especially for individuals and small-group purchasers, (2) to expand Medicaid to the working poor with income up to 133% of the federal poverty level, and (3) to change the way that medical decisions are made. All 3 objectives rely primarily on private choices rather than government regulation and are rooted in expectations of rational decision making shaped by incentives but unfettered by other constraints. The implicit assumption is that individuals and groups will act within these reforms to produce a valued good (access to medical care) at an appropriate price (what it would cost an efficient provider) financed by fair risk sharing (spreading the cost of necessary services across a large pool). The result will be affordable care.
This is at its clearest in the most famous part of the Act, the part that actually is a sort of "Republican program": the way people buy their insurance in the individual market for the 8 or 10% of households that don't get it through their employers or through the traditional socialist programs, where they need to go to the online Marketplace to select a tax-subsidized policy from a list of plans that offer a certain fixed minimum of benefits and guarantees (the free wellness visits, the ability to keep your kids on your plan until they're 26, etc.), on the basis of a clear and thorough presentation of the costs and benefits of each plan. The procedure was designed to bring the competition for quality and price right onto the consumer's computer.

This is meant to correct the market failure of the old system, a rent-seeking scheme in which insurance companies were able to mystify the customer into buying essentially worthless "catastrophic" policies on which most would basically never collect, decent policies were wholly unaffordable for all but the wealthy, and government paid the tab for the uninsured visiting hospital emergency rooms for basic care. It would be much simpler to correct it by having the government provide insurance directly, as it does for the poor and elderly, but all the economists kept saying market mechanisms will do the job better, so that's what we got.

And the thing on the whole has been working pretty well, not only in expanding the number of people with health insurance, but in incentivizing things like the small-scale private emergency care facilities sprouting up all over city streets, the new-style outcomes-based pricing experiments, and so on. If there's a real problem it's that there aren't enough market mechanisms to guarantee competition: in particular there need to be more functioning co-ops, multistate plans, and state- or federal-owned insurance companies (the so-called "public option") providing competition where the insurance companies hesitate—of course insurance companies and the Republican legislators they contribute to have been fighting these things as hard as they can, because they don't want competition.

The object of Republican plans isn't to introduce market mechanisms into the system, but to get rid of them, or at least some of them, with a vague promise that the market failures of traditional health care provision will stop on their own, but with the real aim of furthering monopolies/monopsonies in their unfettered rent-seeking. If they meant what they say about market mechanisms they'd worship Obamacare, but they don't mean a word of it. (The reason the Heritage Foundation released its proposals in the early 1990s was not to get them enacted but to claim they had an alternative to the Clinton plan, to give legislators an excuse for not voting for that.) It's still to be hoped, in my view, that we can preserve what we've got, because they'll never come up with anything that looks like a workable plan.

Brooks has no clue, of course.

Old Brooks is in some kind of collapse mode, I fear. The house-hunting thing read like a "ladies'" advice column from the 1960s (decide to visit a list of 50 places, look at 18 without making a commitment, then buy the next place that's better than the previous 18, can't find out what self-help book that comes from—he capitalizes "Realtor", so perhaps it's some trade publication), written because

I’ve been thinking about the big decisions in life: How do people choose careers, colleges, spouses and towns. Of those decisions, buying a home ranks with the most difficult.
I wonder if he's getting married? He's thinking about the mistakes he made last time, with the "vast spaces for entertaining":

You may have dreams of being the sort of person who has a fantastically eclectic house, filled with beautiful and exotic objects and where you can host squads of people for big dinners and parties; and that you can have a house that is a crossroads for diverse populations.
But when you actually survey the homes you are drawn to, you realize that you in fact love your privacy; that you don’t care enough about interior design to spend years searching for the fascinating objets; that in real life the thought of neighbors constantly coming over fills you with exhaustion; that a sense of quiet, tranquillity and privacy is more important to you than the frenetic chaos that comes with running Grand Central Station.
How important to you is the frenetic chaos that comes with running Grand Central Station?

And the moral issue in buying a house?

This is where Donald Trump comes in. We’ve become a ferociously fragmented country. People move close to people just like themselves.... In 2017 it’s probably necessary to put a moral onus on realty decisions, to be seriously bothered by the temptation to talk about diversity but move to homogeneity.
And that's where Donald Trump exits, too, presumably because Brooks is not looking at any integrated neighborhoods, or on the other hand maybe he is. If he's planning to move into one of those gentrifying sites, is he worried about the moral implications of making it unaffordable for brown people who have lived there for decades?

We're all floundering, I guess, in this scary new era. Brooks is just more frazzled than most.

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