As you know, McConnell finally unveiled the Republican health care bill in Senate, which was immediately described as genocide by liberals. (I say that in jest, but I have no doubt that some people will actually say that, if they haven’t already.) Before I go on, I should say that I have read almost nothing about this bill yet, so I have no opinion whatsoever about it. What I want to talk about in this post are the reactions to it, which I think illustrates why viewpoint diversity is important. I’m sure that most people who have already reacted to that bill haven’t read more about it than I did, but it doesn’t prevent them from being completely hysterical. If you want to have a sense of the kind of vitriol that one can read on social media about this, you should have a look at the reactions to Avik Roy’s tweet about the bill, which he apparently finds very good:
Finished reading the Senate HC bill. Put simply: If it passes, it’ll be the greatest policy achievement by a GOP Congress in my lifetime.
— Avik Roy (@Avik) June 22, 2017
I usually find Roy’s opinion on health care interesting, even though I don’t always agree with him. (I don’t necessarily disagree with him either, it’s just that I don’t know enough about health care policy, so I tend to remain agnostic on that issue.) Again, for all I know, the bill could be horrible and Roy’s tweet could be complete nonsense. But he certainly does not deserve the abuse he received after he posted this.
However, what I find really striking about the reactions to the Republican bill is not so much the hyperbole, which is par for the course, but rather how simplistic a vision of the debate most opponents of the bill have. Again, they may be right that it’s a terrible bill, but they are clearly not in a position to know that. One of the most common criticism of the bill is that it ends Obamacare’s expansion of Medicaid. I don’t even know if that’s true, but even if it is, it speaks volumes that opponents of the bill think it’s obvious that any bill which rolls back the expansion is bad. If you think it’s obvious, then you clearly haven’t thought this through, because the only thing that’s obvious about this is that it’s not obvious. I encounter that kind of misplaced confidence all the time, because as a result of the ideological uniformity in academia, academics only hear one viewpoint on many political issues. This is why it’s often so embarrassing to hear them talk about politics, because when you only hear one side, you are usually clueless and end up saying a lot of stupid shit. I’m sure it’s also true of conservatives, but most of the people I hang out with are liberals, so it bothers me less.
So right now everyone on my social media feed is saying that Republicans are murderers because of that health care bill. (These are the same people who constantly admonish me for my tone. This should no longer surprise me, but the lack of self-awareness that some people show never ceases to amaze me.) Apparently, if you support a bill that rolls back Obamacare, you hate poor people and want them to die. I know it sounds like I’m exaggerating when I say that, but I’m really not, I have read literally dozens of posts saying exactly that. They keep repeating that repealing Obamacare would deprive millions of people of insurance and therefore kill a lot of them. Now, as I have already noted, I haven’t read enough about that bill yet to know whether it’s true. In fact, since the bill was just released and it takes time to do that kind of estimation seriously, I imagine that nobody really does. But if the bill really ends Medicaid’s expansion, then it’s clear that many people will lose coverage and that some people will die as a result, although it’s hard to say how many.
I will come back to the difficulty of quantifying this shortly, but first I want to discuss something that is implicit in what most opponents of the bill say. They seem to think that, if a law results in the death of some people, then it’s a bad law. Similarly, you often hear people say that, if voting a law would save lives, then it should be voted. But this is clearly nonsense and, since I hear that kind of things all the time, I thought it couldn’t do any harm to point it out. For instance, if Congress voted a law to limit speed to 20 miles per hour on every road, it would no doubt save thousands of lives. But nobody thinks it would be a good idea because it would be a huge pain for everyone and would cost the economy hundreds of billions of dollars. Conversely, if someone proposed to cut regulations that cost the economy a trillion dollar every year but resulted in the death of a few more people, people would still think it’s a good idea because a trillion dollar could have a very large effect on the well-being of a lot more people. People who say that kind of things seem to think that a human life is incommensurable with any amount of money, but if they thought about it for a second, they will realize that it’s obviously false.
Thus, even if it’s true that the Republican health care bill would kill some people, it doesn’t follow that Congress shouldn’t vote it. It depends on how many people it would kill, how much money it would save, what effect it would have on taxes, etc. It also depends on philosophical issues such as the nature of justice that philosophers have been debating for more than 2000 years. Those are very complicated questions and, if you think that, just because the GOP bill would end Medicaid’s expansion, it’s obvious that Congress shouldn’t vote it and that Republicans are evil, then you are completely irrational. Again, I’m not saying it’s a good bill, I have no idea. It may be that, despite what Roy seems to think, it’s actually a terrible bill. I thought the bill proposed by Republicans in the House a few months ago was terrible, although they were right that the CBO estimate was nonsensical, but unlike the latest plan I had time to read a lot about it. (By the way, Roy also thought it was awful, so it’s not as if he were just a cheerleader for any plan the GOP proposes.) But if people want to argue that it’s bad, they must say more than just point out that it would end Medicaid’s expansion.
In particular, people often confuse health care insurance coverage with access to health care, but they are not actually the same thing. You can be insured and have very poor access to health care services, because your deductibles are ridiculously high. Conversely, a lot of people who aren’t insured nevertheless get access to health care, because in practice nonprofit hospitals are acting as “insurers of last resort” for people who can’t pay and pick up the bill for them. (Which should be taken into account when calculating the cost of government-provided health care insurance, something that further complicates the debate. Not only does it make the cost-benefit analysis more complicated, but it also requires to answer difficult questions about who ought to carry the burden of providing health care to people who can’t afford it on their own.) Indeed, although nobody seriously doubts that having coverage through Medicaid has some positive effect on health, that’s not a very interesting claim. What is more interesting, but a lot more complicated to figure out, is the magnitude of that effect.
Now, I haven’t read a lot about the Republican bill, but I have read more about the effect of health insurance coverage on mortality and health in general, so I unlike the people who throw around figures they heard on Democracy Now, I actually know how difficult it is to determine what the effect is. I’m not going to review the evidence here, because it deserves a whole separate post, but let’s just say that it’s mixed and that it’s a very complicated question. But this is crucial because, if you want to do a cost-benefit analysis of something like Obamacare’s expansion of Medicaid, you need a good estimate of the magnitude of that effect. The methodological obstacles are formidable enough to leave a lot of room for rational disagreement and, as I have noted above, this is just one aspect of the debate. Even if we just focus on the effect that Medicaid has on mortality, it’s not enough to just say that ending the expansion put in place by Obamacare would kill 
You also need to understand that the world is not as simple as John Oliver makes it sound when you watch his show. I know he’s funny and has a cool English accent, but he also has no fucking clue what he is talking about, only he doesn’t know that. Perhaps more importantly, you need to understand that not every person who disagrees with you on that is a monster who just wants to kill children, I can assure you that most of them don’t want that anymore than you do. For what it’s worth, as I have argued before, I think there is a good case that poor people in the US should receive subsidies from the government to be able to afford health care insurance, though I have no idea what’s the best way to implement that. In particular, I wouldn’t be surprised if the GOP plan was really bad, but I don’t know that yet. I’m sure the points I made in this post will be obvious to a lot of people, but judging from what I read on social media and from the conversations I’ve had about this, there are even more people who have never heard any of that because they live in a bubble where everyone thinks the same thing as them. Ideological uniformity just makes people stupid.
EDIT: On that issue, see also my exchange with Justin in the comments of my reply to Green on conservatives in academia, where I say a bit more about why I think the debate about health care policy is more complicated than many people assume.
Like you, the only people whom I converse with are leftwing. I agree with you that ideological uniformity makes people stupid or at least unthinking (which is not quite the same thing as “stupid”).
However, from following the news fairly closely, I see that people on the right are equally unthinking, probably because on most issues they defend the status quo and defending the status quo takes almost no thought.
Most of the most worthwhile critical social thought in the past 100 years comes from people on the left, even though, as you point out, your average leftist is as
unthinking as your average rightwinger.
Most of us are fairly tribal in our ways of thinking. You, for some reason, seem to be uncomfortable with all forms of intellectual tribalism. I imagine that that does not make life easier for you.
Most of the destructive, murderous social thought of the past century also comes from the left. Was the gulag worth it for the sake of Social Security? Maybe, especially if you value American lives more than Russian ones (as who would not?).
Y81,
I come from Chile, and I don’t value American lives more than Russian ones.
Hmm, that points against the left having a net positive value for human welfare during the 20th century, since you can hardly argue Roosevelt did more good than Stalin did bad. Maybe the 21st century will be better.
There is a difference between the claims that 1) Republicans want to hurt the poor and the sick, and 2) this health care bill will hurt the poor and the sick. You are right that some opponents of this bill, especially those who want to sell newspapers, keep claiming 1. But, I doubt any Republican has an attitude of hope or desire towards the proposition that the poor and sick will get hurt.
While I agree with you on that, Republicans also claim that 3) they want everyone to have access to affordable, good quality health care, including the poor and those with pre-existing conditions. At least, this is what Trump wants and I just heard McConnell saying the same thing on the radio. They might be honest about wanting this, but they are being either dishonest or delusional if they think this bill would achieve that.
Suppose they said the following: ‘look, I want everyone to have access, including the poor and the sick, but I also want a Porsche. Just as I’m not going to get a Porsche, this bill won’t get me this other thing I want, namely, the poor and sick having access to good quality health care. But that’s ok. You don’t always get what you want, and there are these other things that are really important that we will get with this bill, e.g., a bunch of other people will have cheaper access to insurance.’
I would be ok with that. At least, we could then focus on what the priorities should be. But they don’t say that. They keep claiming 3, but they know that 2 is true.
It’s also just crazy making how they think this will lower health care costs. For instance, Medicare pays a portion of the cost for training residents (people don’t talk about that much). There has been a cap on that funding, and the number of residency places has remained constant even as the number of medical school places has increased. The number of doctors retiring has also increased, so the supply of doctors coming through residency programs is nowhere close to providing for the relevant demand (for a biased summary on this, see here: https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/). This is why so many hospitals are having to pay recruitment bonuses to physicians. You can easily now get $50k, which inevitably gets passed on to patients. That’s all because the competition is so insane. We’re even seeing salaries for primary care physicians—not the best paid specialty— shoot up. The new GOP bill abolishes the Medicare payroll tax. That will reduce the amount available to fund residency programs, which will again reduce the places and restrict physician supply. Maybe they’ll make it up some other way. But, given that the lack of physicians is one reason why health care is expensive, this bill doesn’t fix it and risks making it worse. (The ACA was also crazy making for doing little to address the supply of physicians. It’s like policy makers can’t understand how employers need to outbid each when there are a limited number of available employees.)
The bill also does not provide funding to hospitals who will once again have to treat patients without insurance (you mention this in your post). Hospitals receive payments through what is called the Medicaid Disproportionate Share Hospital (DSH) for treating patients without insurance. These are being phased out next year under the ACA as more patients have Medicaid; hospitals were to receive Medicaid dollars through Medicaid plans rather than the DSH. The GOP bill continues the phase out for states that expanded medicaid, but gives an exemption for nonexpansion states until the early 2020s. As DSH, medicaid, and private insurance dollars start declining, either for expansion states next year or non expansion states in the 2020s, the hospitals will have to recoup the cost from somewhere. Prices, of course, will go up.
Of course, this might be ok. Perhaps, as you point out, there are more important things that we might want to achieve that come at the cost of restricting access to health care for the poor and the sick. But I wish Reps would say that instead this.
I agree that Republicans are dishonest, but it’s just politically impossible to say that you want to restrict access to health care for poor people, even if you have a good case in favor of that policy. So it’s just unrealistic to expect anything else from them. Similarly, I don’t expect the Democrats not to accuse the Republicans of killing people, but I do wish than in both cases intelligent commentators, as opposed to people involved in day-to-day politics, would recognize the complexity of the issue, which they largely don’t. This is what my post was about.
On the shortage of doctors, the problem you describe seems like a classic case of a state intervention that messes things up. If the government wasn’t artificially restricting the number of residents, the supply of doctors wouldn’t so low compared to the demand, and hospitals wouldn’t have to pay them as much. I don’t know exactly how this works in the US, I would say that somehow the doctor lobby determines how many resident slots there are, which allows them to raise the wages in their profession. So, if I’m right, it’s also a classic case of a special interest coopting the government to defend its interests. But you tell me.
Some are in fact arguing that an expansion of medical coverage provides no health benefits. Google Oregon Health Insurance Experiment.
Others present evidence that expanding Medicaid actually increases health problems and deaths. Spotted Toad had a series of posts on this back in March.
I know about the Oregon study, but it’s statistically underpowered, so it’s less interesting than some people think. I just saw Spotted Toad’s posts on Twitter yesterday and it looks really interesting! It’s a complicated issues and I would need a detailed post to address it satisfactorily. Perhaps I will write one eventually, but right now I don’t have time.