(Bloomberg Opinion) -- At the Democratic debate this week, Senator Elizabeth Warren won loud applause, and helped define the Democratic presidential race, when she exclaimed, “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for.”
It was a powerful moment. But it fits with a strategy, now prominent on the left, of characterizing reform-minded pragmatism as a form of cowardice, a capitulation to the right, a demonstration of spinelessness, a Republican talking point or a failure of nerve or character, rather than what it usually is: a matter of principle.
Consider the debate over Medicare for All. Why are so many people skeptical about the ambitious proposal, championed by Warren and Senator Bernie Sanders, to abolish employer-provided health insurance and shift to a government-run system?
A good answer can be found in one of the most illuminating books of the last quarter century: “Seeing Like a State,” by James Scott, a political scientist and anthropologist at Yale.
Scott’s subtitle captures his theme: “How Certain Schemes to Improve the Human Condition Have Failed.” His central argument is that public officials often intervene in complex systems that they do not sufficiently understand. Offering examples from city planning, agriculture and bureaucratic management, he contends that “the aspiration to the administrative ordering of nature and society” is often doomed.
For Scott, whose book was published in 1999, the problem is that administrators necessarily resort to “thin simplifications” of social reality, which is what actually happens on the ground. That reality tends to be immensely complicated. It is a product of the decisions of countless people, whose responses to social interventions are difficult and sometimes even impossible to predict.
As an example, consider fuel-economy regulation. An ambitious plan, finalized by the Barack Obama administration in 2012, depended on assumptions about consumer behavior that have not held just a few years after.(2)
Among other things, officials anticipated a continuing trend away from purchases of light trucks, which tend to use relatively more fuel than other vehicles. Contrary to expectations, there has been a substantial increase in their market share. As a result, the 2012 regulation, now being rethought by the Trump administration, is achieving lower benefits than originally anticipated, because the mix of vehicles is different from what was expected.
With the risk of unintended consequences in mind, Scott thinks that public officials should usually take small steps rather than large ones. Human beings will inevitably move in unexpected directions, undermining and potentially destroying official plans. Aware of that risk, smart officials take steps to ensure that whatever they do is reversible (as the fuel-economy regulations are).
All this provides a loud warning whenever public officials try to take over or restructure a large portion of the economy. To be sure, a warning is nothing like a stop sign. The Social Security system has been a big success, and the same is true for Medicare and Medicaid. We should celebrate the Clean Air Act and the National Traffic and Motor Vehicle Safety Act.
But even with a transition period, a national shift from employer-based insurance to Medicare for All would create serious risks, and (almost certainly) unanticipated challenges.
Sanders, Warren and others are right to draw attention to the many problems in the current health-care system. Just one example: Administrative costs and paperwork burdens are wildly excessive. Some of those costs and burdens are a product of government regulation, but hardly all of them. Progressives are right to object that profit-minded companies impose excessive form-filling requirements. Trying, and sometimes failing, to meet them can be frustrating, harmful or even devastating for patients.
If we were building a health-care system from scratch, we would not build the one we have. It is not easy to know, in the abstract, whether the plan favored by Sanders and Warren would work for the U.S.
But we are not starting from scratch. Right now, about 158 million Americans get their health insurance through an employer, and an additional 14 million obtain private insurance through the individual market.
A shift would immediately create uncertainty for about 172 million people – and the uncertainty would involve something of fundamental importance to their daily lives. Many of those millions much like their current plans.
It’s true that many others have had bad or even terrible experiences with their insurance companies. Even so, they might well be jarred, or worse, by the prospect of having to deal with a system very different from the one to which they have long been accustomed.
Everyone should agree that health care is a right, not a privilege. At least among Democrats (and many Republicans), that’s not what the disagreement is about. It’s about who’s right on policy, not about who’s brave and who’s spineless.
There is more than one way to turn the right to health care into a reality – and some are a lot riskier than others.
(1) Disclosure: As administrator of the Office of Information and Regulatory Affairs from 2009 to 2012, I helped oversee that regulation.
To contact the author of this story: Cass R. Sunstein at firstname.lastname@example.org
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Cass R. Sunstein is a Bloomberg Opinion columnist. He is the author of “The Cost-Benefit Revolution” and a co-author of “Nudge: Improving Decisions About Health, Wealth and Happiness.”
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