It's easy to get lost in the weeds when talking about health care reform. But, like all great public issues, the health care debate is fundamentally a debate about values. It's a debate about what kind of country we want America to be.
During the first many decades of this nation's existence, the United States was a wide-open, dynamic country with a rapidly expanding economy. It was also a country that tolerated a large amount of cruelty and pain — poor people living in misery, workers suffering from exploitation.
Over the years, Americans decided they wanted a little more safety and security. This is what happens as nations grow wealthier; they use money to buy civilization.
Occasionally, our ancestors found themselves in a sweet spot.
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They could pass legislation that brought security but without a cost to vitality. But adults know that this situation is rare. In the real world, there's usually a trade-off. The unregulated market wants to direct capital to the productive and the young. Welfare policies usually direct resources to the vulnerable and the elderly. Most social welfare legislation, even successful legislation, siphons money from the former to the latter.
Early in this health care reform process, many of us thought we were in that magical sweet spot. We could extend coverage to the uninsured but also improve the system overall to lower costs. That is, we thought it would be possible to reduce the suffering of the vulnerable while simultaneously squeezing money out of the wasteful system and freeing it up for more productive uses.
That's what the management gurus call a win-win.
It hasn't worked out that way. The bills before Congress would almost certainly ease the anxiety of the uninsured, those who watch with terror as their child or spouse grows ill, who face bankruptcy and ruin.
And the bills would probably do it without damaging the care the rest of us receive. In every place where reforms have been tried — from Massachusetts to Switzerland — people come to cherish their new benefits. The new plans become politically untouchable.
But, alas, there would be trade-offs. Instead of reducing costs, the bills in Congress would probably raise them. They would mean that more of the nation's wealth would be siphoned off from productive uses and shifted into a still wasteful health care system.
The authors of these bills have tried to foster efficiencies.
The Senate bill would initiate several interesting experiments designed to make the system more effective — giving doctors incentives to collaborate, rewarding hospitals that provide quality care at lower cost. It's possible that some of these experiments will bloom into potent systemic reforms.
But the general view among independent health care economists is that these changes will not fundamentally bend the cost curve. The system after reform will look as it does today, only bigger and more expensive.
As Jeffrey S. Flier, dean of the Harvard Medical School, wrote in The Wall Street Journal last week, "In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it." Rather than pushing all of the new costs onto future generations, as past governments have done, the Democrats have admirably agreed to raise taxes. Over the next generation, the tax increases in the various bills could funnel trillions of dollars from the general economy into the medical system.
Moreover, the current estimates almost certainly understate the share of the nation's wealth that will have to be shifted. In these bills, the present Congress pledges that future Congresses will impose painful measures to cut Medicare payments and impose efficiencies. Future Congresses rarely live up to these pledges.
Somebody screams "rationing!" and there is a bipartisan rush to kill even the most tepid cost-saving measure. After all, if the current Congress, with pride of authorship, couldn't reduce costs, why should we expect that future Congresses will?
The bottom line is that we face a brutal choice.
Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we've already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one.
We all have to decide what we want at this moment in history, vitality or security. We can debate this or that provision, but where we come down will depend on that moral preference. Don't get stupefied by technical details. This debate is about values.
THE NEW YORK TIMES NEWS SERVICE