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  • There are More Ways to Go Wrong Than to Go Right.

    Posted by Shannon Love on June 18th, 2009 (All posts by )

    Megan McArdle makes a very good general point in her post on the illusion that socialism will reduce health-care costs:

    We have been trying to control health care costs since the 1970s made it clear that Medicare was going to get really, really expensive.  And any idea that you care to name, from comparative effectiveness research to healthcare IT to preventive medicine . . . these have all been on the table for more than thirty years, under one name or another.  They haven’t happened.
     
    The answer that those promising magical cost reductions need to ask is “Why haven’t they happened?” and “What has changed to make them feasible now?”  But when I ask this question, I get angry demands that I put forward my plan for cost control, rather than merely critiquing everyone else’s.  This seems rather like demanding that I put forward my design for a perpetual motion machine before I am allowed to point out problems in the US energy market.

    I was reminded of this style of argumentation by Harry Angstrom’s comments in my previous post, where he makes this exact argument. In thinking about it, I realized that a lot of debates with leftists often come down to this type of, “I have an idea and you don’t, therefore I must have the best plan,” argument. 

    I see this a lot in debates over energy. People will argue that since they believe fossil fuels cause global warming, and since nuclear power is too dangerous, therefore solar and wind power must be viable technologies. Unfortunately, the fact that one specific technology has problems has nothing to do with whether another unrelated technology will work. Just because we can’t use fossil fuels and nukes has no bearing on whether weather-dependent energy sources can actually power our civilization. 

    The urge to do something, anything, to solve a problem can backfire badly. Before scientific medicine, doctors could do little to treat disease yet they felt compelled to do something, anything to try and help. That is how we ended up with bleeding and other counter-productive treatments. Likewise, Herbert Hoover felt he had to do something about the recession that started in 1929, so he raised federal spending, raised taxes and the Congress pitched in by raising tariffs. Their urgency to do something, anything, ended up turing a bad recession into an unprecedented depression that lasted a decade. 

    People immersed in politics begin to think that that since there are only two major divisions in our politics there must be only two altnerative solutions to any problem. They begin to think that if one side’s idea is bad then the other side’s idea is good. These people forget that there is only one optimum solution for any particular problem but a functionally infinite number of ways to make a problem worse. If we implement policies based on the idea that any idea is better than no idea at all, we are more likely to implement a policy that does more harm than good than a policy that helps. There are more ways to go wrong than to go right.

    A bad idea is a bad idea independent of any other ideas. It doesn’t matter if that idea’s critics don’t have a superior idea themselves. You don’t have to know how to make a practical jet-pack yourself to know that it is a bad idea for someone to try to fly by strapping 50 roman candles to their back and setting them off.

     

    19 Responses to “There are More Ways to Go Wrong Than to Go Right.”

    1. Brett_McS Says:

      In teen years I unquestioningly assumed that any idea that popped into my head was automatically right – I didn’t even think to question its veracity. However, sometimes I would make the mistake of expressing the idea to someone who actually had real knowledge of the subject; then it would typically be shot down in flames. After that happened a few hundred times I started to realize that just because an idea pops into my particular noggin that doesn’t give it some sort of divine status.

    2. methinks Says:

      Shannon,

      There are a few good ways to bring down costs.

      1.) reduce state mandates which decrease the number of plan choices and increase costs for consumers.

      2.) We need a free market in health care. Deregulate insurance companies to a large extent. Industry captures regulators and it is because of this that cash paying patients have to pay more and why an insurance company can use the excuse of switching employers or states to break coverage. As long as you’re paying the premiums to Aetna, your employer or residence shouldn’t matter but the industry got the regulators to write in these breaks for it. Imagine the innovation and cost reduction that would occur if we forced doctors and health insurance companies to compete for patients.

      3.) Kill the AMA. The organization serves one purpose – to reduce the number of medical professionals in order to increase the incomes of doctors. The AMA lulls unsuspecting patients into a sense a false sense of comfort because the AMA certifies doctors. In fact, there are plenty of incompetent doctors and I would love to see competition for the AMA.

      4.) Once a procedure’s cost is determined by the market, the only way to bring down cost is through innovation. The government cannot reduce costs. It can merely reduce expenditures on health care by rationing. This doesn’t reduce cost, though. It should be noted that people already reduce expenditures and ration their health care by deciding what they want to pay for.

      But, the leftists don’t care about real arguments. We all know that that the issue of socialized medicine is not medicine at all, rather it is an issue of state control and of enslaving the population to the state.

      Here’s what Reagan had to say about it in 1961.

      http://www.youtube.com/watch?v=fRdLpem-AAs&eurl=http%3A%2F%2Fmjperry.blogspot.com%2F&feature=player_embedded

    3. Kirk Parker Says:

      These people forget that there is only one optimum solution for any particular problem” [emphasis added]

      That itself is an unfounded supposition: there’s no reason why a particular issue might have several optima.

    4. cjm Says:

      getting the malpractice situation under control would go a long way to lowering costs. replace malpractice laws with an effective way to remove bad doctors. start by publishing success/failure statistics on every doctor.

    5. bgates Says:

      Kirk – or none at all.

    6. onparkstreet Says:

      Quick anecdote

      Yesterday, at our Grand Rounds, a physician specializing in diabetes flashed up a Power Point that showed about five new drugs, of a particular class, that were put on the market JUST FROM 2001. Technology, and the desire to ‘push on and do more’ is not going away in any system. It’s just not the way we work.

    7. veryretired Says:

      OT–I posted a comment on a thread at Samizdata regarding the bulldozers being proposed to level homes in Flint, Michign, that you referred to awhile ago. I hope I didn’t misstate your point in that post. If so, I apologize for dragging your name into something you have already dealt with here in detail.

    8. orthodoc Says:

      Methinks: “Kill the AMA. The organization serves one purpose – to reduce the number of medical professionals in order to increase the incomes of doctors. The AMA lulls unsuspecting patients into a sense a false sense of comfort because the AMA certifies doctors. In fact, there are plenty of incompetent doctors and I would love to see competition for the AMA.”

      Can we please please please stop claiming that the AMA has anything to do with the supply of doctors. It doesn’t. It has zippo, nada, zilch to do with it. The number of medical slots is set by the AAMC (American Association of Medical Colleges), which has been trying for 15 years to INCREASE the number of medical school positions. The number of residencies is set by the Federal Government, which pays hospitals for the post-graduate training of physicians. As for “certification,” that’s done by the various state licensing boards, and by the American Board of Medical Specialties.

      The AMA, which I don’t belong to, by the way, is an advocacy group and PAC. Not that there’s anything wrong with that.

      Finally, doctors’ incomes are set for the most part by CMS via Medicare rates and the ICD/CPT/DRG system. You do procedure X, you get paid $Y. If you do a thousand X, you get $1000Y. As the reimbursement has dropped for procedure X, doctors have responded by doing it faster and trying to do more of them. Simple.

    9. Ginny Says:

      My impression was that we had too many lawyers because law schools are cheap and legislatures are made up of lawyers and the biggest schools are the state ones; we had fewer doctors because med schools are expensive and legislatures aren’t made up of doctors. Vet schools (which here are harder to get into) are even fewer in number and even more expensive to set up.

      These generalizations I’ve heard numerous times, but I don’t know if they are true. I do know that I keep getting in my lit classes people who have graduated but need it for med or vet school (this semester for physics grad school). This may seem strange but I’m glad to have them and not surprisingly they are excellent students (besides intelligence they have 4-5 years of good study habits & maturity, along with a purpose). I doubt people are showing up in physics courses because its a requirement for law.

    10. Anonymous Says:

      “A bad idea is a bad idea independent of any other ideas. It doesn’t matter if that idea’s critics don’t have a superior idea themselves. You don’t have to know how to make a practical jet-pack yourself to know that it is a bad idea for someone to try to fly by strapping 50 roman candles to their back and setting them off.”

      Actually I don’t know if I agree that a bad idea is bad “independent” of any other ideas. Bad is relative – in the jetpack example, if I had nothing but the fifty roman candles and was facing an imminent horde of zombies, I might give it a shot. Not a perfect example, because we know for sure that fifty roman candles strapped to your back will not help you fly, but I’d say the health care reform proposals we’re discussing here don’t rise to that level of ridiculous.

      I think it’s fair to ask for an alternative proposal, because if you have no alternative proposal, what you’re proposing is the status quo. You are saying this specific proposal is bad relative to doing nothing. When someone asks that you present your own idea rather than merely critiquing everyone else’s, they are (probably incorrectly) assuming that you agree with them that doing nothing is not an option. In such a situation, I’d say the more productive response would be “I do have a better idea – do nothing” and then defend that assertion. I realize that this statement is probably implicit whenever you criticize a proposal and argue against implementing it without presenting a better proposal, but it might help discussion to make the point explicitly.

      Sorry if that came off as preachy or anything.

    11. Shannon Love Says:

      Anonymous,

      Bad is relative – in the jetpack example, if I had nothing but the fifty roman candles and was facing an imminent horde of zombies, I might give it a shot.

      Bad isn’t really relative in a lot of cases. Ideas that simply do not work are equally bad. For example, all ideas that do not allow you to fly off the roof of a tall building are all equally bad because they all end in your death if you try them.

      Worse, trying to fly off the building seals your fate whereas had you not attempted it, you might have found another solution.

      When someone asks that you present your own idea rather than merely critiquing everyone else’s, they are (probably incorrectly) assuming that you agree with them that doing nothing is not an option.

      Or, as is the case in the health care or energy debate, your opponent simply dismisses your suggestions out of hand and then claim that you have no alternatives.

      As Megan McArdle pointed out, Obamacare offers no new solutions. Everything he suggest (as is the case in all his policies) has been on the table since the 1970’s. If these ideas worked, we should have seen them working on a smaller scale already. If government management of health care worked well, then medicare, veterans care, military health care and tribal nations health care should all be paragons of cost containment combined with high levels of care. Instead we see the opposite pattern. We know that these ideas will not work because we’ve tried them all.

      A person shouldn’t have to either defend the status quo or offer a detailed counter-plan just to have the moral authority to point out that any specific plan has been proven not to work.

    12. Anonymous Says:

      I think there’s something of a trick in using the phrase “proven not to work.” What exactly is the threshold for working or not working?

      From my perspective, the question is not whether something works, but whether it makes us better off than anything else we could do. If you say we should not try comparative effectiveness research, how can you avoid inherently asserting that we are better off without it than with it, i.e., that the status quo is better? Saying it won’t work sounds like you mean that it will not do what its proponents say it will do, which does not necessarily mean it won’t bring some benefits, or that it is not worth doing.

      If the benefits of conducting that research are only trivial, and the costs are high, then yes, this is not something we should do because we would be better off doing nothing. And yes, we should always keep in mind the opportunity cost, but that cost gets pretty speculative when nobody knows what the alternative opportunity is. At some point, you have to stop searching for hypothetical better solutions, and choose from the options you’ve got. My reading of your post is that we would be worse off instituting such-and-such “leftist” proposal than maintaining the status quo, defining status quo as “Not actually implementing a change – still looking for better ideas.”

    13. Anonymous Says:

      Also I just wanted to re-emphasize that I think a lot of what I’m saying is sort of just implicit whenever someone attacks a proposal without offering an alternative, so in a sense I’m just quibbling. However, I do think that it is reasonable to insist that someone give you a better choice than the one you are proposing if they are going to attack it and advocate against its implementation, even if the better choice you advocate for is simply doing nothing now and continuing to look for better ideas.

    14. harry.angstrom Says:

      simple: the pharmaceutical and insurance industries block via our congress all attempts to improve things. ex: Dodd’s wife tied into the health industry; Lieberman has been bankrolled by Hartford Insurance industry and his wife a very big lobbyist for pharmaceutical industry. All attempts to improve have been stifoled thus far. Conservatives simply offer: cut costs on what we presently have. That is but a modest start and adds little to a major needed change.
      ps: sprinkoiong in the word “lefty” in every few sentences changes nothing in the debate.

    15. Bill Hartsell Says:

      My field is oncology – and I would argue that the status quo is much more likely to be better than any of the proposed changes. A study last year from Lancet Oncology compared survival rates for patients with cancers diagnosed in Europe and the United States. The US had the highest overall 5 year survival rates (for men, 66% vs 47% for the European average, with Sweden the only country close at 60%, and for women the US rate was 63% vs 56% for European women, again with the US higher than all the rest). Some striking figures – the overall 5-year survival rates were greater than 90% for 5 types of cancer in the US, compared to only 1 type in Europe. The 5 year survival rate for lung cancer is dismal on both continents but is 16% in the US vs 11% in Europe.

      In Chicago, if a patient does not have insurance s/he can still get access to care – all patients with breast or cervical cancer are covered through the state program; for the other cancers, the patient can either go to one of the county facilities (eg, Stroger Cook County Hospital), apply for Medicaid, or get treated with “charity care” at a private hospital.

      As Shannon suggested, doesn’t it seem that more things can go wrong than right by a significant change in the current system?

    16. Shannon Love Says:

      Anonymous,

      I think there’s something of a trick in using the phrase “proven not to work.” What exactly is the threshold for working or not working?

      Yes, your right. I wondered off into a slightly different discussion. Nevertheless, my main point stands. Any proponent of a new idea has the burden to prove that a new idea is better than the status quo. No one else has an obligation to prove any competing idea or even to offer any valid criticism.

      Why? Because there are far, far more bad ideas than good ones. McArdle’s mention of perpetual motion resonated with me because I have of late been posting on the Mythbuster’s web forum where perpetual motion/free energy claims are rife. There are a lot parallels between the way that perpetual motion advocates debate and the way that pro-politically managed health advocates debate but the most relevant parallel is the assertion that the burden of proof lays on the skeptic to demonstrate that any particular device does not work.

      Now, as a practical matter, if we actually adopted that standard, physicist and engineers would spend most of their time debunking perpetual motion machines. Anyone can slap some weights and magnets together, post a youtube video of it supposedly running and then place the burden of proof on someone else to prove that it doesn’t work.

      You don’t have to go so far a field as perpetual motion to understand where the burden of proof should lay. Every year people come out with real technologies that they believe everyone else should buy. There are obviously a lot more ideas for technologies than their are technologies that will work under real-world conditions. Look at the dot.com bubble. Should we place the burden of proof on consumers to demonstrate whether a new technology works or should we place the burden of proof on the manufacture to make a product that fits the needs of consumers? Should people have to buy products and use them before they can decide the product doesn’t fit their needs?

      Likewise, shouldn’t the burden of proof be on those who advocate politically managed health care? There are far more ways to screw up the system than there are ways to improve it. Shouldn’t they at least have to demonstrate that it will work on the small scale before applying to the entire system? Isn’t plausible to ask that they prove that current politically-managed health care e.g Medicare, Veteran’s care etc produce the cost savings and high levels of care before we spread those systems to everyone?

      We don’t require that a skeptic of a perpetual motion machine have any understanding of physics before we let them place the burden of proof on the machine’s builder. Why should we require that anyone else skeptical of any new idea have to have a detailed understanding of the new idea in order to put the burden of proof on the idea’s advocate?

      Leftists try to shift the burden of proof by creating the illusion of a crisis in the status quo so dire that any alternative is likely to be better. They essentially attempt to create the mindset you mentioned above in your thought experiment with the zombies. This form of argumentation in itself suggest that the ideas are weak and unlikely to work. In the real-world, good ideas start out small and grow because people see them work and adopt them. It doesn’t take fear of cataclysm for people to see the value in the new idea.

      Like the inventors of supposed perpetual motion devices, leftists continually try to shift the burden of proof to their critics. Just like those with science educations on the Mythbuster’s forums, non-leftists end up sending a lot of their time explaining why leftists ideas will not work instead of advancing their own ideas. It’s a neat bit of slight of hand but it doesn’t lead to good decision making.

    17. sol vason Says:

      Medicare does more than pay for health care, It opporates a very thorough ststem of national price controls that are just like the price controls created in the seventies.
      And just as the price contriols of the seventies drove the price of oil higher and higher, so does medicare drive health care prices higher and higher.

      When Reagan ended price controls ALL AT ONCE (“COLD TURKEY”) wise men predicted catastrophic price increases would occur. Instead prices fell immediately by oner 50%.

      Price controls always cause prices to sky rocket.

    18. Shannon Love Says:

      Sol Vason,

      When Reagan ended price controls ALL AT ONCE (”COLD TURKEY”) wise men predicted catastrophic price increases would occur. Instead prices fell immediately by oner 50%.

      I have to disagree with you on that one. The fall in prices was not immediate.

      Carter ended oil price controls but replaced them with a windfall profits tax that had the same economic effect of suppressing domestic oil production. Reagan ended the windfall profits tax in 1981 and oil prices immediately increased. I know because I was a teenager in Texas at the time and for four years Texas had an unprecedented boom. The fall in oil prices did not occur until 1984 but when they did fall they fell 80% in 9 months. Also, as I noted in a previous post, the oil industry has unique features that make its pricing gyrate more than other commodities.

      Price controls create shortages. When those controls are lifted, the shortages drive up prices until the market can create enough product to fill the shortages. The only way to try to get around this is to give the produces a significant lead time, say 6 months or so, before lifting the price controls so they can ramp up production. This doesn’t work real well because producers use price signals as their primary information about demand so they can’t really set production levels until prices controls are lifted and market signals begin to work again.

    19. Marty Says:

      1. Brett_McS caught the essence of the liberal view of this issue in the first comment–it is an immature, childish view of life that permeates much of what passes for thought on the left.

      2. “Bad” can be an absolute, does not require a comparison, but it has to be stated in terms of some criteria which it fails to meet. “Worse” is a comparative that requires something to compare it to.

      3. I like Virginia Postrel’s point about Medicare and Megan McArdle’s about the VA health system: show us how to make them efficient, and then we can talk about how to generalize those techniques to the total system. I don’t see any takers, tho.