I am waiting for some solid criticism of President Obama’s health care reform proposals and I’m not getting it. Just so you know what I have already heard and junked I will set it out.

1. It will lead us down the road to socialism. I’m never quite sure what to make of this. It’s delivered, I know, like the criticism that will make an opponent’s knees disappear. But my inclination is to say: So what? Disease is socialized. The top ten health care systems in the world are socialized. What’s the point? It is, of course, fear-mongering reminiscent of Fifties red-baiting. But is there more to it? It does seem there are those who think that the purpose of government is not to provide for the common welfare but rather to preserve some ideological (and imaginary) purity of form. But insurance is socialism. Funds are pooled so that risks may be spread. From each according to the needs of the fund and to each according to individual need. Right now we have lots of little pools. Risks are spread, but not very widely. If we had one big pool, risks would be spread as widely as they can be. No, I just don’t see the road to socialism argument.

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2. It will be too expensive. I thought that was the point. What we have is too expensive and likely to become more so. Expensive or not we can fund the President’s plan, but it will mean imposing a small burden on those who have done well. Some oppose the imposition of such a burden as if it were a threat to national security. It isn’t. And the amount of the burden is unlikely to cause any hardship on those called upon to bear it. It certainly will cause no hardship comparable to that born by those who have no insurance. What does it mean to be a society if not that we will sustain each other in time of need, back each other up and share burdens? Do we want to live in an every-man-for-himself jungle of narrow self-interest? Disease would love it.

3. The level of care will suffer. I suppose that in some sense this is true. As a general proposition if you have a certain number of healthcare providers and you increase the number of people who are able to get healthcare the amount of time and resources available for each of them will decrease. From a societal perspective one would still have to determine whether the reduction in service level was worse than the existing failure to provide any service to many. But this contention is never presented in a neutral fashion. Rather we are “entertained” with anecdotes about people who died waiting in line for service or who died because a needed treatment was denied. Undoubtedly, such stories could be matched by those whose access to service or to specific treatments was delayed or denied under the current system. It could surely be matched by those who have no insurance. But why would we want to settle an issue of such fundamental national importance on the basis of anecdotes? The plain fact is that plans that provide for national health insurance have produced better results in infant mortality and longevity along with a host of other objective measures than our current system which relies on a hodge-podge of private insurers. That in individual cases there are lapses and shortcomings does not furnish a rational basis for rejecting the plan.

4. It will be a government-run program. This criticism is not intended as a mere description. It is akin to the contention that the program will lead us down the road to socialism. Its premise, as a criticism, is that the government cannot administer a program as well as a private business. This is a commonly held belief and beliefs are not very susceptible to rational discussion. My experience is that large bureaucracies, be they public or private, have advantages and disadvantages. Among the disadvantages are a lack of flexibility, a necessary reliance on procedures that naturally produce delays, and a tendency on the part of those within the bureaucracy to not appreciate that rules that sustain the internal functioning of the organization and give it cohesion and consistency often make little sense to those outside the organization. The advantages consist principally of economies of scale and the capacity to deal with large numbers of people. Many privately run bureaucracies are as institutionally unresponsive as government run bureaucracies. Of course, with government bureaucracies we do have some voice as they are answerable to our representatives. With private bureaucracies we have no voice. And, of course, government bureaucracies ostensibly have some purpose other than financial gain. When health concerns require a bureaucracy to take a loss in any given year government can do it. Private bureaucracies can’t. So, the “government-run” criticism is another I find unpersuasive.

5. Loss of Choice. I’ve been trying to figure out what choice I would be losing. True enough there are some choices I could do without. Everytime I’m faced with the plethora of plans offered by the phone companies I want to run and hide. How many minutes? How many text messages? Family and friends? Family and enemies? Friends and enemies? I don’t need the choices. You didn’t used to have to make them. There was the phone company. There was the Public Utilities Commission. And there was a phone in your house like everybody else’s and you paid what everybody else paid and I never heard anyone complain. Maybe it’s the cell phone that changed everything. It does mean no one has to plan anything anymore. Everything can be impromptu and subject to unremitting change. Virtually gone are pay phones and all the romance associated with them. Auto accident statisticians have a new category. But enough.

Like most people I get a plan through my employer. Sometimes they offer several and my choices are set out in a booklet forcing me to predict what my health needs will be. But the choices are definitively not negotiable. And once I’m in I’m stuck with it until the next enrollment period. The booklet is hard to read. It uses terminology I’m not particularly familiar with. It sets out the limits of coverage for various services and that would be fine if I had any idea what the services usually cost. If it’s an HMO, I am assigned a doctor or given two or three to choose from. I don’t know most of them and have found the recommendations of friends or fellow employees to be of unpredictable value. When I needed the attention of a specialist, my HMO doctor made a referral which the plan declined offering the doctor other specialists who were participants in the plan. He advised me against consulting with any of them and eventually left the plan because it wouldn’t allow him to refer patients to doctors he trusted. So I had to fork out cash to see the doctor he had recommended. That doctor gave me a prescription for medication that the pharmacist couldn’t fill without prior authorization from my insurance company. The insurance company wanted me to get a different drug and advised that the doctor would have to contact the insurer to tell it that the drug he prescribed was the one he wanted me to get. When I asked why my insurer thought the doctor would prescribe me that medication if it wasn’t the one he wanted me to get, I was told that it was just the insurer’s policy. That something is somebody’s policy seems these days to be the final answer. It reminds me of when you tell your kid that he or she has to do or not do something just because you said so.

Loss of choice can be a hard thing. I admit that. I’m just not feeling that I have a lot of choice right now and so the contention that I might lose it doesn’t have a lot of weight. Besides, and probably more to the point here, nobody who has insurance or wants to get insurance and exercise freedom of choice is kept from doing it under the President’s plan. You want to choose, fine. Choose. But if you don’t choose, you will get insurance. You are not going to be uninsured. So I suppose the loss of choice criticism amounts to losing the choice not to have insurance. For those so inclined, my sympathies. But, frankly, those who want insurance and can’t get it from any private plan are a much larger number. For them we need something.

6. The government and not you and your doctor will make your health care decisions. This amounts to saying that you can’t always get what you want. My doctor and I don’t make the final decision now. My insurer has to approve it. If it doesn’t and I don’t have the money to pay for it on my own, I don’t get the care my doctor and I decided on. If I’ve got the money to pay for it, then I will get that care. The government, as the insurer, will play the same role my private insurer plays now. It may approve it. It may not. If it doesn’t, I can write my newspaper, the tv station, and my elected representatives. Who do I write if my private insurer doesn’t approve it? In short, this criticism is applicable to every form of health care provision and, therefore, contributes nothing to an evaluation of any particular one.

7. If our health care system is so lousy why do people come here for care? This rather rhetorical question was thrown at me over a dinner conversation after I noted that the World Health Organization has placed our health care system at 37th in the World. We are neck and neck with Costa Rica. It has a sort of facts be damned ring to it with overtones of gritty stick-this-in-your-pipe-and-smoke-it no nonsense reality. Yes, indeed. Why do they come? A small amount of reflection will yield a solid answer. There is probably no place in the world where you can get better care than the United States. Obviously with certain treatments you can get the same quality of care in many places. But for some very specialized forms of treatment our medical establishment is at the very forefront. In the Olympics of medical treatment we could probably score gold in a lot of areas. But Olympic gold is not what we are after in designing a health care system. We are not interested in which country produces the fastest runner but rather which country produces the fastest population. The question is not what is the very best a country can produce but rather what is available to the average citizen given what the society spends. By this measure we have lagged seriously behind. And while people may come here for the most advanced medical care that can be offered this does not change the fact that of the fourteen wealthiest nations we have the worst infant mortality rate and the next to worst life span or longevity rate. At the same time we are spending almost 50% more per person than our closest financial competitor among the top fourteen and 250% more than the average expenditure per person among the wealthiest fourteen. Not much bang for our buck. Where is this money going? Much of it goes to administrative costs and studies make clear that as between private for profit hospitals, private non-profit hospitals and public hospitals the public hospitals have the lowest administrative costs (22%) and the private for profit hospitals have the highest (34%). Overall from 20 to 25 cents of every dollar we spend goes to administrative costs. A substantial cause of this is our complex multiple payer system. Another cause is our failure to furnish health care to all of our citizens. Among the developed nations we are the only one that fails to cover all of its citizens. As a result many conditions that are treatable or preventable if caught at an early stage, go untreated until they have advanced to the point where significantly more expensive care is necessary.

So, there they are these contentions I have found unpersuasive. I am waiting for one that has meat. But, to be honest, you may want to save your breath, because the portrait of our health care system that the facts paint is so ugly that almost any change would be good.

I have to say that I do not believe that reform of the structure is a panacea. Our diet is deplorable and our lifestyle stressful and sedentary. There is much we need to change, but since Reagan’s dismantling of our public health care system we have lacked both the institutions and the policies necessary to promote and direct that change.

For any useful exchange of ideas it is necessary that all parties agree that they might be wrong. My support of the President’s efforts to reform health care might be wrong. If it is, let me know why. Just don’t feed me any of the arguments I’ve already considered. As to them, I’m not wrong.