I know it may seem like I (and many others in the lefty blogosphere) spend a lot of time slamming David Brooks -- after all, he's just a guy paid (a whole lot of money) to sling bullshit a couple of days a week at the nation's paper of record and on various public television and radio outlets. But it is for precisely that reason -- he's the thinking man's conservative, the reasonable one, the guy the Obama Administration wants to appeal to -- that makes him far more consequential than he ought to be, and hence, a suitable target for all of the derision heaped upon him.
Today he has a column that demonstrates once again how little substantive knowledge he brings to the table and the degree to which he is simply a sly right wing propagandist. (Contrast Brooks with someone like Ezra Klein, who has actually done the hard work of studying and mastering arcane detail about the day to day workings of our health care delivery system and those of other countries.) Brooks, in his encomium to Chief Justice Roberts' sense of restraint, proclaims that we are now ready to proceed with the real nuts and bolts debate of how to furnish health care coverage to people. He proclaims:
Liberals tend to argue that major structural changes can be made within the framework of Obamacare. Republicans tend to believe that the perverse incentives can only be corrected if we repeal Obamacare and move to a defined-benefit plan — if we get rid of the employer tax credit and give people subsidies to select their own plans within regulated markets.
He then goes on to state in the very next paragraph:
Personally, I think the Republicans’ defined-contribution approach is compelling. It’s a potentially effective way to expand coverage while aligning incentives so that people make cost-conscious, responsible decisions. But the truth is neither I nor anybody else really knows what works. We’re going to have to go through a process of discovery. We’re going to have to ride the period of rapid innovation that is now under way.
The truth is David Brooks doesn't know what the fuck he is talking about as "defined benefit plans" and "defined contribution plans" are opposite approaches to funding something -- and neither are traditionally thought of as approaches to financing health care.
Defined Benefit Plan is a pension term of art describing a traditional retirement program where a participant is assured a guaranteed monthly income for life (and often the life of his/her spouse), with the monthly benefit based on some defined formula attributable to years of service. I have never seen it used in the context of a health plan and I've been doing work for union health plans for 27 years.
Defined Contribution Plan is also a pension term of art describing an individual account retirement arrangement, like a 401(k) plan, where one gets at the end of one's career a payout of the amounts that you or your company contributed, plus any investment earnings thereon. There are no guarantees of what that amount will be and no assurance that the amount saved will be adequate to last until one's death. Again, this is not a term that I have seen associated with health plans as a general rule.
A defined contribution approach to health care would be, I suppose, one in which an individual sets aside a certain amount of money to cover actual health care costs incurred over time. This is a spectacularly bad idea and one at odds with the entire historical concept of insurance, which is all about socializing risk. Anyone who has worked with health plans knows that roughly 20% of the covered population will incur about 80% of the costs. (And you should thank whatever deity you thank if you are not among that 20%.) Catastrophic health occurrences are not evenly distributed and they are very often simply random events that victimize people for no particular reason. (I know any number of people who at young ages have suffered from cancers or other genetic diseases that were immensely expensive to treat and that were in no way related to unhealthy behaviors -- not that I think the latter should matter.) If this is what Brooks and the Republicans are advocating, it is a terrible idea.
Finally, the notion that we don't know what works in this realm or that there is some great mystery about controlling costs is simply nonsense. There are any number of models out there of how to run a health care system more cheaply than we do in the U.S. and with universal care provided. Brooks can choose to ignore this as they are all in some form or fashion examples of national health care, but the notion that this is all shrouded in mystery is just more bullshit from the master. The issue addressed by the ACA is trying to cobble together a system that approaches universality and bends the cost curve down without arousing too much opposition from insurers, hospitals, providers, and the pharmaceutical industry. It is complex out of political necessity, not because health care delivery needs to be complex. Brooks' fellow Republicans have made cost containment more difficult by their demagogic campaigns against "death panels" and the "$500 billion cut from Medicare by Obama," i.e. cuts to Medicare Advantage providers, all the while plotting to impose significantly larger obligations on individuals to pay for health care as necessary "skin in the game."
The bottom line is that this latter approach will only serve to further deny needed care to people, while doing nothing to promote universality or contain costs. In this policy debate, the right (and Brooks) literally have nothing to offer.
Lastly, I note that Brooks has the old "tort reform" canard in his column. This ignores consistent findings that malpractice suits do not add significantly to the cost of medicine as well as the fact that many states, like Texas and Florida, have already enacted tort reform -- seemingly without any boost to getting people insured. My question is how can all of these principled federalist take the position that Congress has the power to legislate on tort law, an area that has traditionally been the province of the states, when it cannot dictate terms to states under Medicaid?