I. Squeezing Blood from a Stone

(This is part of a series: start here if you please.)

I have in the past recommended the fantastic book Policy Paradox by Deborah Stone. Besides being excellent, it had an outsized impact on me as a young convert to public policy from the staid world of physics. It coaxed me to abandon naïve ideals of policy as some sort of quasi-science mucked up by the messiness of political decision-making. It opened my eyes to the fascinating, unsettling reality that even (apparent) facts and figures are at their heart political/philosophical questions. This was the start of a fundamental shift in my worldview from which I've never quite recovered.

Much of the book is structured around Stone’s conception of political philosophy as a dichotomy between two philosophical constructs: the Market and the Polis. She didn’t capitalize them but, for allegorical purposes, I will. 

For many reasons, this Manichean picture of political decision-making strikes me as an apt model for understanding the two pre-eminent dueling narratives about the future of the American health system. Two competing philosophical visions of what health care can (and should) be. Delightful!

One centered on the individual and driven primarily by self-interest, the other oriented around the community and motivated primarily by the public interest. A key difference between the two is that in the latter “system” is not a structure that emerges merely from the myriad interaction of individual rational actors making decisions against some structured backdrop, but rather is a deliberate and purposive creation:

It would be as much a mistake to think that the market has no concept of public interest as to believe that the polis has no room for self-interest. But there is a world of difference between public interest in a market and a polis. In theory, the public interest or general welfare in a market society is the net result of all individuals pursuing their self-interest. In economic theory, given a well-functioning market and a fair initial income distribution, whatever happens is by definition the best result for society as a whole. In a market, in short, the empty box of public interest is filled as an afterthought with the side effects of other activities. In the polis, by contrast, people fill the box intentionally, with forethought, planning, and conscious effort.

The Market and the Polis distinctions characterize so many political-policy debates and health care is no exception.

For our purposes (considering the next steps in extending and improving upon the Demi-Decade of Cost Control), each primarily attacks a difference piece of the health care cost equation. When we think of costs we’re really thinking of health care spending, both in the aggregate (national health expenditures) and in our personal lives, when it comes to how much money flows out of our wallets and paychecks and into the health sector.

But, at the risk of oversimplification, cost is the product of how high the price is and how much we need to buy: 

The Market and the Polis distinctions characterize so many political-policy debates and health care is no exception. And they correspond loosely to the prices and quantity consumed components of this not-quite-real equation, respectively. I believe they give us the best window on the two prevailing theories of how we ought to go about maximizing quality while minimizing costs.

Onward to the Polis.