David Brooks has done what seems to me a balanced piece on the fundamental philosophical issues underlying the current debate on reform of entitlements, role of government,etc. I find myself less reflexively opposed to his conservative sympathies after reading his description of different strategies for effecting change. The basic issue boils down to "What is the best mechanism for effecting change in enormously complex social systems." Brooks, in the tradition of the British philosopher Oakeshott (seems to me he should have referenced his own essay on Oakeshott), thinks that decentralized bottom-up market based solutions are the best way to reform medical care, noting that
...competition-based plans (favored by Republicans) have improved outcomes in many places. Such plans cover employees of the University of California and state employees in California, Wisconsin and Minnesota. They also note that the Medicare prescription drug benefit also uses a competition model. Consumers have been adept at negotiating a complex marketplace, and costs are 41 percent below expectations.The alternative (liberal, Democratic) view is that the best mechanism of change is top-down control that
...seeks to concentrate decision-making and cost-control power in the hands of centralized experts. Under the Obama health care law, a team of 15 officials will be created to discover best practices and come up with cost-cutting measures. There will also be a Center for Medicare and Medicaid Innovation in Washington to organize medical innovation. Centralized officials will decide how to set national reimbursement rates.They argue that
Health care is phenomenally complicated. Providers have much more information than consumers. Insurance companies are rapacious and are not in the business of optimizing care.Brooks:
...there is no dispositive empirical proof about which method is best — the centralized technocratic one or the decentralized market-based one. Politicians wave studies, but they’re really just reflecting their overall worldviews. Democrats have much greater faith in centralized expertise. Republicans (at least the most honest among them) believe that the world is too complicated, knowledge is too imperfect. They have much greater faith in the decentralized discovery process of the market.So here we go, another either/or Manichean kind of presentation... maybe we should reference a biological model, take a lesson from how our brains organize our behavior, both from the bottom up AND from the top down, with feedback loops continually connecting the two.