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Wednesday, March 29, 2017


The fetish of choice

by Tom Sullivan

Unquestioned assumptions abound in political debate, but the relative advantage of more choice is one that is both ubiquitous and rarely challenged. More is better. End of discussion. At The Week, Damon Linker looks at how Paul Ryan's trying to sell health care reform on choice doomed it. Ryan's American Health Care Act (AHCA) treats patients as consumers looking for the best bargain:

It's hardly surprising that Ryan took this approach. The right is obsessed with the cost of health care, both for individuals and in the aggregate, and it believes that spending can be most effectively contained by increasing options and competition. That makes choice a means to the end of cost savings. Then there's the fact that the right also makes a fetish of choice for its own sake. It's simply better, apparently, for individuals (acting as consumers) to have more insurance policies, doctors, and hospitals to choose from.
It is also more tedious. Quite frankly, I hate shopping. I don't mind going out and buying when I already know what I want, but I hate shopping. Loathe it. When on rare occasions the mood strikes, I go out and buy what I need for the next year so I won't have to shop again for months. The Paul Ryans of the world insist I spend the rest of my life doing what I hate simply because it fits the ideology of their economic cult.

Linker points to a 2011 post by Bloomberg View economist Noah Smith who found the toll constant transaction costs take in a culture where they are everywhere. If private everything is better, Japan must be a libertarian paradise, Smith mused:
For example, there are relatively few free city parks. Many green spaces are private and gated off (admission is usually around $5). On the streets, there are very few trashcans; people respond to this in the way libertarians would want, by exercising personal responsibility and carrying their trash home with them in little baggies. There are also very few public benches. In cafes, each customer must order something promptly or be kicked out; outside your house or office, there is basically nowhere to sit down that will not cost you a little bit of money. Public buildings generally have no drinking fountains; you must buy or bring your own water. Free wireless? Good luck finding that!

Does all this private property make me feel free? Absolutely not! Quite the opposite - the lack of a "commons" makes me feel constrained. It forces me to expend a constant stream of mental effort, calculating whether it's worth it to spend $4 to sit and rest for 10 minutes, whether it's worth $2 to get a drink.
Linker extends that experience into the realm of medical care:
As options proliferate, individuals face the need to choose among a growing list of high-stakes possibilities. Should I opt for catastrophic coverage that costs less but allows me to see a doctor only if I'm in a severe car accident or suffer a heart attack? Should I purchase something more expensive that will enable me to make an appointment if I'm merely running a fever, worried about the occasional tightness in my chest, or concerned about the mysterious lump in my neck? Or should I take on the enormous medical and financial risk of foregoing coverage altogether?

If I opt for little or no coverage, I'm gambling that I'll be lucky. If I win that bet, the choice will be retrospectively vindicated. But if I'm unlucky, the choice will seem horribly foolish, contributing either to much worse medical outcomes, much worse financial consequences, or both. If, on the other hand, I opt to pay for maximal coverage and I get sick, I'll feel wise. But if I stay healthy, I'll likely end up feeling like a sucker who's wasted enormous resources just to ease my mind.
Sometimes I don't need or want more choice. Yes, I can have a coffee maker that is also a timer, an alarm clock, satellite radio, and that starts and warms up my car on cold mornings. But all I really wanted was a cup of coffee.

It is also hard to escape the feeling that the fetishizing of choice comes from people who fancy themselves more savvy than their neighbors. “I’m, like, a really smart person” types. Your basic social Darwinists who imagine themselves at the top of the social order and who would like to structure it so they stay there. Imagine how a confusing array of choices might make it easier for them to fleece their neighbors, especially when the neighbor's child is in distress or the, uh, "consumer" faces a medical emergency. If Americans wanted to shop for "best buys" in medical care, they'd already be selling it through big box stores.

Which is why a single-payer health care system makes more sense, Linker writes, "everyone pays in, and everyone is eligible for benefits. Choice has nothing to do with it." A medicare for all system that leaves no American behind. But who would propose a system like that?