Coyote Blog

David Zetland sent me this writeup on a plan I had not heard of -- apparently Amtrak has a $150 billion plan to improve speeds on the northeast corridor

Take, for example, Amtrak's proposal to bore a 10-mile rail tunnel underneath Philadelphia. As Steve Stofka, a transport blogger, explains, this proposal would require the most expensive type of tunnel imaginable—"It is freaking expensive to bore a ten-mile-long tunnel through an alluvial floodplain under a highly urbanised area—and to maintain it, since it will reside below the water table," Mr Stofka writes. At $10 billion, he notes that the project would be about three times as expensive per mile as the Gotthard Base Tunnel under the Swiss Alps. And all this is for marginal improvements in speed and access. The tracks around and through Philadelphia aren't, generally, big obstacles to high-speed rail—the tunnels in and around Baltimore, Maryland are. It would be much cheaper to replace Baltimore's terrible tunnels than to build a fancy new one under Philadelphia.

The Philadelphia tunnel, unfortunately, isn't even the worst part of Amtrak's plan. That honour goes to a $7 billion renovation of Washington's Union Station (pictured), which Slate's Matthew Yglesias rightly calls"insane".

From Mickey Kaus:

Democratic blogger Ezra Klein appears to be positioning Dem health care reforms as a way to cut costs, on the grounds that a reformed system will be able to make "hard choices" and "rational" coverage decisions, by which Klein seems to mean "not providing" treatments that are unproven or too expensive--when "a person's life, or health, is not worth the price." Matthew Yglesias' recent post seems to be saying the same thing, though clarity isn't its strong suit. (He must have left it on Journolist.)

...

The "rational," cost-cutting, "hard-choices" pitch isn't just awful marketing--I don't even think it's accurate. Put it this way: I'm for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling's example of a young patient with cancer, where "the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200." No "rational bureaucracy" would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life.  But I think the government--faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public's sentimental bias toward life--is less likely to be "rational" than the private sector.

That is to say, the government's more likely to pay for the treatment (assuming a doctor recommends it). So it's government for me.

He comes oh-so-close to getting it right, but then falls short.

Klein is right that the pressure will be to ration care -- we already see such rationing being seriously considered in Massachusetts (the model of choice for Democrats) under the weight of massive expenditures.

But Kaus is correct that if some high-powered and well-funded interest group gets behind a certain procedure, cost-effective or not, the government overlords of the program will likely approve it.   As a result, for example, no potential treatment for breast cancer will ever be denied given the proven strength of women's groups lobbying for breast cancer treatment (already, breast cancer research is hugely over-funded vs. other diseases given its mortality, due in large part to this powerful lobbying).

But it is not one dynamic or the other.  Both will exist.  There will be huge pressures to cut back somewhere, as costs skyrocket.  And there will be huge pressure from certain interest groups to fund treatment for certain diseases in unlimited amounts.  The result will not be, as Kaus posits,  that everything will be funded more than it is today -- the result will be that certain procedures and conditions with strong lobbying and political muscle will get funded more, with the difference being made up from cutting funding for conditions and procedures without a well-organized lobby.

Access to care will no longer be determined by money, but by political pull.  (Yeah, I know, it's Ayn Rand's world and we all just live in it).

The best answer, of course, as to why single-payer is bad is that the single-payer will not be me, and therefore will not make trade offs about my health, money, time, etc. in the same way I would.  One of the many problems with polling on issues like this is that someone asks a question like "Are you satisfied with your health care" and when XX% of people say "no", the person using the poll goes on to postulate that the people are dissatisfied for Y reason.  But people may be dissatisfied for many reasons.  For example, I know that many people's main source of dissatisfaction is that their current insurance company was callous in rejecting them for so-and-so procedure.  But do they really think the government is going to be less callous?

Unfortunately, this best answer does not seem to be getting anywhere, so I will offer another answer.  Single payer health care will almost certainly lead over time to single provider health care.  What is my evidence?  Well, that is what happened in K-12 education.  And note the very very strong opposition to migrating education from single-provider to single-payer by the exact same people who are the intellectual driving force for some kind of massive new federal intervention in health care.  Kevin Drum and Matthew Yglesias both argue that single payer is inherently unfair.  So get ready, Walter Reed and the Post Office may soon be teaming up to provide your medical care.