|Everybody's Got One
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Tuesday, January 27, 2004
Choosing two (at most) - or not
Fast. Cheap. Good.You've probably seen the sign in an understaffed office somewhere. Anyone who works in customer service wishes that people could have this basic trade-off pounded into their heads. Many service problems arise when the customer expects all three features, or really wanted a different pair than the provider thought were being requested.
For public goods, the priority list is
Universal. Affordable. Effective.Meaning, Choose one feature you want to focus on, one that you expect to get some or most of, and one that you won't get at all. Because of the greater scope and potential for friction in society-wide endeavors, you can't even get two out of three completely.
Some examples. For public education, our society has chosen Universal as the top priority. In second place is Affordable, because education is funded locally, usually by property taxes, and homeowners see their tax bills every year. As for Effective, well ... it's no surprise that schools are terrible. Not because they're asked to do too much, or the teachers' unions, or parental non-involvement, or popular culture (none of which help) but because of the fundamental choices our society has made about priorities and necessary trade-offs. (In Tom Daschle's memory-land of high-quality public schools, they weren't Universal. Schools were segregated, as Instapundit and others have pointed out, disruptive students were routinely suspended or expelled, and students who couldn't or didn't do the work didn't get social promotions and were not-so-subtly encouraged to drop out and find one of the plentiful unskilled jobs. None of those things would be acceptable today.)
For Social Security, we've also chosen Universal. But because we refuse to choose between Effective and Affordable, we're well on the way to getting neither. Social Security alone is not enough to keep anyone above the poverty line, and funding the Boomers' retirement is going to cause the budget to implode anyway. So not choosing a secondary priority only makes things worse.
For the arts and culture, we've chosen Affordable. Funding this stuff isn't anyone's top priority, but we pay for what we can. Second choice is Effective; what programs exist are generally pretty good, but there aren't many. Universal is off the table. Lots of communities have had to close library doors, or restrict hours or access; schools cut arts programs first when the budget starts to pinch, because it's not considered crucial. Some localities or Arts NGOs try to step up the Universality factor, usually with outreach programs that are shallow and less Effective, so that everyone gets just a tiny little taste with very little opportunity for follow-up or deeper appreciation.
For health care, we've chosen Effective. The American health care system is the best in the world, bar none, and improving every day. Second choice is Universal; but because it's the secondary priority we don't get all of it, and there are serious gaps. People without coverage get their treatment in emergency rooms and public hospitals, where the costs get passed on to other payees, sending Affordable out the window. But this is the way it has to be because of the choices made.
Whenever I hear someone complain that health care needs to be made Universal, or Affordable, or both, I want to sit them down and ask in all seriousness what they're willing to give up to get that. Not monetary costs, but systemic trade-offs. Do you want a rationed Canadian set-up where non-emergency appointments have 6- to 24-month waiting lists, where those who can, cross the border to get timely, high-quality American health care out-of-pocket? Do you want French hospitals that are unstaffed in the middle of a killing heat wave? Do you want Chinese or Cuban barefoot doctors with minimal training and minimal resources roaming the countryside to soothe the suffering of those they can't treat? Where do you plan to go to get top-quality health care when American society decides to no longer prioritize it? Where do you expect advances in treatment and medical technology and drugs to come from then?
Anyone who won't address this question of priorities and trade-offs is not a serious person, and their observations and proposals should not be treated with a seriousness they don't deserve.
For decades, the default Democratic party priority value has been Universality. Also for decades, the default Republican value has been Affordability. (Partly that's a consequence of being out of power, as born-again Democrat deficit hawks demonstrate, but partly it's a legitimately principled choice.) Where Bush is throwing a spanner into the Washington works is by becoming a champion of the Effective – and neither party knows how to deal with that, because it upsets their traditional assumptions and reflexes. Democrats think he's a right-wing extremist – which any rational observation of reality would contraindicate – because he's gone beyond arguing for Affordable and has come up with this crazy Effectiveness thing! Republican small-government conservatives think he's busting the budget just like any irresponsible Democrat would, if perhaps less enthusiastically, by extending the Welfare State even further.
But consider. No Child Left Behind has a Universalist name, but it's fundamentally an Effectiveness program – and Democrats are complaining now that it isn't Affordable, that the accountability mandates were unfunded, that the schools simply can't do it. Not as currently organized and prioritized, no; and that's the point.
Personal Savings Accounts would be far more Effective than Social Security at providing retirement income and private sector capital for economic growth – but Krugman and DeLong thunder that we can't Afford the transition. Not in a recession; but the time to float the idea is before the boom starts, not after it's peaked.
Prescription drug coverage for seniors isn't Affordable, Republicans say; it's another open-ended entitlement program that Democrats will expand and Universalize the minute they get back in power – and that's a legitimate concern. But the Effectiveness feature is that it's not a one-size-fits-all government program, but can have coverage tailored to an individual's usage and needs. This kind of product segmentation is something the private sector is actually pretty good at doing – and that government has (traditionally) been lousy at.
Maybe that can begin to change.
Update: More support for the Effective priority theory. Moneyquote:
The Left keeps screaming about how dim George Bush is, but in the meantime, he has illuminated one area of public life after another with immensely talented and articulate people.
posted by Kelly | 11:10 AM link