Obamacare: On a Slippery Slope to Where?

Slippery slope arguments are often derided as inherently fallacious. As my friend and colleague Eugene Volokh has pointed out, however, there are a number of situations in which slippery slope arguments are perfectly valid. Sometimes the first step down a slope reduces the costs of taking the second step, which reduces the cost of taking a third, and so on. Alternatively, sometimes a seemingly desirable first step creates a situation in which not taking the second step is too costly. A different type of slippery slope exists where the first step changes attitudes, making a second step seem less objectionable. A related phenomenon is suggested by the parable of the boiled frog: A frog put in cold water can be boiled because it becomes desensitized to gradual changes in termperature.

Obamacare potentially entails both types of slippery slopes. As we take the first step down whatever road Obamacare puts us on, it may become too costly not to take a further step designed to control health care costs. A first step down this road may also start a process by which people become desensitized to the growth of government control.

Obamacare also could trigger what Volokh calls a "political power slippery slope." Sometimes an initial change shifts the political balance of power in favor of proponents of taking the second step. Obamacare will create new special interests favoring government intervention as well as creating a new dependent class that acts as a constituency for ever increasing benefits. As Volokh observes: "People who become users of a valuable government service become a constituency for political decisions that preserve and expand this service."

In addition, however, Obamacare also illustrates yet another situation in which slippery slope arguments are valid; namely, the case in which the proponents of taking the first step intend to keep pushing us down the slope. Again, I quote Volokh:

... movements rarely just disband after a victory. Successful movements often have paid staff who are enthusiastic about pushing for further action, and unenthusiastic about losing their jobs. They have experience at swaying swing voters. They have an organizational structure, media contacts, and volunteers and contributors. It seems likely that they will choose some new proposal to back.

This possible slippage seems likelier still if the pro-A movement’s leadership is already on the record as supporting a broader proposal B. For instance, many leaders in the gun control movement have publicly supported total handgun bans, even though their groups are today focusing on more modest controls; and some gun control advocates have specifically said that their strategy is to win by incremental steps. Likewise, if a group’s proposal is so modest that it seems unlikely to accomplish the group’s own stated goals, then one might suspect that a victory on this step will necessarily be followed by broader proposals—which might be more easily implemented because of the momentum created by the first step. In such cases, foes of B may well be wise to try to block A, rather than wait until the pro-B movement has been strengthened by a success on A.

This is precisely the problem with Obamacare.

Paul Begala was quite explicit on this point in a recent op-ed:

I am a proud progressive Democrat, someone who believes affordable, quality health care is an economic necessity and a moral imperative. ...

Progressive politics is, in my view, a movement, not a monument. We cannot achieve perfection in this life, and if that is our goal we will always be frustrated. ...

Our history teaches us otherwise. No self-respecting liberal today would support Franklin Roosevelt's original Social Security Act. It excluded agricultural workers -- a huge part of the economy in 1935, and one in which Latinos have traditionally worked. It excluded domestic workers, which included countless African Americans and immigrants. It did not cover the self-employed, or state and local government employees, or railroad employees, or federal employees or employees of nonprofits. It didn't even cover the clergy. FDR's Social Security Act did not have benefits for dependents or survivors. It did not have a cost-of-living increase. If you became disabled and couldn't work, you got nothing from Social Security.

If that version of Social Security were introduced today, progressives like me would call it cramped, parsimonious, mean-spirited and even racist. Perhaps it was all those things. But it was also a start. And for 74 years we have built on that start. We added more people to the winner's circle: farmworkers and domestic workers and government workers. We extended benefits to the children of working men and women who died. We granted benefits to the disabled. We mandated annual cost-of-living adjustments. And today Social Security is the bedrock of our progressive vision of the common good.

Health care may follow that same trajectory.

Begala's not alone on the left in seeing Obamacare as the proverbial camel's nose. Based on his past pronouncements, there's good reason to think Obama himself views it as such:

For example, there's a video being circulated online of Barack Obama telling the Illinois AFL-CIO in 2003, "I happen to be a proponent of a single payer universal health-care program . . . we may not get there immediately" and then telling an SEIU Health Care Forum in 2007, "I don't think we're going to be able to eliminate employer coverage immediately. There's going to be some transition process. I can envision a decade out or 15 years out or 20 years out where we've got a much more portable system."

It may be the case that there are liberals, like our old friend Kevin Drum, who would settle for "basic care funded by taxes, with additional care available to anyone who wants to pay for more. France and Holland, not Britain or Canada," is their model.

But James Joyner points out that there are also an awful lot of Begalas out there:

Many of the leaders of the pro-reform side are rather dishonest in their presentation, however. They insist that what’s written in the bill should be the limit of legitimate debate when, as Kevin admits and Obama once did, single-payer is the ultimate goal. The current “as much as we can get” measure is not only a step in that direction but one that will make it inevitable over time as it kills off the existing system of employer-financed insurance. So, while it’s dishonest to argue against the proposed legislation as if it were NHS-style “socialized medicine,” it’s perfectly legitimate to treat it as HillaryCare Returns.

Personally, I would not oppose modest reforms along the lines Whole Foods CEO John Mackey recently proposed.

But only if the legislation contained strong institutional barriers to taking the second step on the slippery slope to "NHS-style 'socialized medicine.'"

The trouble is that slippery slopes in politics appear to obey the same laws of physics that control friction in real-world slopes; in both cases, it takes more energy to start something sliding than it does to keep it sliding once it gets moving. Designing an effective and credible obstacle to taking the next step beyond Obamacare to "NHS-style 'socialized medicine'" is a nontrivial task. Maybe it's possible. But until somebody proves to me that is possible, I for one intend to continue opposing taking the first step.

Update: Megan McArdle has also been blogging about the "camel's nose" problem and more recently explains that:

My objection is primarily, as I've said numerous times, that the government will destroy innovation.  It will do this by deciding what constitutes an acceptable standard of care, and refusing to fund treatment above that.  It will also start controlling prices.

Now, at this point in the discussion, some interlocutor starts chanting what I've come to think of as "the mantra": othercountriesspendlessandhavelongerlifespans.  Then they ask me how I can ignore the overwhelming evidence that national health care is superior to our terrible system.  Now, what's odd about this is that all of those countries do precisely what I am concerned about:  slap price controls on the inputs, particularly pharmaceuticals.  Their overwhelming evidence indicates that I am 100% correct that a government run system in the US will  destroy the last really profitable market for drugs and medical technology, and thereby cause the rate of medical innovation to slow to a crawl.

If she's right, and I believe she is, the rest of the world will come to regret Obamacare. They've been free riding on US health care consumers whose high costs have subsidized innovation that then spreads throughout the world.

The point is nicely illustrated by a WSJ op-ed by Universal Health Services CEO Alan Miller, who writes:

My company's experience with health care in the United Kingdom illustrates the point. In the 1980s, we opened The London Independent Hospital to serve the private medical market in the U.K. The hospital had not been open long when representatives of a 1,000-bed government-run hospital located a short distance away approached us to borrow high-tech equipment and instruments. Because people were ill and needed procedures the government hospital could not provide, we provided that hospital with the help it needed. But that experience convinced me that under a single-payer system hospitals do not receive the money required to purchase advanced technology or provide quality care. ...

The reality is that Americans have come to expect the best health care in the world, and to provide that, hospitals must continue to invest in advanced medical technology, salaries for well-trained nurses and technicians, and state-of-the-art facilities. If hospitals were required to operate solely on revenue from a single-payer system, they could no longer afford to provide the care that Americans deserve.

The government run UK hospital quite literally depended on medical innovation financed by US-style private health insurance. Once the US starts down the slippery slope from Obamacare to the NHS, where will innovation come from?

It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their self-love, and never talk to them of our own necessities but of their advantages.

Ditto medical advances. Reduce profits, reduce incentives, reduce innovation.

Comments

[pireader]

Professor Bainbridge --

You've got a theory that President Obama's national health-insurance proposal could lead us down a slippery slope.

That theory applies equally well to the dozens of other developed countries around the world that have had national health insurance for decades. But none of them took the path that your theory anticipates ... which suggests strongly that it's a bad theory.

[JR]

"" But only if the legislation contained strong institutional barriers to taking the second step on the slippery slope to "NHS-style 'socialized medicine.'" ""

You mean other than the filibuster, the extensive ties between the health insurance industry and the Democratic party, and the fact that even with 59% of the House and 60% of the Senate and the White House the best this half-hearted excuse for a party can come up with is a non-universal, non-single payer mushy compromise that won't even have the same authority as Wal-Mart to negotiate drug prices?