In Praise of Tinkering: Health Care Reform

By Joe Campbell
January 6th, 2010

Critics of the health care reforms before Congress can be divided into two camps:

  • those who claim that the legislation would simply be a “government takeover” of one sixth of the economy – which is simply nonsense; and
  • those who claim the bill doesn’t do enough, that it doesn’t have an overarching theory, that it merely “tinkers” with the problems with health care.

I won’t be dealing with the nonsense claim today. As to the second claim, I concede that the bill merely tinkers with solutions to our problems – but that is the main reason I am optimistic about its success.

Not everyone feels this way: Opponents use this perception to attack the bill from both the left and right, some on each side seeking to make the case for more radical changes and some for leaving things as they are. The Iowa State Senate Democrats wrote, “As a nation we can not continue to tinker with health care reform.  We must make major transformations.” Donna Edwards warned that the health care reforms being debated without a public option were “just tinkering around the edges.” Then from the right, there are those pressing the radical measure of ending Medicare and Medicaid and every other government involvement in health care – and those who favor allowing insurance to be sold across state lines which would eradicate most regulations as states raced to the bottom to attract the insurance industry. Others say that the bill’s modesty is a reason to give up, lest by trying to fix things we mess things up more. A conservative editorial claimed that “tinkering with a mess only makes a prettier mess.” Chairman of the RNC Michael Steele meanwhile made it his mantra to claim that the Obama administration is “conducting a dangerous experiment” and a “risky experiment with health care.”

Even many of those defending the bill seem disappointed but resigned to its modesty. They often blame Obama for deferring to Congress rather than proposing his own legislation, presuming that if the Obama administration took a stronger hand in shaping the bill it would have a grand logic, a coherent and fully formed strategy for universalizing health insurance and curbing health care costs. (Though the bills now under consideration are almost exactly what Obama proposed during his campaign.)

This perception of mere tinkering rather than some grand social engineering project has been the bill’s political weakness. Without a coherent big idea or story to sell the plan, it created an opportunity for Republicans to take each individual part and make it a bogey-man for some big idea that they would claim was the real reason for the reform: rationing! euthanasia! government-mandated abortion! socialist indoctrination of your children! &tc. Later, progressives, feeling betrayed at the demise of the public option which many had considered the real reason for the reform, and similarly unable to find the big idea behind the plan, quickly settled on the idea that it was a bailout to the insurance industry.

But despite these political disadvantages, a bill that is modest enough to tinker is the best policy solution. This approach is epistemologically modest – it seems designed to avoid hubristic assumptions about the power of government and to take advantage of the process that Nassim Nicholas Taleb called “black swans

Trial and error will save us from ourselves because they capture benign black swans. Look at the three big inventions of our time: lasers, computers and the internet. They were all produced by tinkering and none of them ended up doing what their inventors intended them to do.

This idea of tinkering imbues all of Obama’s policies and his governance so far. It represents a synthesis of the core conservative critique of Reagan, Hayek, &tc with an empirical approach towards government generally favored by liberals. In other words, Reagan correctly saw that there are limits in how well government can address societal problems – as liberal projects of social engineering backfired. He demonized it in his affable way, for example claiming that “The ten most dangerous words in the English language are ‘Hi, I’m from the government, and I’m here to help.’ ”

Barack Obama absorbed this critique – and saw the limits of centralized planning and the power of markets that lay at the core of Reagan. But he did not adopt Reagan’s visceral hatred for government. Instead, he believed government could be useful. Rather than seeing government as something that needed to be attacked, he adopted Hayek’s view that “we needed to think of the world more as gardeners tending a garden and less as architects trying to build some system.”

As I wrote as part of my summing up of the case for Obama last November:

Tinkering is the best we can do in a world we only imperfectly understand. Anyone looking at Obama’s policy proposals can see that he is a tinkerer rather than a revolutionary. For example, he seeks to build upon our current health care system rather than demolish it as McCain does in one manner and socialists do in another.

With the impending fiscal crisis upon us, driven by rapidly rising health care costs, the primary goal of the reform has been to cut costs. (Which counter-intuitively actually is aided by universal coverage, as even the libertarian Nobel-prize winning economist Milton Friedman acknowledged.) A number of health care experts have similarly praised the current health care reform effort for its modest but positive steps coupled. Atul Gawande in an influential piece in the New Yorker asks: “The health-care bill has no master plan for curbing costs. Is that a bad thing?” He concludes:

Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf though it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

After the Senate released their version of the bill, health care expert Jonathan Gruber was quoted:

My summary is it’s really hard to figure out how to bend the cost curve, but I can’t think of a thing to try that they didn’t try. They really make the best effort anyone has ever made. Everything is in here….I can’t think of anything I’d do that they are not doing in the bill. You couldn’t have done better than they are doing.

Health care reform is the clearest experiment testing whether the government can work by properly aligning incentives rather than brute, centralized takeover.* It is an attempt to tinker with our unsustainable system – which on its own would be “sure to raise your taxes, increase your out-of-pocket medical expenses, swell the federal deficit, leave more Americans without insurance and guarantee that wages will remain stagnant” – rather than to demolish it and start anew.

It isn’t as exciting as some grand effort to re-shape 1/6th of the economy or a moral crusade to help those being victimized by evil private industry. Rather, it is a bet that out of a million pilot projects, something will help and we will be able to see that it does, and adapt it to a larger scale. It is a bet that it is better to expand health insurance as much as possible and to establish it as a universal right and responsibility than to wait for something better. It is a bet that government can improve things, while acknowledging that unintended consequences will ensue and it should tread carefully. It isn’t the exciting rhetoric of Change You Can Believe In! – but it is a step towards change we can believe in.

Update: I would propose this explanation – of tinkering and epistemological modesty is a better explanation than either of the two described by Ed Kilgore in a very interesting piece for The New Republic:

To put it more bluntly, on a widening range of issues, Obama’s critics to the right say he’s engineering a government takeover of the private sector, while his critics to the left accuse him of promoting a corporate takeover of the public sector.

* Though sometimes, brute, centralized government takeover is best – the military and the courts being two items like this everyone could agree on.

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