So I don’t really understand how the current legislation or any of the ideas currently in circulation are really supposed to help anything. Requiring continuity of coverage, preventing discrimination based on existing conditions, and (above all) forcing plans to include preventitive care all make a good deal of sense to me. That last one, especially, is the only thing that really stands out to me as a way to both cut costs and improve outcomes.

But how are these things going to be enforced, really? I haven’t been able to figure that out. If the evil, evil health insurance industry is as nefarious as Rachel Maddow had led me to believe it seems like they will game whatever accountability mechanisms are set up. Even now refusals of coverage are often unjustifieid or illegal but the sick folk don’t know what their recourse is.

And then this public option bit. Would it keep costs down? Hard to say! Isn’t the funamental assumption there that there really is a big anti-competitive conspiracy? I.e., it’s possible for insurers to be profitable but charge less and cover better but they don’t do it because there’s no market pressure? That’s a hefty accusation and if it’s the case it seems like there should be ways to make the market competitive without the politicaly contentious and (in all honestly) bureaucratically nightmarish public option.

I like the presentation of the public option as offering the post office of health care: a government subsidized minimum alternative. But health care is a bit more complicated than sending packages. And if there were no post office and FedEx and UPS were charging a lot to ship packages because it was really expensive to ship packages for stupid reasons then offering a government subsidized alternative doesn’t really…fix much.

And that is in fact the case! The more I try to figure out what the hell is going on the more it becomes overwhelmingly apparent that the fee-for-service model makes health care in the US ridiculously expensive and bad.

What if the postal service and private delivery companies actually employed the same set of regional delivery people? And what if these delivery people charged based on which tests people demanded be run on their mail? And what if these delivery people stood to make lots more by convincing the mail insurance providers not to cover things like nutrition so that they could sell people hell of diabetes meds when they are too fat to be shipped?

Or whatever.

The analogy breaks down because there’s not a great way to simplify or reduce the situation. There’s not even a great way to hover above the problem and offer platitiudes about requiring better behavior by the alleged bad guys or some more benevolent “public” option without avoiding the basic massive screw ups that make the health care system/market such a tragic mess.

LET’S PAY DOCTORS AND OTHER HEALTH PROVIDES BASED ON HOW GOOD A JOB THEY DO. LET’S NOT PRETEND THAT YOU AND YOUR RANDOM FAVORITE DOCTOR MAKE THE BEST DECISIONS JUST BECAUSE THAT IS WHAT PEOPLE SEEM OBSESSED WITH BELIEVING. LET’S MAYBE CONSIDER THE THING MCCAIN WAS INTO ABOUT HOW THE EMPLOYER PROVIDED HEALTH CARE SETUP IS A BIG MARKET DISTORTION THAT DOESN’T MAKE A LOT OF SENSE.

“Does Barack Obama want to pull the plug on Grandma?” OH NO THEY ARE DISTRACTING FROM THE REAL DEBATE ABOUT HOW REPUBLICANS ARE TRYING TO RUIN OBAMA’S PRESIDENCY! “Death Panels?” PUBLIC OPTION! “Is it OK to bring a gun to a town hall?” ASTROTURFING!

I guess I’m not allowed to have a point here. It would be “crazy” to suggest a higher level of national discourse. Why would I want Obama to do something as politically self-destructive as be even more wonkish and talk not just about confusingly specific goals but actually go into detail about how particular policies would play out?

And wait, the defecit? Can’t we just spend the stimulus money on this? No, of course not. That money is for…helping the economy? Isn’t a big part of the left’s argument that a non-shitty heath care system would…help the economy? Isn’t that, like, the entirety of the answer to the CBO “scores” that say the current bills would “bankrupt” (?) the government (which a few months ago could print money with magical “quantitative easing”, or something)? No, no, YOU’RE CHANGING THE ASSIGNED PARAMETERS OF THE DISCUSSION. (I’m not suggesting that the stitumlus funds be retroactively reallocated to health care, just that the standards of evaluation in terms of things like the defecit seem so wildly uneven. There’s even talk of a second stimulus bill. Maybe there’s better stimuli than improving health care but birds? stones?)

Please feel free to tell me where I am wrong because I almost certainly am. I have made only sporadic attempts to “understand” what is going on because it seems awfully difficult. My conclusion is basically that the discussion is broadly speaking incoherent because it addresses such fundamental flaws with our social and economic system that it can only be had safely by randomly holding related but insane things constant so that no one gets to reasonably say “Wait, isn’t the whole thing just totally fucked from top to bottom? What about we burn it down?”