I spent a good portion of one of my mornings last week in a meeting. That part is not unusual. What was unusual was the topic: I’m on a committee that has the unenviable task of evaluating my employer’s health care coverage and sorting out competing offers from insurance companies who say, very earnestly, that they want our business but don’t seem to be all that interested in giving it to us at a price any of us can afford. This week we’ll double our pleasure (maybe even quadruple it) when four separate insurance companies come to town to pitch their products to us. They say they’ll be serving lunch that day, but I’m hoping for something stronger.
Sitting through the meeting last week I couldn’t help but flash at times to thoughts about our education system and where it may be headed. It seems reasonable to me to think that the health care “industry,” as we call it, offers a cautionary tale for those of us concerned about the future of public education. Let me see if I can explain what I mean.
We all probably know the outlines of the problem where health care is concerned: health care costs have been accelerating at an unsustainable pace, and finding a way to ensure that everyone has affordable coverage is becoming more and more difficult. (Astute observers will note that this is a problem across a number of different areas of our economy, from housing to higher education; if you’re really astute, you’ll notice that the trend is not confined to a single industry but is, instead, a symptom of something larger—which should, if you’re really really astute, lead you to the conclusion that it’s not individual industries like health care or the housing market or colleges and universities that are irrevocably broken but something else that might be causing the distress. But we’ll come back to that in a minute.) Some years ago we made a political commitment (well, some of us did) to addressing a few of the shortcomings in our health care system—a lack of coverage for people with pre-existing conditions, insurers that kicked children off their parents’ plans, people simply forgoing insurance altogether—via the Affordable Care Act (ACA). I think it’s safe to say that we’re in a better place, collectively, than we were six years ago.
What hasn’t worked, of course, is that ACA (“Obamacare”) was layered on top of an existing health care delivery system that pulls in a very different direction than ACA does. Where the Affordable Care Act is designed to push us closer to the goal of universal health coverage as a fundamental right, the system we have for making sure that happens is a private, profit-driven one motivated by an entirely different set of concerns. In other words, we took a top public priority and asked the private sector to manage its implementation. The results, to my eye, have been pretty predictable. They have been messy, expensive, and unsatisfying.
The system is messy, expensive, and unsatisfying because private insurers are necessarily driven by the need to make their businesses profitable. To do that they offer us choices—lots and lots of choices. Because it’s very difficult to get hundreds (or even thousands) of people to agree on what they want, insurance companies offer us customized plans in an effort to please everybody. Some have higher deductibles. Some require higher co-pays for office visits or emergency room trips. Some increase the limit of out-of-pocket costs in a given year. All encourage us to make risky decisions about our health coverage and finances by offering up a slew of different options that essentially boil down to a simple choice: do you want to pay more now and protect yourself from a possible financial catastrophe later, or do you want to roll the dice and pay less up front, hoping that the catastrophe never comes?
What bothers me about this is not only that it forces people to make excruciatingly difficult decisions for themselves (and their families) without having all the information laid out in front of them, but that it also, by giving us the illusion of choice, leads us to think that ultimately we’re responsible for how things turn out. So you chose that plan with low deductible and the much higher out-of-pocket costs? Well, you shouldn’t have gotten sick then. We all get sick eventually. Why didn’t you plan ahead?
In the process we forget the fact that maybe we shouldn’t have had to make that decision in the first place. I know that sounds naive—if everybody gets a Cadillac health plan, we’re told, we’ll all just give up on trying to be healthy and take advantage of the system and costs will spiral out of control—but just because we’re told that doesn’t make it true. Remember: the folks making that argument are the ones ultimately paying the bill, after your premium is accounted for, and they need to make their investment in this market profitable. They have an incentive to make an argument like that. We could, if we wanted to, build a system that substituted security for choice, a system based on the principle that protecting your health, and the health of your loved ones, is more important than having the right to make a choice. We could focus our resources on that, instead of trying to negotiate our needs through a middleman.
Of course we can’t have that system as long as insurance companies have to find a way to finagle a profit out of us in the process. And this is where we circle back to the education system. Why would we trade a system that ensures that every single child has access to education for one resembling our health care system? Choice is all the rage in education circles right now. We seem to believe, against almost all available evidence, that simply giving parents a choice about where their kids go to school will inevitably make our system better. We’re even willing to let for-profit players enter the space. If parents get to choose then schools will have to compete for students, we’re told. That competition will make them better. Is that how it’s working where your health insurance company is concerned?
Okay, then, we’re told. At least we have to admit that the system has failed too many kids for too long. Breaking up the “government school monopoly” will bring much-needed innovation to the education sector and give those kids who have been left behind a fighting chance at a good life. But the idea that public schools are a government-run monopoly is simply a fantasy. Our tradition of local control ensures that the people running our schools at different levels of government—many of them popularly-elected members of school boards—are as different from each other as the day is long.
The truth is that our ongoing national experiment with school choice has simply reinforced the idea that not all schools are the same—I like to think we knew that already—and that the people running them are really the variables that determine their effectiveness. The only thing school choice has definitively proven is that giving people more options doesn’t, by itself, improve the system. Maybe, in fact, the people running individual schools—and the people responsible for providing them with adequate resources—are where we should focus our energy. Maybe structural change, in the form of more choices, isn’t what we need. Maybe we need to place more emphasis on making sure that every kid attends a school with adequate resources and is taught by teachers who have been professionally trained and are compensated like professionals too. Addressing these fundamentals would be a better use of time and resources than experimenting with an approach that can’t be harnessed, let alone controlled, because it introduces unnecessary complexity into the system.
To me the only choice we need to make is this one: we need to commit to public education for everybody, not just for those lucky enough to win an enrollment lottery or lucky enough to have parents who live in the right zip code. The illusion of choice, as it exists now, simply helps redirect resources away from the places where they’re needed most. The only people who really have choices—and this is true both in health care in in education—are the ones who already have the most resources to begin with. In the end, it’s not a “government monopoly” that’s crippling our potential; it’s power exercised in cruel, unreasonable, and arbitrary ways to ensure that some people get advatanges others can only dream of. If that’s not the definition of tyranny I don’t know what is.