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Today every urbanite's favorite faux-hillbilly -- J.D. Vance -- writes an op-ed in the New York Times about the health care system entitled "A Republican Health Care Fix." I've written a lot of words about this guy over the past year, but as long as people keep giving him platforms on which to share his vacuity, I'll be here to point out just how vacuous it is.
His broad point is not terrible. He thinks the recently stalled GOP health care bill is bad policy and bad politics and something better is needed. Not an earth-shattering argument -- everyone who is not Donald Trump or a Republican member of Congress agrees -- but give him points for saying it.
Beyond that, Vance is attempting, in his own Vancian way, to make a more salient good point: that there should be some sort of baseline of care for people and that no one in need of health care should have the hospital's doors slammed in their face simply because they're poor. While that should, again, not be a very tough bogey to meet, in this day and age it somehow is, especially for conservatives, so give him some points for saying that too.
The problem here, however, is the exact same problem he displayed in "Hillbilly Elegy": he completely misdiagnoses the cause of a real problem and, in doing so, ensures that any solutions for which he or his supporters would advocate are doomed to failure.
Vance's view of the problem: it's the government's fault that there is a health care crisis in America. He argues this by offering a simple-minded analogy about a pedestrian being hit by a government vehicle in order to make a broad "you broke it, you bought it" argument:
This is where the Republican Party hits an ideological barrier that it simply must power through before meaningful reform can happen. Yes, solving problems can be expensive, and yes, that money always comes from taxpayers. But that’s true when a government truck plows into a pedestrian. You break it, you buy it, and the logic applies equally whether the broken thing is an individual or a complex marketplace.
"The government broke health care" position is simply not true. There have been multiple books written analyzing why our health care system is expensive and, in many ways, broken. The uniform conclusion: that while some unique factors drive our costs up compared to other countries (i.e. the United States' unique position in drug research and medical innovation) most of the costs baked into the system are a function of administrative and marketing overhead unique to a for-profit healthcare industry, passing costs on to consumers.
We have a system which incurs massive costs for advertising, branding and the need for hospitals and doctors offices to bill dozens if not hundreds of different insurance companies in dozens if not hundreds of different ways. We have a system that delivers care to different populations via different programs and administrative means based on age, geography, financial status, ethnic background, job status and a dozen other factors, and each of those systems has developed its own infrastructure, raising costs through massive complexity. On top of that a cut is taken for profit. In light of all of this, Vance's premise -- the government broke our healthcare system! -- is exactly backwards.
At this point some might be inclined to say "Hey, Vance is not an expert in this area. You acknowledge that he cares and that he means well, so cut him some slack. He's talking about important stuff!" Sorry, not gonna cut him slack. Partially because Vance has political aspirations now and should not be allowed to get away with broad, misleading generalizing about pressing policy matters of the day. Mostly, though, I won't cut him slack for the same reason I didn't cut him slack for "Hillbilly Elegy."
In my review of that now famous book I noted that, as here, Vance meant well. And that, as here, he was talking about a very real problem: the myriad crisis facing people in rural areas and the working class at large. But just as he does here, he misdiagnosed the cause of the problem. He argued that the crisis is attributable to a lack of character and work ethic by those suffering from it. That the white underclass from which he rose is struggling so mightily because it is not taking responsibility for its own decay. That their moral failures, as opposed to economic challenges, were to blame.
The arguments in "Hillbilly Elegy" were utter hogwash. Hogwash, it should be noted, that adheres pretty closely to the views of the Silicon Valley venture capital class and from which Vance more recently hails and which would pass muster with GOP political leaders who will, eventually, be asked to aid his political ambitions. But more importantly, it's hogwash that stands in the way of solving the very problems Vance claims to care about.
If one does not acknowledge the external forces working against the victims of the 21st century economy, one can never hope to solve them. If one blames the victims of that economy, one can easily wash one's hands of them. Indeed, the prevalent opinion of people I know who have read "Hillbilly Elegy" and who are not personally familiar with rust belt or Appalachian life is "Those poor people. Their problems seem impossible to solve!"
In this "Hillbilly Elegy" is a work of absolution. It reassures its readers -- mostly coastal and/or urban-dwelling elites -- that they and the system which has benefitted them is not to blame for what's happening in places like Ohio and Kentucky. In turn it gives them license to look away after they've gotten their 272 pages worth of rural poverty porn, content in the notion that they cannot do anything to help and thus cannot be criticized for turning away.
His take on the health care system is no different. He cares. He claims that he wants things to be better. But by blaming the government for the problem he necessarily encourages readers to get behind market-based solutions which are actually responsible for the problem. Yes, he allows that the government should play some role in that, but his "you broke it, you bought it" framing ensures that that role should be limited and exercised only out of shame and guilt. After all, if you break a wine decanter at Crate and Barrel, you don't get to make decisions about restocking and inventory. You cut a check and, preferably, get the hell out of the store, never to return.
It's not unheard of for a patient to get better after a doctor misdiagnoses her condition. But it's not common, especially if, like the current state of the U.S. health care system, the condition is serious, complex and requires a lot of hard work to cure. It's also the case that, once a doctor has made a spectacularly wrong diagnosis, one should not go back to him the next time one gets sick.
Yet platforms like the New York Times continue to turn to Dr. Vance, under the delusion that he has insight and solutions. This despite the fact that, when it comes to public policy, J.D. Vance has already proven himself to be a quack.