If I favor spending x to deliver a given service, I am a good person. If I favor spending 2x, I am a really good person who wants to make an investment in the future. If I instead favor spending x-y I am a bad person, unless y is a negative number, in which case I’m a good person again.
Before accepting this logic, I’d want to know a few other things. What is the lowest price at which we can get some institution, public or private, to deliver this service at an acceptable level of quality? Is it 3x? Is it .5x?
I’ve been thinking about the Medicaid debate. Medicaid dollars aren’t flowing into the hands of poor people. Rather, Medicaid dollars flow into the hands of providers, who use this money to compensate health workers and to make capital investments, etc. The Medicaid debate has been framed as those who want to cut the Medicaid budget vs. poor people. But one can also characterize the debate as those who want to cut the Medicaid budget vs. medical providers, for whom what the rest of us characterize as “the misalignment of incentives” is an economic boon.
A sobering fact about our democracy is that poor voters are less politically engaged than middle-class and rich voters. Many critics of Medicaid cuts see themselves as champions of voiceless poor voters, who find themselves badly overmatched in public debates. Yet the opponents of Medicaid cuts are also championing the interests of incumbent providers, who have deep pockets and a strong interest in characterizing these debates in moralistic rather than technocratic (e.g., are state governments really getting the most of out Medicaid managed care organizations? should state governments embrace a more centralized model for delivering health services to the poor?) terms.