ObamaCare for some,
miniature American flags for others
Things in Washington are getting pretty tense. On October 1st, the ObamaCare healthcare exchanges are set to go live. October 1st is also the date on which, unless the Congress can pass a continuing resolution for appropriations, the government will go into shutdown. Also looming on the horizon is another debt ceiling fight.
The confluence of these events has led to a substantial amount of political brinksmanship, with some Republicans demanding that ObamaCare be defunded or delayed in exchange for agreeing to a CR and/or debt ceiling increase. For their part, both Obama and most Congressional Democrats have stated that they will not negotiate over the debt ceiling, and that implementation of ObamaCare should go forward as planned.
The two sides seem irreconcilable. But as it turns out, there is a way for both sides to claim victory. Are you ready? Here it it:
Congress should delay ObamaCare AND allow it to go forward.
More specifically, Republicans and Democrats should agree to randomly split the states into two halves. In the first group, ObamaCare will go forward as planned; for the second, implementation will be delayed indefinitely.
It's important to note here that the two groupings must be truly random. I'm not proposing that ObamaCare go into effect in blue states but not in red states. It's quite possible that ObamaCare would go into effect in Mississippi but not in Minnesota. In fact, you would want a mix of red and blue states in both groups.
Randomizing implementation of ObamaCare would have several key advantages.
First, it would help us learn more about the true effects of the law. Right now, many conservatives are convinced that ObamaCare will make the healthcare system worse, whereas many liberals think it will be beneficial. You might think that, once the law does go into effect, this debate will be settled. But as the continuing debate over the effectiveness of the ARRA shows, this is not necessarily the case. If the implementation of ObamaCare is followed by higher prices, a decline in healthcare quality, or plagues of locust, those on the left can (and probably will) claim that these bad things would have happened anyway, and in fact would have been worse if not for the ACA. If prices fall, quality improves, and research reveals that eating banana splits cures cancer, then those on the right can (and probably will) claim that these good things would have happened anyway, and in fact would have been better if not for the new law.
Turning ObamaCare into the world's largest randomized controlled trial solves this problem. Instead of having to guess counterfactually about what would have happened if ObamaCare either had or hadn't been enacted, we could just compare the changes in healthcare in states with ObamaCare to those without.
Because of this, randomizing ObamaCare ought to be an acceptable compromise to both sides of this particular argument. Granted, supporters of ObamaCare will at first only get to see it enacted in half the states. But if the law turns out to be as beneficial as they claim, then the popular opposition to the law will fade, and the electorate will soon demand that the law be extended to all fifty states. Likewise, if, as conservatives claim, ObamaCare is a disaster waiting to happen, then it won't be long before those suffering under the law look at how much better their non-ObamaCare neighbors are doing, and will demand full repeal. The more certain each side is about the effects of the law, the more willing they should be to go along with this compromise.
UPDATE: In the comments, "Waffles" suggests that denying ObamaCare to half the country would be unethical:
[I]t's pretty undeniable that the subsidies provided by the law are going to be a huge help to Americans who aren't as well off as yourself. There's a reason that there are pretty high ethical standards for human experimentation in the social and medical sciences, and your suggestion is way, way, way beyond that ethical line.
Of course, RCT's routinely do precisely what Waffles says is way over the line, that is, giving potentially life-saving subsidies to one group while denying them to another. The Rand Health Insurance Experiment, for example, did this, as did the more recent Oregon Medicaid RCT. In fact, one can read entire books recounting the results of this type of experiment (incidentally, my wife's job used to be doing compliance for human experimentation, and she confirmed that Waffles' comments were off base).
But while Waffles' objection is factually wrong, his/her objection to the ethics of RCTs is hardly unique. I'm reminded here of an old anecdote from Dr. E.E. Peacock, which I'll pass along via Marginal Revolution:
One day when I was a junior medical student, a very important Boston surgeon visited the school and delivered a great treatise on a large number of patients who had undergone successful operations for vascular reconstruction.
At the end of the lecture, a young student at the back of the room timidly asked, “Do you have any controls?” Well, the great surgeon drew himself up to his full height, hit the desk, and said, “Do you mean did I not operate on half the patients?” The hall grew very quiet then. The voice at the back of the room very hesitantly replied, “Yes, that’s what I had in mind.” Then the visitor’s fist really came down as he thundered, “Of course not. That would have doomed half of them to their death.”
God, it was quiet then, and one could scarcely hear the small voice ask, “Which half?”
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