Politics & Culture

A Consequential Month

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What a month it’s been. Our black-robed overlords rescued Obamacare (again) and wrote same-sex marriage into the Constitution. Charleston continues to mourn even as the Confederate battle flag suddenly disappears from the public square and from retail shelves. Pope Francis decided he’s an environmentalist. The surviving Boston bomber got the death penalty, as did one of two prison escapees from New York, and police continue to be recorded while mistreating blacks. And it turns out the IRS has been playing games with Lois Learner’s emails — just as Hillary Clinton has played games with hers. All while Republican presidential candidates pretend that gay marriage really isn’t a thing and no one seems too concerned that the Office of Personnel Management suffered one of the most catastrophic, and most damaging, security breaches in U.S. history.

Sigh.

I survey all of this, but am relatively unmoved by most of it; the one truly touching moment was the way Charleston as a community and the families of the victims as a group came together after the church shooting to be, well, adult in the face of evil.

Perhaps my lack of engagement is a twofold function of my disappointment in the reflexive groupthink increasingly ingrained in public debate, and my belief that deep down, Fukuyama is right and the real crisis facing America isn’t the Red/Blue divide but rather the conflict between various elites seeking to colonize the country’s commanding heights. “Partisanship” is a chimera used to render into the binary a sociocultural struggle that crosses many different subpopulations and many different interest groups.

Take the twin colossi of Obamacare subsidies and gay marriage. On the outcome, I am satisfied with the high court’s conclusions. But in both cases, I think the majority opinions are dangerously wrong-headed, and it doesn’t take a law degree to understand the danger in both majority holdings. The chief justice’s dissent in Obergefell outlines why: It wasn’t the conclusion, but the logic model, that sets us up for more of the same. Kennedy’s majority opinion is filled with trite slogans that retrofit a hodge-podge of vague metaphysical assertions about human nature to justify a foreordained policy preference. And despite the acid of his dissent, Scalia’s rebuttual in King v. Burwell highlights that the majority elected to finesse a partially dishonest read of Congressional intent instead of agreeing that words have meaning and that it’s not the court’s job to pass laws that are internally coherent.

Distilled, my discomfort lies with the regrettable predictability of the political process, leavened with my increasing disdain for activists of any stripe. (Yes, I even loathe activists for my own causes. Do, or do not; there is no protesting.) More and more, I care less about the what and more about the why, and it’s an extrapolation of all these little whys that leave me slightly bearish about the future.

A lot happened this month. Inasmuch as some of what transpired might feel definitive, I cannot help but wonder whether all of these matters — gay rights, Obamacare subsidies, pulpit environmentalism, police aggression — aren’t truly concluded, but rather enter a new phase of social discord.

Like I said: Bearish.

Politics & Culture

Obamacare’s SCOTUS Aftermath: We Need to Limit the Tax Power

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I am glad I didn’t get my hopes up about SCOTUS in re: Obamacare. I was disappointed to hear the entire PPACA was upheld, to be sure, but I wasn’t spiking the football after the public hearings, so I don’t have to walk back any pre-decision irrational exuberance.

The kicker in the Roberts decision is that the Commerce Clause can’t justify the individual mandate, but the same effective result is possible under the federal government’s tax powers.

The Court’s decision, as I understand it (I haven’t read the texts yet so I’m relying on third-party synopses), seems reasonable on its face.

The problem for small-government types seems to be in the Court’s clear holding that there are few practical limits on the taxing power. As long as something can be taxed, it’s open to control even absent any other enumerated power of the federal government to justify non-tax regulations.

Thus: The Congress can’t force you to buy broccoli, but it can fine you if you don’t. From a legal perspective, this is coherent. From a public policy perspective, it’s an absolute mess of the “po-tay-to, po-tah-to” variety.

To fix the problem before it gets worse, conservatives ought to unite around an amendment to the Constitution that sets explicit limits on the scope, nature and purpose of taxation.

Not being a Constitutional scholar, I’m not the guy to draft such a proposal. But I could see something like this:

The Congress shall pass no law affecting public revenues that regulates the behavior of citizens unless such tax, tariff or credit supports a regulatory activity permissible under the non-tax enumerated powers of the federal government.

Yes, we need to repeal and replace. We also need to heed the Roberts Court and put clear constitutional limitations on the federal government’s use of its tax power as the next iteration of an elastic Commerce Clause.

Only by curtailing the scope of the government’s taxing authority can we avoid future debacles like Obamacare.

Politics & Culture

Obamacare's SCOTUS Aftermath: We Need to Limit the Tax Power

1 Comment

I am glad I didn’t get my hopes up about SCOTUS in re: Obamacare. I was disappointed to hear the entire PPACA was upheld, to be sure, but I wasn’t spiking the football after the public hearings, so I don’t have to walk back any pre-decision irrational exuberance.
The kicker in the Roberts decision is that the Commerce Clause can’t justify the individual mandate, but the same effective result is possible under the federal government’s tax powers.
The Court’s decision, as I understand it (I haven’t read the texts yet so I’m relying on third-party synopses), seems reasonable on its face.
The problem for small-government types seems to be in the Court’s clear holding that there are few practical limits on the taxing power. As long as something can be taxed, it’s open to control even absent any other enumerated power of the federal government to justify non-tax regulations.
Thus: The Congress can’t force you to buy broccoli, but it can fine you if you don’t. From a legal perspective, this is coherent. From a public policy perspective, it’s an absolute mess of the “po-tay-to, po-tah-to” variety.
To fix the problem before it gets worse, conservatives ought to unite around an amendment to the Constitution that sets explicit limits on the scope, nature and purpose of taxation.
Not being a Constitutional scholar, I’m not the guy to draft such a proposal. But I could see something like this:
The Congress shall pass no law affecting public revenues that regulates the behavior of citizens unless such tax, tariff or credit supports a regulatory activity permissible under the non-tax enumerated powers of the federal government.
Yes, we need to repeal and replace. We also need to heed the Roberts Court and put clear constitutional limitations on the federal government’s use of its tax power as the next iteration of an elastic Commerce Clause.
Only by curtailing the scope of the government’s taxing authority can we avoid future debacles like Obamacare.

Business Development, Politics & Culture

Meaningful Health Reform: Emphasize Cost Reductions First!

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Recent debate about the constitutionality of the Patient Protection and Affordable Care Act — better known as Obamacare — spins along an interesting but ultimately incoherent central axis: Namely, that access to insurance marks the most significant problem requiring federal intervention within the health care sector.

You hear the lament from President Obama himself. In comments delivered last week in the Rose Garden, he said: “People’s lives are affected by the lack of availability of health care, the unaffordability of health care, or their inability to get health care because of pre-existing conditions.”

Read that again. Now pay attention to several rhetorical sleights-of-hand that too often pass unremarked:

  • “…the lack of availability of health care…” — except, what Obama really means is the lack of affordability of health insurance.  Health care is generally plentiful; in fact, access to it through emergency rooms is enshrined under EMTALA, and communities across the country sponsor government- or church-run free or low-cost clinics. The only places with a lack of specific services result from local problems — e.g., communities with runaway tort awards that makes malpractice insurance for specialties like OB/GYN cost prohibitive for practitioners.
  • “…their inability to get health care because of pre-existing conditions.” Well, no. Again, it’s insurance and not access that’s really under discussion. In any case, people forget that insurance is a financial hedge against a potential future problem. When that problem materializes, ongoing insurance no longer makes sense, as the risk you’re insuring against isn’t theoretical any more. (Hint: That’s why some insurance companies didn’t “insure” against pre-existing conditions, which is much like trying to buy collision insurance the day after you wreck your car.)

In fact, the major problem with the whole debate is the focus on insurance coverage instead of cost reduction. It’s not entirely clear why employer-provided health insurance should be the primary mechanism by which individual citizens gain entry into the high-cost health services market. Nor is it clear why it’s constitutional for the government to require insurance companies to engage in specific behaviors that creates a regulatory regime that later justifies massive market intervention. Justice Kennedy had it right when he asked whether it makes any sense to create commerce just to regulate it. Treating “health reform” as simply expanding the insurance pool fundamentally misunderstands the real problem with health care costs today.

Which is this: As a distressingly large number of patients remain almost entirely disconnected from the actual costs of the services they consume and because they services are covered by third-party payers, the tendency is for prices to increase well above the rate of inflation. This trend makes a degree of sense; if you are sick and directly pay for little or nothing for the care you receive, then of course you want every test, every procedure, every intervention. And why not? Not your dime, after all. Rhetorical emanations from the Progressive Left elevate medical care to the level of a civil right that shouldn’t require anyone to pay out-of-pocket for anything. In a climate where the average person pays little and some activists demand that they pay nothing, it’s not a surprise that most people don’t put a lot of thought into the real cost of the services they consume. And as any marketer will tell you, people want more when they’re not thinking about price — which is basically the same economic model as the iTunes app store and Redbox kiosks.

Funny thing about health care. Contra Obama, you don’t need insurance to access health services. You can pay out of pocket. Doctors and hospitals don’t require insurance before delivering care — you can simply write a check, swipe a credit card or even negotiate a payment plan. Indeed, routine care isn’t really that expensive. An annual physical for someone in good health may cost less than $250 with labs in many markets. And before the wage-and-price controls of World War II, employer-provided health insurance was unheard of. We survived before benefits packages; we can survive when those packages are de-emphasized.

To really get health spending under control, we need to get consumers actively engaged in what health services they receive. The first step involves tort reform — physicians need to be free to recommend the various tests and procedures that are medically indicated without worrying about the lawsuits that lead to expensive “defensive medicine.” A regime that pre-screens medical malpractice claims against a board of physician advisers may well cut off the spigot of dollars flowing from the largess of a medically unskilled jury.

The second step requires patients to have financial skin in the game. Instead of taking refuge in free-lunch insurance programs, health insurance should more accurately reflect the original concept of risk mitigation that undergirds insurance programs as a whole. The best solution — and one that seems to work in hospitals across the country — lets consumers elect high-deductible plans that cover catastrophic illnesses but require patients to front the money for most low-dollar costs up to a specific threshold. These plans generally cost less and make patients think twice about demanding unnecessary care when the funds come directly from their own pockets.

Put differently: If get a nasty head cold, do you tough it out or do you make a trip to the doctor and demand antibiotics (even though antibiotics don’t work on viruses)? With free-lunch insurance, you’ll visit the doctor, get your scrip, maybe offer a token amount as a co-pay, and move on. If you knew you had to pay for the office visit and the drugs, would you bother? Probably not. You would only seek medical services when you believed you really needed them. The Washington Post recently addressed the trend of higher-deductible plans. Although the story may be faulted for assuming that it’s an outrage that people should actually pay for what they use, otherwise the account presents a fairly well-balanced summary of the trend away from gold-plated coverage and more toward consumer-driven health care.

The researchers at RAND Corporation’s health unit have complied extensive and diverse statistics about the long-term trends in health services; the publication is well worth perusing. The reasons for today’s exploding cost model are many, but some of the major contributors include:

  • Increased regulatory burden by governments that drives up costs by as much as 25 percent of the entire sector
  • Increased cost of ancillary services unrelated to the provision of care (e.g., marketing departments, education teams, etc.) — a 2003 New England Journal of Medicine study suggested that administration alone costs more than $700 for every inpatient visit
  • Increased utilization of expensive services like MRIs that may not be clinically warranted but protect the ordering physician from malpractice claims if the patient isn’t happy with his treatment, may raise costs by 5 to 9 percent
  • Cost-shifting from protected patients to non-protected patients — case in point: because Medicare or Medicaid reimburse at less than actual costs, the “gap” is made up in higher prices for everyone else, to the tune of more than $6 billion per year
  • Fixed infrastructure costs — primarily IT — drive up institutional expenses, which are then passed along to patients
  • HMOs and other insurers negotiate separate contracts with providers, and if one insurer gets a sweeter deal patients covered by a different provider may make up for it with higher prices

Health reimbursement theorists look at medical care as a three-legged stool of costs, quality and access. There’s a relationship among these variables: As costs increase, access declines. As quality increases, costs increase. Radically increasing access will make costs skyrocket.

That’s the fundamental problem with Obamacare — it emphasizes increasing access to free- or low-cost medical care, but as costs increase, there’s no obvious payer. Hence the “individual mandate.” If everyone pays into the system, then free-lunch coverage for everyone becomes a more viable option. Without a mandate, there just isn’t enough money to fund all the services that will be demanded at free-lunch prices by the U.S. population. And a single-payer solution won’t fix the problem. The dollars have to come from somewhere, and if individual consumers of health services have zero personal incentive to responsibly align their utilization against their genuine medical need, the system as a whole will suffer from significant and costly inefficiencies that make the entire infrastructure unworkable in the long run.

To really fix the problems with today’s health care market, we should focus on cost reduction. If costs go down, premiums will go down and access will naturally increase. And while we’re at it, we should scrap the antiquated WWII-era model of financing health services through “insurance” and instead open the market to actual costs borne by actual people.

Disclaimer: The writer is an experienced revenue-cycle analyst for a large Midwestern health system. The opinions expressed in this blog post reflect only the writer’s opinions and do not speak for, imply or endorse any position on behalf of the health system.

Philosophy, Politics & Culture, Religion

Observations re: Obamacare at SCOTUS, Contraception, Trayvon Martin, the Ryan Budget, Etch-a-Sketches & Science

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UPDATE: This post reflects an earlier draft, not the final one. Seems WordPress ate the final edit when the coffee shop suffered a Wi-Fi blip. Please forgive typos, grammar problems, and missing hyperlinks. Ill try to re-edit tonight. JEG 4/2/12.

UPDATE 2:  Lightly revised. JEG 4/8/12. 

Bear with me; there’s a lot on the docket (so to speak).

N.B. — This post clocks in at roughly 2,300 words. I’ve bolded the various sections so you can read only the content that interests you.

Obamacare and the High Court

So picture it: The District of Columbia, 2012. The federal capital seized up in gyrations of agony and ecstasy as our black-robed overlords grace us with the gift of their public hearings on the constitutionality of the Patient Protection and Affordable Care Act. Conservatives delighted in both the slap-down delivered to Solicitor General Donald Verrilli and the paroxysms of rage the SG’s performance induced among the progressive commentariat. Some liberals took solace in their Kennedyology, trying to predict how the “swing justice” will rule by divining hints from questions posed by the learned jurist (augmented, no doubt, by a careful reading of the cracks upon heated chicken bones) and suggesting that the court could uphold the law 6-3.

Well.

The Court will do as the Court will do. More intriguing was the general sense among the Left that Obamacare’s constitutionality is a slam-dunk. Across the board, from Verrilli to the lowest FDL blogger, the progressive movement as a whole doesn’t seem to have seriously considered the conservative counter-argument. Verrilli was caught unprepared for questions that conservatives have been asking, loudly, for two years. If you thought Speaker Pelosi’s “Are you serious?” stammering about the constitutional authority of the statute was just Nancy being Nancy, think again.  It’s not for nothing that most of the left-wing legal commentators made a point of referring to justices by ideological label as they summarized the questioning, and it’s an excellent case study in the politics of ideological echo chambers that CNN’s Jeffrey Toobin went from a “strong uphold” to a “OMG, all is lost” based solely on two hours of questioning.

I won’t predict what the Court will do. I will hazard a guess, though, that if the Supremes strike down the mandate (or even the entire PPACA) then we will endure long and loud laments about the Court is too right-wing or that it’s engaging in judicial over-reach or that it’s no longer a legitimate reflector of American virtues and requires radical reform. The Left loves the judiciary until the judiciary proves non-compliant; then the judges become black-robed tyrants. Yawn-worthy in its predictability.

I hope the entire law gets voided. We need to hit the “reset button” on health reform. As a person whose day job lives within a hospital revenue cycle, I can tell you that the real financial crisis for health care isn’t access to insurance, but in the lack of meaningful patient financial participation in the system. It’s as if you’ve got insurance, so you don’t care about pricing or service utilization. To effect a real “bending of the cost curve,” we need to cut out unnecessary tests and procedures (read: tort reform) and give patients meaningful skin in the game about what their treatments really cost. Consumer-driven health care, with high-deductible plans and HSAs to bridge the gap,  makes more sense than mandatory free-lunch coverage. Until you change behaviors and attitudes, no amount of tinkering with the reimbursement model will prove viable in the long run.

[Note: My opinions on health reform are my own and don’t reflect my hospital’s position on this subject.]

Contraception — The Bishops and the Flake

What’s not to love about a good public row about contraception?

This sordid tale of social discontent started during the final votes on Obamacare. To secure passage, the administration had to promise a gaggle of Congresscritters, led by former Rep. Bart Stupak, that the feds wouldn’t upset the abortion apple cart. Obama agreed, providing a wholly insubstantial fig leaf that conservatives decried but let Pelosi and Hoyer get the Senate’s astonishingly incoherent bill to the President’s desk.

Fast forward to 2012: HHS Secretary Kathleen Sebelius announces regulations that force pretty much everyone to cover abortion and contraception services as part of their employer-provided health insurance (so much for that Executive Order, eh Bart?). A storm of protest follows, led by the Catholic bishops. Who, may I proudly add, finally figured out that they really do have spines.

The administration made another make-believe deal but the USCCB rejected it, as did many other conservative and evangelical groups. The drama continues to unfold. But when the House of Representatives got involved, the story took a different turn. Denied the chance to present witnesses for timing reasons at one of Issa’s hearings, the Democrats made Georgetown law student Sandra Flake their poster girl for contraception. That this 30-something grad student at Georgetown should be considered an ideal role model, I find baffling. But there you have it.

The Democrats announced a Republican “war on women.” Republicans were not amused, but then Rush Limbaugh intervened with his infamous “slut” screed and soon the issue blew far out of proportion. Media Matters tried (and woefully failed) to attack Limbaugh. Bill Maher and Louis C.K. earned targets. Hypocrisy raged in typical MSM/Washington style.

Here’s the thing, though:

  1. Contraception in the form of condoms isn’t hard to find. Most bars and health centers have them. If you can’t find a free condom, then something’s seriously wrong with you. Especially if you live in a metro area. Like, ummm … THE DISTRICT OF COLUMBIA. Heck, you can grab free condoms by the handful from any fishbowl at any self-respecting gay bar. That a grad student at one of America’s leading universities should insist that her school pay for her birth control instead of just dealing with it marks an astonishing sense of entitlement and a thought-provoking example of what’s wrong with higher education.
  2. Contraception in the form of birth-control pills aren’t expensive. Flake suggested it would cost her more than $3k per year unless her Catholic school (to which she voluntarily enrolled, knowing its character) paid the bill. Seriously? Is she buying them in platinum bottles? You could get a copper-T IUD for $647 in 2008 or now you can pay $240 per year for The Pill from Planned Parenthood clinics.
  3. If you can’t afford birth control, you always have the right to reduce your “risk” of pregnancy by curtailing your sexual activity. Seriously. Abstinence works, as does non-vaginal sexual behavior.  Point is, no person has a right to force other people to subsidize his or her sexual behavior.

But, hey. How ’bout that war on women? Apparently the politics of demonization is a heck of a lot easier than encouraging responsible behavior among people who really ought to know better.

Trayvon Martin, George Zimmerman and Gun Control

No question, it’s a bad situation. A black Florida teen, Trayvon Martin, was shot and killed by a “white Hispanic” (whatever that is) slightly nutty neighborhood watch patroller named George Zimmerman while the youth was cutting through a gated neighborhood. The facts in this case aren’t clear despite quite a bit of grandstanding; the evidence and witness testimony suggests that both Martin and Zimmerman made repeated, significant and avoidable errors in judgment.

Three observations:

  • This isn’t a slam-dunk case, either for or against prosecuting Zimmerman. As such, the March of the Race Brigade, led by Sharpton and Jackson, probably does more harm than good. No matter how you slice it, this isn’t a case of institutional racism. Of bad judgment? Sure. Of a police department and prosecutor’s office that may or may not be correctly interpreting Florida law? Perhaps. But this isn’t a flash point in a racial war, and every time the usual suspects come out with their manufactured outrage and their political opportunism — including yet more unnecessary meddling in local law enforcement from Barack Obama — justice for both Martin and Zimmerman fades and cynicism about race relations spikes up.
  • I’ve heard people suggest that the real problem here is Florida’s “stand your ground” statute. Florida is one of 30 states with this type of law;  it’s the converse of “duty to retreat” statutes. In Florida, if you’re attacked, you’re authorized to hold your position and fight back when confronted. The argument I’ve heard is that “stand your ground” allows too much of an escalation path for hard cases, and that less violence would result under a “duty to retreat” regime. Maybe. But it seems like rewarding violence and aggression by privileging it under the law empowers the criminals at the expense of the law-abiding.
  • The million-dollar question — and one not really subsumed under the Martin incident — is the extent to which a person is legally entitled to defend himself against aggression. Concealed-carry, castle and stand-your-ground laws represent a swing back from the over-reliance on spotty police protection. Even now, liberals are torn; on one hand, they often excoriate police departments for being hotbeds of brutality, racism and misogyny — but these same departments are the gold standard of community policing, whose mere presence justifies any opposition to more relaxed self-defense statutes. Which is it? Are the cops ignorant buffoons, or Teh Awesomz? Pick one position and stick with it, please. In any case, the presumption that civilians are incapable of exercising good judgement while police officers remain beyond reproach is blown out the water by the fact that a police officer is 11 times more likely to engage in wrongful shooting than a validly licensed citizen. (Read the link; it’s a Cato study that outlines the history of gun-control laws and reveals just how much of an innovation they really are in U.S. history.)

The Ryan Budget

Paul Ryan released a kick-ass budget that just passed the House comfortably. It reduces the deficit, moves to a premium-support model for Medicare and protects defense spending. In short: The gentleman from Wisconsin seems to be the only serious adult in Washington when it comes to spending and entitlement reform. Not only has Ryan submitted a workable model, he’s succeeded in changing the entire intellectual dynamic about taxing, spending and reform in Washington. He’s put Obama on defense.

[Read the passage story about the Ryan budget, including a summary of its major points, from WaPo, then digest commentary from Doug Schoen in Forbes.]

Three cheers for Paul Ryan.

Political Etch-a-Sketches

Eric Fehrnstrom’s comments about Romney and the political Etch-a-Sketch seem overblown. Every politician emphasizes some things in a primary race and other things in a general race. To the extent that the election in its final 12 weeks will look radically dissimilar to the GOP nomination fight, the proper reaction to Fehrnstrom’s statement is … duh.

I can understand liberals trying to make hay from his comments, but for conservatives to keep swiping at Romney — well, it feels like an ongoing tantrum. Look, guys, Romney’s our man in 2012 whether you like it or not. We’re not going to have a brokered convention. Paul won’t win the nomination. Gingrich has no path to victory and increasingly looks like a bad-faith candidate. Santrorum lacks organization and money and his negatives (even apart from his self-inflicted gaffes) make an Obama re-election seem more likely than not. At this point, whether you like it or not, the time has come to circle around Romney and focus on sending Obama back to Chicago for good.

Conservatives and Science

One of the big news stories of last week flowed from a survey that suggests that conservatives have little faith in science. Plenty of stories abound about the study; Ars Technica did a decent job of summarizing the key points.

I think the focus is a bit off. I don’t believe that conservatives distrust science per se; you don’t see many Republicans pretending like organic chemistry is a hoax or that the moon landing was staged or that the laws of physics are a left-wing conspiracy to increase taxes by denying people the ability to fly through the air like Superman. What you see, rather, is conservative distrust in what seems like increasingly obvious alignment between “scientific results” and progressive policy preferences. Like scientists, conservatives are also capable of conducting linear regressions to arrive at reasonable conclusions.

Consider:

  • The theory of anthropogenic global warming is based on science that pretty much everyone acknowledges requires refinement. Climate scientists have done an excellent job of trying to piece together historical evidence of climate change. Much of it is compelling. When they’re up-front about known problems with the data, I trust their conclusions even more. But there’s a world of difference between saying, “here’s the trend over the last 2,000 years” versus “observation X is definitively caused by human behavior, and therefore we scientists must now dictate to you the specific sociopolitical reforms you must immediately execute to avoid Armageddon, conveniently written up for you by your friends from Greenpeace, so STFU and bow to the consensus we’ve manufactured by suppressing contradictory findings.” Climate science can tell — imperfectly, so far — what’s happening. It can speculate as to why. The leap from observation to political change isn’t the realm of science, however. It’s the realm of politics. When scientists insist that disaster is upon us because of our behavior, when their leaked emails note to the contrary, is it any wonder that people lose confidence in those scientists?
  • Watch the Discovery Channel or read some of the scientist profiles in higher-brow popular science magazines. One thing will strike you: No matter the discipline — and, surprisingly, one of the most susceptible seems to be theoretical physics — the group think and polarization is so high that plausible theories don’t get a hearing because senior researchers and theoreticians get an almost partisan adherence to their preferred perspective and won’t listen to countervailing ideas. Study the development of string theory for a case study. Anyone who says “science” isn’t political has never tried to advance a complex theoretical argument lately.
  • Scientists are human beings. Human beings tend to be ideological. Why, oh why, must people assume that scientists are immune to ideology? The jig is up, I think, when scientists sign on to a great number of things (the nuclear freeze, global warming scaremongering, etc.) that almost always fall on the left side of the spectrum. Gee. Can you blame conservatives for being skeptical?

All for now.

Philosophy, Politics & Culture, Religion

Observations re: Obamacare at SCOTUS, Contraception, Trayvon Martin, the Ryan Budget, Etch-a-Sketches & Science

No Comments

UPDATE: This post reflects an earlier draft, not the final one. Seems WordPress ate the final edit when the coffee shop suffered a Wi-Fi blip. Please forgive typos, grammar problems, and missing hyperlinks. Ill try to re-edit tonight. JEG 4/2/12.
UPDATE 2:  Lightly revised. JEG 4/8/12. 
Bear with me; there’s a lot on the docket (so to speak).
N.B. — This post clocks in at roughly 2,300 words. I’ve bolded the various sections so you can read only the content that interests you.
Obamacare and the High Court
So picture it: The District of Columbia, 2012. The federal capital seized up in gyrations of agony and ecstasy as our black-robed overlords grace us with the gift of their public hearings on the constitutionality of the Patient Protection and Affordable Care Act. Conservatives delighted in both the slap-down delivered to Solicitor General Donald Verrilli and the paroxysms of rage the SG’s performance induced among the progressive commentariat. Some liberals took solace in their Kennedyology, trying to predict how the “swing justice” will rule by divining hints from questions posed by the learned jurist (augmented, no doubt, by a careful reading of the cracks upon heated chicken bones) and suggesting that the court could uphold the law 6-3.
Well.
The Court will do as the Court will do. More intriguing was the general sense among the Left that Obamacare’s constitutionality is a slam-dunk. Across the board, from Verrilli to the lowest FDL blogger, the progressive movement as a whole doesn’t seem to have seriously considered the conservative counter-argument. Verrilli was caught unprepared for questions that conservatives have been asking, loudly, for two years. If you thought Speaker Pelosi’s “Are you serious?” stammering about the constitutional authority of the statute was just Nancy being Nancy, think again.  It’s not for nothing that most of the left-wing legal commentators made a point of referring to justices by ideological label as they summarized the questioning, and it’s an excellent case study in the politics of ideological echo chambers that CNN’s Jeffrey Toobin went from a “strong uphold” to a “OMG, all is lost” based solely on two hours of questioning.
I won’t predict what the Court will do. I will hazard a guess, though, that if the Supremes strike down the mandate (or even the entire PPACA) then we will endure long and loud laments about the Court is too right-wing or that it’s engaging in judicial over-reach or that it’s no longer a legitimate reflector of American virtues and requires radical reform. The Left loves the judiciary until the judiciary proves non-compliant; then the judges become black-robed tyrants. Yawn-worthy in its predictability.
I hope the entire law gets voided. We need to hit the “reset button” on health reform. As a person whose day job lives within a hospital revenue cycle, I can tell you that the real financial crisis for health care isn’t access to insurance, but in the lack of meaningful patient financial participation in the system. It’s as if you’ve got insurance, so you don’t care about pricing or service utilization. To effect a real “bending of the cost curve,” we need to cut out unnecessary tests and procedures (read: tort reform) and give patients meaningful skin in the game about what their treatments really cost. Consumer-driven health care, with high-deductible plans and HSAs to bridge the gap,  makes more sense than mandatory free-lunch coverage. Until you change behaviors and attitudes, no amount of tinkering with the reimbursement model will prove viable in the long run.
[Note: My opinions on health reform are my own and don’t reflect my hospital’s position on this subject.]
Contraception — The Bishops and the Flake
What’s not to love about a good public row about contraception?
This sordid tale of social discontent started during the final votes on Obamacare. To secure passage, the administration had to promise a gaggle of Congresscritters, led by former Rep. Bart Stupak, that the feds wouldn’t upset the abortion apple cart. Obama agreed, providing a wholly insubstantial fig leaf that conservatives decried but let Pelosi and Hoyer get the Senate’s astonishingly incoherent bill to the President’s desk.
Fast forward to 2012: HHS Secretary Kathleen Sebelius announces regulations that force pretty much everyone to cover abortion and contraception services as part of their employer-provided health insurance (so much for that Executive Order, eh Bart?). A storm of protest follows, led by the Catholic bishops. Who, may I proudly add, finally figured out that they really do have spines.
The administration made another make-believe deal but the USCCB rejected it, as did many other conservative and evangelical groups. The drama continues to unfold. But when the House of Representatives got involved, the story took a different turn. Denied the chance to present witnesses for timing reasons at one of Issa’s hearings, the Democrats made Georgetown law student Sandra Flake their poster girl for contraception. That this 30-something grad student at Georgetown should be considered an ideal role model, I find baffling. But there you have it.
The Democrats announced a Republican “war on women.” Republicans were not amused, but then Rush Limbaugh intervened with his infamous “slut” screed and soon the issue blew far out of proportion. Media Matters tried (and woefully failed) to attack Limbaugh. Bill Maher and Louis C.K. earned targets. Hypocrisy raged in typical MSM/Washington style.
Here’s the thing, though:

  1. Contraception in the form of condoms isn’t hard to find. Most bars and health centers have them. If you can’t find a free condom, then something’s seriously wrong with you. Especially if you live in a metro area. Like, ummm … THE DISTRICT OF COLUMBIA. Heck, you can grab free condoms by the handful from any fishbowl at any self-respecting gay bar. That a grad student at one of America’s leading universities should insist that her school pay for her birth control instead of just dealing with it marks an astonishing sense of entitlement and a thought-provoking example of what’s wrong with higher education.
  2. Contraception in the form of birth-control pills aren’t expensive. Flake suggested it would cost her more than $3k per year unless her Catholic school (to which she voluntarily enrolled, knowing its character) paid the bill. Seriously? Is she buying them in platinum bottles? You could get a copper-T IUD for $647 in 2008 or now you can pay $240 per year for The Pill from Planned Parenthood clinics.
  3. If you can’t afford birth control, you always have the right to reduce your “risk” of pregnancy by curtailing your sexual activity. Seriously. Abstinence works, as does non-vaginal sexual behavior.  Point is, no person has a right to force other people to subsidize his or her sexual behavior.

But, hey. How ’bout that war on women? Apparently the politics of demonization is a heck of a lot easier than encouraging responsible behavior among people who really ought to know better.
Trayvon Martin, George Zimmerman and Gun Control
No question, it’s a bad situation. A black Florida teen, Trayvon Martin, was shot and killed by a “white Hispanic” (whatever that is) slightly nutty neighborhood watch patroller named George Zimmerman while the youth was cutting through a gated neighborhood. The facts in this case aren’t clear despite quite a bit of grandstanding; the evidence and witness testimony suggests that both Martin and Zimmerman made repeated, significant and avoidable errors in judgment.
Three observations:

  • This isn’t a slam-dunk case, either for or against prosecuting Zimmerman. As such, the March of the Race Brigade, led by Sharpton and Jackson, probably does more harm than good. No matter how you slice it, this isn’t a case of institutional racism. Of bad judgment? Sure. Of a police department and prosecutor’s office that may or may not be correctly interpreting Florida law? Perhaps. But this isn’t a flash point in a racial war, and every time the usual suspects come out with their manufactured outrage and their political opportunism — including yet more unnecessary meddling in local law enforcement from Barack Obama — justice for both Martin and Zimmerman fades and cynicism about race relations spikes up.
  • I’ve heard people suggest that the real problem here is Florida’s “stand your ground” statute. Florida is one of 30 states with this type of law;  it’s the converse of “duty to retreat” statutes. In Florida, if you’re attacked, you’re authorized to hold your position and fight back when confronted. The argument I’ve heard is that “stand your ground” allows too much of an escalation path for hard cases, and that less violence would result under a “duty to retreat” regime. Maybe. But it seems like rewarding violence and aggression by privileging it under the law empowers the criminals at the expense of the law-abiding.
  • The million-dollar question — and one not really subsumed under the Martin incident — is the extent to which a person is legally entitled to defend himself against aggression. Concealed-carry, castle and stand-your-ground laws represent a swing back from the over-reliance on spotty police protection. Even now, liberals are torn; on one hand, they often excoriate police departments for being hotbeds of brutality, racism and misogyny — but these same departments are the gold standard of community policing, whose mere presence justifies any opposition to more relaxed self-defense statutes. Which is it? Are the cops ignorant buffoons, or Teh Awesomz? Pick one position and stick with it, please. In any case, the presumption that civilians are incapable of exercising good judgement while police officers remain beyond reproach is blown out the water by the fact that a police officer is 11 times more likely to engage in wrongful shooting than a validly licensed citizen. (Read the link; it’s a Cato study that outlines the history of gun-control laws and reveals just how much of an innovation they really are in U.S. history.)

The Ryan Budget
Paul Ryan released a kick-ass budget that just passed the House comfortably. It reduces the deficit, moves to a premium-support model for Medicare and protects defense spending. In short: The gentleman from Wisconsin seems to be the only serious adult in Washington when it comes to spending and entitlement reform. Not only has Ryan submitted a workable model, he’s succeeded in changing the entire intellectual dynamic about taxing, spending and reform in Washington. He’s put Obama on defense.
[Read the passage story about the Ryan budget, including a summary of its major points, from WaPo, then digest commentary from Doug Schoen in Forbes.]
Three cheers for Paul Ryan.
Political Etch-a-Sketches
Eric Fehrnstrom’s comments about Romney and the political Etch-a-Sketch seem overblown. Every politician emphasizes some things in a primary race and other things in a general race. To the extent that the election in its final 12 weeks will look radically dissimilar to the GOP nomination fight, the proper reaction to Fehrnstrom’s statement is … duh.
I can understand liberals trying to make hay from his comments, but for conservatives to keep swiping at Romney — well, it feels like an ongoing tantrum. Look, guys, Romney’s our man in 2012 whether you like it or not. We’re not going to have a brokered convention. Paul won’t win the nomination. Gingrich has no path to victory and increasingly looks like a bad-faith candidate. Santrorum lacks organization and money and his negatives (even apart from his self-inflicted gaffes) make an Obama re-election seem more likely than not. At this point, whether you like it or not, the time has come to circle around Romney and focus on sending Obama back to Chicago for good.
Conservatives and Science
One of the big news stories of last week flowed from a survey that suggests that conservatives have little faith in science. Plenty of stories abound about the study; Ars Technica did a decent job of summarizing the key points.
I think the focus is a bit off. I don’t believe that conservatives distrust science per se; you don’t see many Republicans pretending like organic chemistry is a hoax or that the moon landing was staged or that the laws of physics are a left-wing conspiracy to increase taxes by denying people the ability to fly through the air like Superman. What you see, rather, is conservative distrust in what seems like increasingly obvious alignment between “scientific results” and progressive policy preferences. Like scientists, conservatives are also capable of conducting linear regressions to arrive at reasonable conclusions.
Consider:

  • The theory of anthropogenic global warming is based on science that pretty much everyone acknowledges requires refinement. Climate scientists have done an excellent job of trying to piece together historical evidence of climate change. Much of it is compelling. When they’re up-front about known problems with the data, I trust their conclusions even more. But there’s a world of difference between saying, “here’s the trend over the last 2,000 years” versus “observation X is definitively caused by human behavior, and therefore we scientists must now dictate to you the specific sociopolitical reforms you must immediately execute to avoid Armageddon, conveniently written up for you by your friends from Greenpeace, so STFU and bow to the consensus we’ve manufactured by suppressing contradictory findings.” Climate science can tell — imperfectly, so far — what’s happening. It can speculate as to why. The leap from observation to political change isn’t the realm of science, however. It’s the realm of politics. When scientists insist that disaster is upon us because of our behavior, when their leaked emails note to the contrary, is it any wonder that people lose confidence in those scientists?
  • Watch the Discovery Channel or read some of the scientist profiles in higher-brow popular science magazines. One thing will strike you: No matter the discipline — and, surprisingly, one of the most susceptible seems to be theoretical physics — the group think and polarization is so high that plausible theories don’t get a hearing because senior researchers and theoreticians get an almost partisan adherence to their preferred perspective and won’t listen to countervailing ideas. Study the development of string theory for a case study. Anyone who says “science” isn’t political has never tried to advance a complex theoretical argument lately.
  • Scientists are human beings. Human beings tend to be ideological. Why, oh why, must people assume that scientists are immune to ideology? The jig is up, I think, when scientists sign on to a great number of things (the nuclear freeze, global warming scaremongering, etc.) that almost always fall on the left side of the spectrum. Gee. Can you blame conservatives for being skeptical?

All for now.

Politics & Culture

Thoughts on the “With What” Part of “Repeal and Replace”

No Comments

Diagnosis: Miserable Failure.

Yuval Levin’s analysis of Obamacare is a cogent but brief summary of the problems arising out of the newly passed Patient Protection and Affordable Care Act. His review is merely one of thousands, from both sides of the political spectrum, that tears apart the new law.

Concerns about Obamacare are as substantial as they are plentiful:

  • The new law does very little to reduce costs — indeed, it is likely to increase them substantially in the long run, because of the “trick” in delaying the provision of benefits against the immediate collection of tax revenues in order to bring in a 10-year cost of less than $1 trillion.
  • The expected revenues (e.g., Medicare cuts and the long-delayed tax on “Cadillac plans”) are almost surely not going to be imposed because of a lack of Congressional fortitude, which will add to significantly higher long-term federal deficits and unsustainable growth in state liabilities for Medicare and Medicaid recipients.
  • The law is internally incoherent: It was designed to accommodate a public option, which was later stripped, but the context of the law does not adequately reflect the removal of the public option.
  • The most serious barriers to public access to health care are not addressed.
  • The law creates perverse incentives to dump employees from company benefit plans into private exchanges, but the exchanges are unlikely to materialize as intended because it would be financial suicide for an insurance company to enter the private market under the current Obamacare regulations.

Conservative activists are pushing the “repeal and replace” mantra. Whether this goal is politically feasible is too early to tell — realistically, repeal cannot happen until after 2012, assuming Obama doesn’t win a second term. In terms of public discourse, three years is an eternity.  Some options, like refusing to fund the development of Obamacare if the GOP takes the House this fall, are on the table, but any opposition strategy could backfire horribly. Only a crystal ball will show whether the public’s zeal for repeal will survive the test of time.

That said, the question remains of what the “replace” part of “repeal and replace” might look like.  Some conservatives have offered incremental reform options that are essentially tweaks to the current system. Although there is a degree of prudence to this, there is also a danger — the current system’s whole approach is methodologically flawed.  Employer-paid comprehensive health insurance is simply a dead end, and propping up the system’s inevitable collapse seems dangerously short-sighted.

So if I could blow up the system and impose a new health-care industry by fiat, it would look like this:

  1. Employers would get out of the health-insurance business altogether. There is absolutely no reason that my boss needs to help me pay for a doctor’s visit.  Employer-provided insurance is a relic of World War II, when business first offered benefits packages as a way of getting around Roosevelt’s wage and price controls. Although the people tended to like these benefits, as a matter of pure reason, there is no justification for keeping employers in the middle of a person’s relationship with their doctors.  None whatsoever.  And freeing individuals from the perceived need to stay in a job with benefits may improve employee portability and risk-taking and encourage entrepreneurship.
  2. Routine well-care and ordinary medical expenses are solely the responsibility of individual citizens. We sometimes forget that insurance is a risk-adjusted method for protecting a person against possible loss. In a health context, however, we use insurance to handle things that have very little to do with risk mitigation, a practice that is borderline irrational and shifts the financial burden from those who are high-cost consumers of health services to those who are low-cost consumers (after all, you pay the same premium as your coworker even if your annual insurance billings total $100 and hers totals $15,000). In a perfect world, people will attend to their routine medical needs just like they attend to things like hygiene and clothing and auto repairs, none of which require an employer or governmental subsidy — and if they don’t, then this reflects a disordered prioritization of expenses by the consumer and not a systemic problem requiring an expensive public fix. Especially if we impose meaningful tort reform, to limit malpractice claims to situations that a team of physician advocates (instead of a lay jury) agree rises to the level of gross malpractice, the cost of services like annual physicals, immunizations, and diagnostic radiology will plummet and be affordable across the board.  To assist with individual cost management, a person could open a health savings account, accessed at the point of service by a debit card, funded with pre-tax voluntary contributions from payroll, so that even routine care doesn’t require a direct out-of-pocket cash outlay. Side note:  To those who are concerned about costs … what about costs for people who overpay?  In the last five years, I have paid more than $8,000 in insurance premiums while collecting less than $3,000 in total benefits.  Economically, it would have been significantly cheaper for me to forego insurance and pay for everything out-of-pocket, but if all the healthy and self-reliant did that, then those seeking insurance under the current system would have astronomically high premiums.  Hence the need for Obamacare’s “individual mandate” — it shifts costs to people like me, from people who go to the doctor every time they get a sniffle.  How, exactly, does forcing the healthy to subsidize the unhealthy pass social-justice muster? Under what ethical paradigm does forcible charity become an intrinsic public good?
  3. Health insurance is available, voluntarily, to protect against genuine catastrophic risk.  These plans will be more consistent with genuine insurance coverage, insofar as they have nothing to do with routine well-care and everything to do with protecting against major loss from serious, unexpected injury or unforeseen acute medical conditions.  Trauma risks (e.g., getting hit by a car) could be covered in full, with a fairly low annual premium to reflect the relative infrequency of major traumas.  Protection against clinical risks like strokes or heart attacks would also be available for optional purchase — a risk-adjusted model based on factors like behavior or family history would be more expensive, but may be an option that some would prefer to purchase.  Actual prices would be based on an actuarial assessment of a person’s likelihood of loss, relative to the total pool of covered lives, in accordance with free-market principles.  Allowing companies to offer insurance across state lines is a good first step toward building the right kinds of pools that would make true catastrophic care comprehensive but inexpensive in an open, personal market.
  4. State or community programs will manage risk-adjusted chronic-disease populations.  A major question within the health-care industry today is how to best manage people who have long-term chronic conditions like cancer or diabetes or HIV.  There is no right answer.  Some people respond well to ongoing medication, others to diet and exercise modification. Some people need ongoing dialysis or expensive drug therapies.  These are things that contribute to insurance costs. However, a registry-based program that allows teams of specialists including doctors and nurses and community health workers to engage with patients in a comprehensive manner to address all aspects of their chronic condition is a step in the right direction. The question, however, is cost:  Who pays?  A chronic condition is not an insurable condition, but it’s also not clear that it’s appropriate that the rest of society subsidizes treatment costs, particularly for conditions that are largely the result of lifestyle choices.  One option: Registries.  Allow people to sign up for programs to treat their condition at low or no cost, with actual costs borne by drug companies or community non-profits or even local or state governments. Hospitals and physician practices could receive tax incentives for contributing to registries, because there is a public interest in managing chronic conditions before they become major (and expensive) health crises.  The market could work its magic with registries.  For example, a leukemia registry may be funded by pharma companies that actively solicit patients to engage in drug research.  Or a diabetes registry in one state may be funded by a health-focused private foundation that thinks it has a better option for disease management and is willing to fund a demonstration project that is applicable across the country (Gasp! Federalism! Diversity in programming!  Oh, l’horreur!)
  5. Local communities could provide well-care subsidies for low-income families.  Yes, we all want to make sure babies, including poor ones, get proper treatment and immunizations.  To that end, local communities could provide health clinics to assist low-income families cover costs.  Churches could pool donations with local foundations to hold a free-clinic day every few months, for example.  Or county governments could operate basic clinics for families with incomes below a certain level.  There are many options for assisting low-income populations short of a massive, mandatory, one-size-fits-all social-welfare scheme.

The bottom line:  We must inculcate the attitude that the only person responsible for my health is me.  Not the government, not my boss, not an insurance company.  Me.  Health care is a routine part of life, and the provision of health insurance as an employer-provided benefit to so many for so long has led some people — mostly on the Left — to conclude that the government has an affirmative duty to keep people healthy.  This assumption is patently absurd, but it persists, and any viable repeal-and-replace program must convincingly show an average citizen how self-responsibility provides greater flexibility and lower cost than the chimera of Obamacare or the siren song of universal single-payer insurance.

Some readers of this blog are aware that the author is affiliated with a West Michigan-based hospital. The comments in this posting reflect only the author’s perspective and should not be considered a reflection on the hosptial’s perspective, nor a statement offered in the author’s capacity as a hospital employee.

Politics & Culture

Thoughts on the "With What" Part of "Repeal and Replace"

No Comments

Diagnosis: Miserable Failure.
Yuval Levin’s analysis of Obamacare is a cogent but brief summary of the problems arising out of the newly passed Patient Protection and Affordable Care Act. His review is merely one of thousands, from both sides of the political spectrum, that tears apart the new law.
Concerns about Obamacare are as substantial as they are plentiful:

  • The new law does very little to reduce costs — indeed, it is likely to increase them substantially in the long run, because of the “trick” in delaying the provision of benefits against the immediate collection of tax revenues in order to bring in a 10-year cost of less than $1 trillion.
  • The expected revenues (e.g., Medicare cuts and the long-delayed tax on “Cadillac plans”) are almost surely not going to be imposed because of a lack of Congressional fortitude, which will add to significantly higher long-term federal deficits and unsustainable growth in state liabilities for Medicare and Medicaid recipients.
  • The law is internally incoherent: It was designed to accommodate a public option, which was later stripped, but the context of the law does not adequately reflect the removal of the public option.
  • The most serious barriers to public access to health care are not addressed.
  • The law creates perverse incentives to dump employees from company benefit plans into private exchanges, but the exchanges are unlikely to materialize as intended because it would be financial suicide for an insurance company to enter the private market under the current Obamacare regulations.

Conservative activists are pushing the “repeal and replace” mantra. Whether this goal is politically feasible is too early to tell — realistically, repeal cannot happen until after 2012, assuming Obama doesn’t win a second term. In terms of public discourse, three years is an eternity.  Some options, like refusing to fund the development of Obamacare if the GOP takes the House this fall, are on the table, but any opposition strategy could backfire horribly. Only a crystal ball will show whether the public’s zeal for repeal will survive the test of time.
That said, the question remains of what the “replace” part of “repeal and replace” might look like.  Some conservatives have offered incremental reform options that are essentially tweaks to the current system. Although there is a degree of prudence to this, there is also a danger — the current system’s whole approach is methodologically flawed.  Employer-paid comprehensive health insurance is simply a dead end, and propping up the system’s inevitable collapse seems dangerously short-sighted.
So if I could blow up the system and impose a new health-care industry by fiat, it would look like this:

  1. Employers would get out of the health-insurance business altogether. There is absolutely no reason that my boss needs to help me pay for a doctor’s visit.  Employer-provided insurance is a relic of World War II, when business first offered benefits packages as a way of getting around Roosevelt’s wage and price controls. Although the people tended to like these benefits, as a matter of pure reason, there is no justification for keeping employers in the middle of a person’s relationship with their doctors.  None whatsoever.  And freeing individuals from the perceived need to stay in a job with benefits may improve employee portability and risk-taking and encourage entrepreneurship.
  2. Routine well-care and ordinary medical expenses are solely the responsibility of individual citizens. We sometimes forget that insurance is a risk-adjusted method for protecting a person against possible loss. In a health context, however, we use insurance to handle things that have very little to do with risk mitigation, a practice that is borderline irrational and shifts the financial burden from those who are high-cost consumers of health services to those who are low-cost consumers (after all, you pay the same premium as your coworker even if your annual insurance billings total $100 and hers totals $15,000). In a perfect world, people will attend to their routine medical needs just like they attend to things like hygiene and clothing and auto repairs, none of which require an employer or governmental subsidy — and if they don’t, then this reflects a disordered prioritization of expenses by the consumer and not a systemic problem requiring an expensive public fix. Especially if we impose meaningful tort reform, to limit malpractice claims to situations that a team of physician advocates (instead of a lay jury) agree rises to the level of gross malpractice, the cost of services like annual physicals, immunizations, and diagnostic radiology will plummet and be affordable across the board.  To assist with individual cost management, a person could open a health savings account, accessed at the point of service by a debit card, funded with pre-tax voluntary contributions from payroll, so that even routine care doesn’t require a direct out-of-pocket cash outlay. Side note:  To those who are concerned about costs … what about costs for people who overpay?  In the last five years, I have paid more than $8,000 in insurance premiums while collecting less than $3,000 in total benefits.  Economically, it would have been significantly cheaper for me to forego insurance and pay for everything out-of-pocket, but if all the healthy and self-reliant did that, then those seeking insurance under the current system would have astronomically high premiums.  Hence the need for Obamacare’s “individual mandate” — it shifts costs to people like me, from people who go to the doctor every time they get a sniffle.  How, exactly, does forcing the healthy to subsidize the unhealthy pass social-justice muster? Under what ethical paradigm does forcible charity become an intrinsic public good?
  3. Health insurance is available, voluntarily, to protect against genuine catastrophic risk.  These plans will be more consistent with genuine insurance coverage, insofar as they have nothing to do with routine well-care and everything to do with protecting against major loss from serious, unexpected injury or unforeseen acute medical conditions.  Trauma risks (e.g., getting hit by a car) could be covered in full, with a fairly low annual premium to reflect the relative infrequency of major traumas.  Protection against clinical risks like strokes or heart attacks would also be available for optional purchase — a risk-adjusted model based on factors like behavior or family history would be more expensive, but may be an option that some would prefer to purchase.  Actual prices would be based on an actuarial assessment of a person’s likelihood of loss, relative to the total pool of covered lives, in accordance with free-market principles.  Allowing companies to offer insurance across state lines is a good first step toward building the right kinds of pools that would make true catastrophic care comprehensive but inexpensive in an open, personal market.
  4. State or community programs will manage risk-adjusted chronic-disease populations.  A major question within the health-care industry today is how to best manage people who have long-term chronic conditions like cancer or diabetes or HIV.  There is no right answer.  Some people respond well to ongoing medication, others to diet and exercise modification. Some people need ongoing dialysis or expensive drug therapies.  These are things that contribute to insurance costs. However, a registry-based program that allows teams of specialists including doctors and nurses and community health workers to engage with patients in a comprehensive manner to address all aspects of their chronic condition is a step in the right direction. The question, however, is cost:  Who pays?  A chronic condition is not an insurable condition, but it’s also not clear that it’s appropriate that the rest of society subsidizes treatment costs, particularly for conditions that are largely the result of lifestyle choices.  One option: Registries.  Allow people to sign up for programs to treat their condition at low or no cost, with actual costs borne by drug companies or community non-profits or even local or state governments. Hospitals and physician practices could receive tax incentives for contributing to registries, because there is a public interest in managing chronic conditions before they become major (and expensive) health crises.  The market could work its magic with registries.  For example, a leukemia registry may be funded by pharma companies that actively solicit patients to engage in drug research.  Or a diabetes registry in one state may be funded by a health-focused private foundation that thinks it has a better option for disease management and is willing to fund a demonstration project that is applicable across the country (Gasp! Federalism! Diversity in programming!  Oh, l’horreur!)
  5. Local communities could provide well-care subsidies for low-income families.  Yes, we all want to make sure babies, including poor ones, get proper treatment and immunizations.  To that end, local communities could provide health clinics to assist low-income families cover costs.  Churches could pool donations with local foundations to hold a free-clinic day every few months, for example.  Or county governments could operate basic clinics for families with incomes below a certain level.  There are many options for assisting low-income populations short of a massive, mandatory, one-size-fits-all social-welfare scheme.

The bottom line:  We must inculcate the attitude that the only person responsible for my health is me.  Not the government, not my boss, not an insurance company.  Me.  Health care is a routine part of life, and the provision of health insurance as an employer-provided benefit to so many for so long has led some people — mostly on the Left — to conclude that the government has an affirmative duty to keep people healthy.  This assumption is patently absurd, but it persists, and any viable repeal-and-replace program must convincingly show an average citizen how self-responsibility provides greater flexibility and lower cost than the chimera of Obamacare or the siren song of universal single-payer insurance.

Some readers of this blog are aware that the author is affiliated with a West Michigan-based hospital. The comments in this posting reflect only the author’s perspective and should not be considered a reflection on the hosptial’s perspective, nor a statement offered in the author’s capacity as a hospital employee.