Archive for the ‘Health Care’ Category

Unfortunately, the DC Circuit slapped down a challenge to the surviving and strict antigun rules of Washginton DC post-Heller to allow various restrictions on firearms, while allowing a narrow right to own a handgun.  Of course, in other areas of law, we would not expect a constitutional right to be treated this way.  A law allowing newspapers, but not magazines, would not pass muster under the First Amendment.  Likewise, allowing people to vote, provided they do so in the most inconvenient times and places and with various prohibitive fees, was struck down in a series of decisions in the 1960s.  Thankfully, there are relatively few anti-gun jurisdictions these days:  Chicago, Wisconsin, California, and some of the Northeast are pretty much it.  “Shall Issue” concelaed carry is now extant in approximately 40 states.   It would be unwise to appeal this decision to the Supreme Court until there is a bona fide circuit split.  For now, residents of the Imperial Capital must make due with Draconian registration requirements.

Incidentally, there is a lot of talk on the right that the individual mandates of the Health Care Law are unconstitutional.  As a matter of first principles, arguably this law and 90% of other things the federal government does is unconstitutional because they do not flow from an enumerated power.  Of course, there is a lot of water under the bridge, and the idea that the law’s individual mandate is intrinsicly unconstitutional and will be found so by the courts is somewhat fanciful. 

For starters, the mandate proceeds through a penalty tax:  get insurance or pay a higher tax.  The tax power is very broad; it was the basis of federal regulation of narcotics upheld in the 1919 Doremus decision, and it is the basis of a great many regulatory schemes, including the original 1934 National Firearms Act (which taxed but did not outright prohibit machine guns).  Most critics seem unacquainted with this body of jurisprudence.

Second, direct federal regulations such as OSHA, EPA, Clean Air Act, etc. control individual conduct all the time, such as in the requirement that cars have catalytics converters.   To undo the individual mandate would likely endanger all of this.  Perhaps that’s a good thing, but it seems a step that no court would take. 

Finally, at the very earliest stages of the American Republic–and coming full circle from Heller discussed above–Congress mandated under the Militia Act of 1792 that individuals own a musket, 20 rounds of ammunition, and other accoutrements to be prepared for military service.  And this mandate covered nearly the entire male population of the country.  This seems a very useful precedent for the health care defenders, but I’ve seen little reference to it in the papers and on the blogs.

There might be some basis on constitutional grounds to argue that conscripting states to implement the program dragoons their employees unconstitutionally into doing the bidding of the federal government (i.e., the holding arising from the Brady Bill in Printz v. United States (1997)), and there is also a growing (but largely irrelevant) body of law that certain non-commercial activities cannot be regulated under interstate commerce. That said, it’s highly unlikely a court challenge will undo this monstrosity, and, since the law is so unpopular, a court challenge is probably not the best way to proceed in order to cement the legitimacy of any such undoing.   It would be far better for the country, far more salutary to our character as a people, to reject this soundly and with much fanfare through the legislative branch.

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Interesting article on Obama’s penchant for issuing deadlines.  I think this is a mark of his lack of previous management experience; he has not lost face previously from setting deadlines that others and events outside of his control have rendered irrelevant.  He is a novice, and his leadership style shows it:  replete with abusive and over-heated rhetoric, unrealistic deadlines, contradictory directions to subordinates, paper threats, and increasingly ineffective strings of generalities he calls “speeches.”

It would be fun and funny if it all weren’t so deadly serious.  At least health care looks like it’s gone from very bad–socialism that destroys the independence and innovation of American medicine–to the merely bad, in this case a crony capitalist giveaway to insurance companies with toothless limitations on costs.  There will be some redistribution, mostly from the young to the old and, along the same lines, the healthy and insurable to those with chronic health problems.  But the government won’t (right away) be deciding who gets care and who doesn’t, private insurance will remain, and the Democrats will probably get wolloped in 2010.  And Obama will own this thing along with all the problems of American health care going forward.

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I’m in a bit of a blog rut. The same news basically keeps repeating itself: Obama’s abominable healthcare bill, our massive debt, our ailing economy, our lack-of-strategy or will or purpose in Afghanistan, and the general and increasing weakness of the country under Obama. What else is there to say about the latest behemoth healthcare bill. It’s an atrocity, and let’s hope it fails, but I have no particular ability to handicap its likelihood of passage or not.

As for the economy, the situation is bad and Obama is making it worse by running up huge deficits. Friends from extremely normal backgrounds–i.e., they weren’t reading Paladin Press books in college like I was–are talking about stockpiling guns, survival retreats, and general doom and gloom. These are guys that walk lon Wall Street and the Chicago commodities exchange, not habitual survivalist oriented nut jobs like yours truly.

Times have been worse of course. And God has his own mysterious unfolding plan in store for us individually and collectively. But I hate to write about the same things in the same way over and over again. I’m not quitting the blog. It’s still fun and helps me collect and clarify my thoughts. Something interesting and new should be on the horizon before long. But for now I feel great weariness.

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Ace hits the nail on the head in a recent entry. You would have thought abortion was a minor issue in the health care debate. You might not have even realized the House plan and ever-morphing Obama non-plan covered abortion. But it turns out it may split the Democratic coalition and this news has been a long time coming, but the media wanted it to be kept under wraps:

The media is never interested in covering wedge issues that effect Democrats. A wedge issue is any issue that divides the party. They’re always damaging in terms of getting elected or getting legislation passed, because, if there is a resolution on the issue, it is clear one wing has won and another wing has lost, and that causes all the internecine fighting we see all the time on the Republican side of the aisle.

A party’s best strategy — as far as simply acquiring and maintaining political power — is to obscure these wedge issues, ignore them, finesse them, leave them unresolved, to keep it unclear as possible who has won and who has lost.

And then, only later, once they’ve accomplished their short-term goals, do they deal with the political fall-out.

It is against a party’s interests to see these splits come to the forefront before they’ve achieved their short-term goals.

Clarity, in other words, hurts in politics. Witness Obama’s gauzy, empty campaign of change and hope without many people knowing what that meant. Liberals, leftists, independents and even some Republicans each read those empty words in a different way, each believing Obama would govern as they preferred.

Three of those groups were wrong. Had Obama been clear about his intentions and politics, three of those groups would have known they would be in the Out Group in any Obama presidency, and would have voted differently.

But because the media gave Obama a free pass on remaining utterly obscure, he prevailed.

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Obama is surprisingly naive for a guy who spent so much time in Chicago; there will be a million ways to bankrupt his healthcare system and exploit its vulnerabilities, and the end result will be an unpopular, unworkable, and very expensive system that will alienate his marginal supporters among white yuppies and independents.

Consider the scenario envisioned by Dick Morris:

Will a young, healthy, childless individual or couple buy health insurance costing 7.5 percent of their income, as required by Obama’s health legislation? Not until they get sick. Then they can always buy the insurance, and the Obama bill requires the insurance companies to give it to them. And if the premiums come to more than 7.5 percent of their income because they are now sick, no problem. Obama will subsidize it.

Instead, young, healthy, childless people will likely opt to pay the $1,000 fine (aka slap on the wrist) mandated in the bill. After all, even if they make as little as $50,000 a year, the fine is a lot cheaper than 7.5 percent of their income (or $3,500 a year)!

So … these young households will not contribute to the coffers of any health insurance company until they are sick and need the coverage. By then, their costs will come to vastly more than their premiums.

Who will subsidize the difference? We will.

“We,” by the way, are the “money people,” the 30-40% net contributors of the federal government’s revenues. These people of the upper middle and upper class, typically professionals or small business owners who have decent incomes–a far cry from the idle rich–will be ground into dust under Obama, and perhaps this is the real goal even beyond universal health care.

I’m not sure, though. Naivite, wishful thinking, and outright stupidity often explain things more fiathfully than grand and malevolent conspiracy theories. If there is one thing Obama has demonstrated in spades since his election, is that he’s not as sharp or even as street smart as his credentials would suggest. He’s a man of idealism and attainment more than actual achievement.

Naivite is exactly what we would expect from a guy with the “golden resume” rather than actual life experience. Rahm Emmanuel on the other hand . . .

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Obama showing his great political acumen and sense of American anger at his health care proposal, proposes to legalize illegal aliens so that illegal aliens are not covered under the health care proposal.  “You lie,” is simply too kind of a way to describe this kind of treachery and boot-strapping of an even more unpopular proposal to his health plan.

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I thought Obama’s big speech was more of the same. It seemed more of a pep rally than an attempt at persuasion. I doubt it moved the ball much.

I think Obama has read the anger of the last few weeks and his declining poll numbers not as a rejection of his extremism, but as a call to rally the faithful and the American people, who supposedly endorse this liberal craziness. He continues to misread moderates, old folks, and Reagan Democrats. The speech manifested an echo-chamber belief that the only problem is a lack of Democratic Party unity and passion, rather than principled disagreement and abject fear among critics.

I thought shouting “Liar” by Congressman Joe Wilson was a bit out of line, but, then again, there are times when a man’s passion for truth gets the best of him. . . . particularly if he’s of Scots-Irish descent.

This is fundamentally a health insurance debate, not a health care debate. People basically like their doctors, the high tech tests, the state of the art medicines, the rosacia drugs, and the idea that doctors will do anything and everything to save you. Because all of this high quality care is subsidized either through employers or group plans or Medicare and Medicaid, we don’t have a culture of economizing; people like the gold-plated care. But this is only because people don’t pay for it.

If people had to pay for it, though, they’d accept lesser quality of care, and this and this alone would drive down prices. It’s a chimera to say earlier interventions and less use of emergency rooms and records-keeping innovations alone would significantly reduce costs. The tests themselves are expensive, and they would reveal expensively treatable but otherwise serious or fatal conditions before they lead to death. This is probably a good thing from a social welfare standpoint, but it’s not cost-saving.

The Democrats’ beef with health care are contradictory, namely,

Democratic Diagnosis of Healthcare “Crisis”

1. There are too many uninsured.  Perhaps.

2. Costs are going up too much and too quickly.  But this is itself a phenomenon of third party payment, which will be made worse by expanding insurance coverage. See point 1.

3. They say there’s too much gold-plating and too much care at end of life.  But they do not state a willingness to embrace explicit rationing as a necessary feature of government-provided health plans. Further, these “problems” are quite popular with recipients, and channeling these people to government care worries them.

4. There are system-wide inefficiencies and inequities as a consequence of employer provided coverage, such as widely varying and confusing pricing, lack of portability, penalties for preexisting conditions.

My diagnosis of the problem is quite different, and it points to different solutions.

Conservative Diagnosis of Healthcare Problems

1. Too much goldplating and overconsumption due to third party payment.

2. Costs not transparent hindering competition in general and for copays due to widely varying private party negotiated prices and Medicare reimbursements.

3. Not enough penalties and incentives to self-insure leading to
abuse of emergency rooms .

4. Not enough demanded of recipients of public aid to reimburse and internalize costs of activities and poor choices .

Obama’s talk of paying for his plan by efficiencies in record-keeping, negotiated prices, limits on care, limits on “waste and inefficiency” is either disingenuous–the equivalent of proposing “flying cars”–or the inefficiency talk is a Trojan Horse for painful rationing that will be necessary to maintain Medicare and this new regime as solvent.

I have no problem in principle saying that we’re irrationally spending more on health care than we should. We are.  But we are because other people are paying for it. This is natural and predictable. But the market can and should decide the “right” amount through the kinds of insurance people choose ex ante and the kinds of care they choose ex post when they have to pay for it. I think most people will 80/20 everything and look for bargains when it’s up to them, just as they do on other necessities like housing, food, clothing, and cigarettes.  Those that want more will pay more.

Perhaps, people will think twice about destroying their kids’ inheritance for long shot care after a certain age, but, maybe not. Either way, that’s OK. It’s their choice, when it’s their money.  The problem with Obama’s plans is that this type of high quality care is not available, and the rationing is the choice of a government death panel. We make similar choices about homes to buy, cars to fix, and other necessities every day, and we do so privately with little government interference or subsidization.

I am above all a realist. There is a problem with people not doing what is in their own interest and abusing the welfare regime in place through emergency room visits. There is a problem when people are locked into jobs where there are ones at which they’d be more productive due to fears of lost coverage.  There are also problems with the lack of transparency in pricing, which hurts competition. With this view in mind, I would propose something like the following:

1. Limit Third Party Payment: End the preferential tax treatment of benefits. Mandate employers who drop insurance must pass some percentage of lost benefits to employees in terms of increased wages. (Admittedly, this is kind of crazy and interventionsist, but it’s necessary to sell the transition, and this is equitable to workers and should be revenue-neutral or revenue-positive to employers).

2. Mandate Rational Catastrophic Care: Require everyone individually to get absolute bare-minimum insurance or face extreme tax penalties and mandatory channeling to government poor-house care. This is paternalistic but necessary.

3. Accept Variable Quality of Care: Have low requirements for minimum policies that contain all kinds of limits on care in order to cut price and costs. This way people, not the government, are choosing to get state-of-the-art circa 20 or 30 years ago complete with generics, leeches, mercurochrome, whatever.

4. Make Welfare Painful: For those who are totally broke or improvident, channel funds and provision of care to government-run and charitable clinics, but make these sources suitably unpleasant with long waits, mandatory community service in case of nonpayment, and the like in order to encourage people to buy their own insurance. End mandatory emergency room care and transport the uninsured to this regime.  As a civilized society, we should not let people die of easily treated illnesses, but we should make public care costly in other ways so that recipients know they’re on welfare and will want to get off of it quickly.  This regime should completely replace Medicaid.

6. Transition From Medicare and Limit Costs: On Medicare, there’s a bit of an equity question. People have planned their affairs on the basis of expected benefits. But the system is going broke. I’d raise eligibility requirements, push out the retirement age, and phase-in means testing. I would also create financial incentives for the transition of younger individuals to lifetime, portable insurance contracts along the lines of life insurance policies. Those 45 and younger should have to do this.  This way people can pay a little more when they’re young than their immediate risk profile would suggest, but the risk is spread lifetime, and they’re choosing the level of care they want and can afford. Perhaps some tax benefits for choosing lifetime, over immediate care, policies would make sense.

7. Transparency: On prices, mandate something like the Truth in Lending Act.  Only allow one price for everything. Insurers can pick it up to whatever amount their agreement with their customer says. The rest can either be paid by the patient or written off by doctor.  Ban price discrimination between insurers, uninsured, different classes of plans, or the like. Mandate publishing online so people can check out-of-pocket expense based on their insurance plan.  It doesn’t matter what’s done with that price once it’s in place, so long as it’s out in the open.  The present-day regime of hidden, negotiated, and opaque pricing now hinders competition massively.

Clearly I don’t like the government involved in any of this, but other than facilitating the transition, an approach like this would radically reduce (a) government involvement in health care and (b) unrealistic expectations of highly subsidized government welfare. Instead, the government would only be doing things to avoid fraud and facilitate markets–such as measures to permit price transparency–and making people do what they would do if they were rational and responsible to avoid being wards of the state.

While not a perfect approach, this is a hell of a lot more freedom-oriented and reasonable than Obama’s. It would preserve the high quality and freedom associated with the American system, while addressing the genuine problem of skyrocketing costs, middle class anxiety over losing coverage, and the burden on the system and the public from the spread-out costs of the uninsured.

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Camille Paglia, an honest left-of-center commenter on all things political, takes Obama to task:

There is plenty of blame to go around. Obama’s aggressive endorsement of a healthcare plan that does not even exist yet, except in five competing, fluctuating drafts, makes Washington seem like Cloud Cuckoo Land. The president is promoting the most colossal, brazen bait-and-switch operation since the Bush administration snookered the country into invading Iraq with apocalyptic visions of mushroom clouds over American cities.

You can keep your doctor; you can keep your insurance, if you’re happy with it, Obama keeps assuring us in soothing, lullaby tones. Oh, really? And what if my doctor is not the one appointed by the new government medical boards for ruling on my access to tests and specialists? And what if my insurance company goes belly up because of undercutting by its government-bankrolled competitor? Face it: Virtually all nationalized health systems, neither nourished nor updated by profit-driven private investment, eventually lead to rationing.

And on the dubious condemnation of angry American citizens, she adds:

And what do Democrats stand for, if they are so ready to defame concerned citizens as the “mob” — a word betraying a Marie Antoinette delusion of superiority to ordinary mortals. I thought my party was populist, attentive to the needs and wishes of those outside the power structure. And as a product of the 1960s, I thought the Democratic party was passionately committed to freedom of thought and speech.

But somehow liberals have drifted into a strange servility toward big government, which they revere as a godlike foster father-mother who can dispense all bounty and magically heal all ills. The ethical collapse of the left was nowhere more evident than in the near total silence of liberal media and Web sites at the Obama administration’s outrageous solicitation to private citizens to report unacceptable “casual conversations” to the White House. If Republicans had done this, there would have been an angry explosion by Democrats from coast to coast. I was stunned at the failure of liberals to see the blatant totalitarianism in this incident, which the president should have immediately denounced. His failure to do so implicates him in it.

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This is called doubling down on a failed p.r. strategy: Nancy Pelosi calls protesters at health care town halls “un-American.” This after a few weeks of calling them “mobs” and similar calumnies.

I think whenever the legitimacy of opposition is questioned, as when Bush and Cheney suggested some anti-war protesters were unpatriotic, that is strong language that galvanizes one’s opposition and makes the speaker appear unhinged and afraid of criticism. Since Obama and his people have not made a positive case for health care reform, they’re now just going on the attack to distract the public from their lack of a persuasive and clear proposal.

At least Clinton’s ’94 proposal had a simple logic: there’s 40mm uninsured Americans, and his plan would entail universal coverage. Obama’s plan does not have universal coverage, and the plan is being promoted in wonkish detail without a unifying narrative: it will reduce costs supposedly, but it will not ration; it will cut from Medicare; it will wean people off private insurance; it may or may not fund abortion; it may or may not cut care to the elderly; it will allow you to keep your doctor, but what it won’t allow and how it will save costs and not raise taxes is still hazy.

All the public choice factors are in place for weak support and strong opposition. The people who care about health care the most–the long-term ill, doctors, the elderly with their gold-plated and highly subsidized Medicare–have no reason to embrace this unknown change, and neither is there any basis with which to create less passionate but more widespread support among the rest of us. It’s all pain and no apparent gain, it sounds expensive, and they haven’t even come up with a basic theme of what the benefits are. This is pathetic salesmanship. It mirrors the campaign with its glittering generalities, but here the object is not a charismatic leader who will supposedly heal our divisions, but a law with practical, indeed, life-and-death, consequences.

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Obama likes to manage the message in all its contradictions.  For him and his ardent supporters, it’s misleading to quote what he himself said about his goals when those quotes are inconvenient. Far from being a misstep, I believe these rather heavy-handed tactics to suppress come from The Man himself, the old Community Organizer, the Saul “Get in Their Faces” Alinsky disciple.  This arrogance was evident early on in a striking image:  his physical confrontation with a persistent reporter during his first trip to the White House briefing room.  How dare a journalist ask questions when he doesn’t want to be asked?

There is a lot of fairly pointless speculating about Obama’s secret life. He’s a Muslim.  He’s born in Kenya.  He’s a Manchurian candidate.  This is all mostly ignorant stuff.  But every presidency spawns its paranoid myths.  For Bill Clinton, it was the “black helicopters” and the UN plan to destroy Christianity and take away our guns.  For Bush it was that he was behind 9-11 and was going to create further pretexts to start wars with Iran and China.  Without regard to their truth or falsity–they’re nearly all  unbelievable on their face–these myths tell us something important about the anxieties a president provokes.  For Clinton, it was that he was too beholden to liberal and non-American values.  For Bush, that he was a militarist tool of shadowy forces.

Obama provokes the anxiety that he secretly is something quite alien from us–at best, a hardcore partisan for an extreme leftism, who is merely playing the political game as best he can to conceal the long-term agenda.  The myths gain credibility because of his secrecy about his leftist past in Chicago.  His centrist image is undermined when an old video or unscripted truth slips out, whether the talk of “bitter and angry” gun owners during the campaign, or siding against law enforcement in the Henry Gates situation, or suddenly embracing his middle name, Hussein, when crapping all over America’s reputation in Cairo.

The perception of Obama as a secretive, alien figure creates special anxiety in his attempts to change health care, because health care depends upon intimacy and trust of the doctor and patient.  This trust would be broken down by unknown and opaque government directives to save costs, to promote the “public health” agenda on guns or birth control, or cost-saving pressure in regard to inconvenient patients that “hurt the common good.”  In response to this narrative, Obama’s angry and forceful attempts to maintain his image will only reinforce such anxieties about the “Real Obama” among Americans already uneasy with him and his agenda.

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I love politics.  I read the political news regularly.  Yet I have no idea what the basics are of the Obama health plan.  I have no idea what problem it is supposed to solve.  I don’t know how it works.  I know it keeps changing.  But I don’t know how it benefits or hurts me.  I do know it will cost a lot of money, and I know it will expand the government.  I think lots of conservatives and moderates and even Democrats are in this same boat of bemusement and skepticism.

This is the first moderately complex policy Obama has pursued.  Everything else as been ready “off the shelf,” such as the “grab bag” stimulus or has been no policy at all such as his “Hate America” speech in Cairo.  Pushing policy is where skills besides speechifying come into place:  he must have the ability to translate complexity, the ability to compromise, and the ability to separate needs and wants in major legislation.  He’s shown none of those skills.  He’s descended into policy wonk abstractions talking about “the government option” or whatever it is this week.  He’s gotten side-tracked by abortion and other concerns.  He’s seen revolts from the Democratic Party’s left and right.  He’s been called out on his lies and exaggerations by the CBO Director.  In short, he’s failing before our eyes, just as Clinton failed, with an overly ambitious and scary policy that may radically change and ruin the quality of health care we receive.

The truth is most people want something impossible on health care:  the same level of care and benefits, while paying less, with minimal out of pocket expense, no penalties for preexisting conditions, and without regard to whether you’re employed.  This is impossible.  Either costs must continue to rise, benefits must be cut, or both.  That is called reality.  Obama is avoiding reality in his plan by suggesting the richest Americans can foot the entire bill.  But some of his critics are living in fantasy land too if they think the distorted market we have is an efficient one.  It’s probably overly generous in terms of quality of care, patient choice, and investment in R&D.  But that can all be easily fixed by giving people more pain from high medical costs and by giving people “good enough for government work” options of lower quality (but cheap) clinics and insurance.

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Medicare and Medicaid are hemorrhaging money. The biggest reason health care costs are constantly rising is that most of the price pressure is not felt by the consumers in the case of both the judgment-proof poor people who use emergency rooms without paying or the well-insured employed who pay small co-pays.

This situation has persisted for decades ever since benefits of all kinds were used during WWII to get around wage controls and have not been taxed as income ever since. Any restoration of cost controls in health care must bring the costs to the consumer, who are quite capable of economizing in every other area of life whether shoes, food, clothes, or housing when they must bear the lion’s share of the cost. In those areas of health care that are market driven–such as LASIK–costs come down over time and access is expanded. The same progress whereby luxuries become necessities works just fine in health care, so long as markets are allowed to work.

Even in a perfect world, it’s not so obvious why an advanced economy such as ours would not have expanded percentage of the economy spent on health care. As an economy develops, various luxuries like appliances, air conditioning, cars, etc. become more widely diffused as they become more affordable. Once those perceived minimum material requirements are met, why wouldn’t we expect people to spend a lot simply to prolong the time and energy with which they can enjoy those already-bought material goods?

Obama sometime suggests digitizing medical records will reduce medical costs and reduce medical errors. This is probably true, but it has nothing to do with the socializing ideas he wants to impose, such as subsidized insurance. What makes no sense with Obama’s plan is the notion that expanding the entitlement to insurance is somehow supposed to reduce costs. Insured people consume more health care. They particularly use more late in life when they bear no cost at all under Medicare, and the marginal utility of these public monies at their death is, for them, zero.

Reducing costs while expanding insurance will be impossible without severe rationing. Such rationing might make sense, but unlike a market regime, consumers may have little opportunity to spend their own dollars directly on health care outside the system, as is the case in such locales as Belgium or Canada. This is un-American and will occasion much grumbling, as too will the prospect of government bureaucrats prolonging wait times, cutting off access to “luxury” and lifestyle medicines and procedures, and other measures imposed to control costs.

Politically, however, this likely is a net advantage for Democrats and that’s why they’ve pushed it for so long. Wealthier people are healthier people, but they’ll spend much more than the actuarial tables dictate in order to finance the loose-living and more physically dangerous lifestyles of the poor (something they and all other insured do now) without the corresponding benefit of higher quality care. At the same time, with a significant government role in health care, every election will be a debate about generosity for the middle class. Republicans can’t win that game, and, as with Medicare and Medicaid, this will be one more nail in the coffin of fiscal responsibility, the spirit of independence among the middle class, and the prospect of constitutionally limited government.

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