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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