22 December 2009

more health care craziness

10 reasons why liberals are idiots

10 reasons why progressives are smarter

Going through these, several seemed like blatant misinterpretations of the present bill. If there is an optimal reason to oppose the present legislation it is indeed because it does not go far enough on some counts (in any ideological direction you could care to come up with, from libertarian to liberal, I'm not totally sure what the conservative direction has to say but then neither are conservatives). What that does not mean is that pundits who want it to go farther should say it's bad because of x-y-z things that actually make sense and were necessary components of the bill itself (as presently designed). Put more simply, if someone wanted the bill to be a stronger move for a single-payer system, placing more of the burden on taxpayers rather than the poor/middle-class say, then they should simply argue for that. That "that" was never on the table, and is most probably politically impossible in America for a number of reasons (generally weak public support for single-payer systems among them), should also be acknowledged. My support for a system that would resemble Wyden-Bennett or Singapore was thrown out of the possibilities almost immediately, so I can sympathize with the single payer folks who got it through their heads quicker that they were out in the wilderness. That neither objective was in play told me the system we would end up with would be a very weak "reform" at best. That does not give me a reason to defeat legislation that incorporates a few of those views (namely taxing high end health insurance plans and creating public risk pool exchanges). Assuming that it would improve upon the status quo which I think it does in some core areas like access to health care markets. I'm less sure if it does on balance because the cost curve issue in the long term is the most pressing reason to reform health care in my opinion. Following the Massachusetts model doesn't seem like the best way to keep that cost containment in place, particularly if they throw out HSAs, which Massachusetts did not do.

So going down the line of specific complaints, the only legitimate, factual ones seem to take on the form of complaining about the mandate (or indirectly, the level of subsidies) and putative restrictions on abortion accessibility. I'll deal with these in a second. The problems of "coverage they cannot afford/use" are more or less idiotic displays that ignore that millions of people who have coverage already cannot use it and millions more cannot afford it at all (or are rejected because of sometimes reasonable medical concerns and sometimes more asinine grounds). Likewise, the complaint about taxing insurance benefits as provided by employers, especially because of the limited nature of those taxes is completely stupid. It was, in my opinion, one of the strongest liberal arguments about taxation and distributive wealth FOR taxing employer benefits, particularly above some "absurd" figure because the primary beneficiaries of such benefits are not middle class "working" people but their CEOs who can then receive not only access to higher quality medical care but can do with tax shelters for the income that they would use to pay for it themselves. I have no complaint if wealthy people wish to have access to the best quality care. But they should at least have to pay for it instead of receiving a tax break for it. So I don't get why liberals would complain about that point at all.

I happen to think individual mandates on this point are better than nothing. We have them at the state level for types of property insurance. They don't reliably work to reduce problems with free-riders (millions of people still go uninsured at a rate roughly similar to that of health insurance already), but they do change the market toward one which offers lower costs to people who participate in it. People who cannot obtain insurance are, in the case of cars, probably people who we don't want driving anyway, but there are many people who wouldn't participate who are perfectly decent drivers and who thus lower costs for people who are slightly less perfect who we would want in that market. The same applies to health insurance. I disagree strongly with some of the mandates which make the market for individual insurance far less beneficial for young individuals like myself, but conceptually I think the argument that (young) people are imposing a cost on others when they free-ride and do not carry health coverage is a strong one in favor of a mandate. It also makes no sense to argue philosophically about the reforms on the table and complain that older people can be charged more for health insurance. I'm positive if I were an insurance agent, I would want older people to be charged more myself because they're far more likely to actually make claims. If you want younger people to buy in politically, you're going to have get old people to share the costs. The fact that "conservatives" have framed the various amendments that make medicare cuts or which may require additional burdens on modestly wealthy older folks doesn't make much sense to me from the ideological framework of "conservatism" but it does make it feel odd when liberals share those concerns now. In order to make this argument you have to overlook that currently, it costs old people even more than 300% more than everybody else, and it costs women a lot more as well. And neither would be the case under the Senate bill. I am not totally convinced that either is a necessary outcome of a market situation, but I would agree that the present case is both unsustainable economically (because we have so many seniors about to enter public subsidized care) and doesn't pass a sort of moral fairness sniff test (because much of women having additional costs constraints is because of gender specific costs that sometimes should be shared by men, ie, pregnancy and it still often doesn't cover other costs which are directly imposed by men, ie, domestic abuse/rape non-emergency and secondary treatment costs).

Supposedly the opposition to mandates is that people couldn't afford it. I think this is an argument, if one is a liberal, for stronger state subsidies or, if one is a libertarian, for (much) stronger cost containment which could bring down costs, but it doesn't by itself make a reliable case against mandates for purchasing insurance. So far it's the only one surfacing (other than some bizarre assumption that it would/could be deemed unconstitutional which while ideologically consistent, is even kookier than the assumption that people couldn't afford it). I have more of a bone to pick with the precise form of what constitutes "insurance" than what constitutes a civic duty on this point. Judging from the form these mandates have taken over the years, it would appear liberals do as well. Though naturally enough it appears they don't understand "insurance" as a financial instrument that exists to protect against individual catastrophe rather than as a pre-payment plan with "insurance" written on the title. Despite that ideological fault line, I see it as a considerable problem to go around complaining about "insurance people cannot use" and then ignore the fact that many people already have insurance they cannot use because it does not provide enough coverage, doesn't cover specific things, and does cover silly things instead (as mandated by the state legislatures or regulatory boards). The one obvious thing this bill does do is expand access to otherwise decent "insurance" that people could actually use to pay for their necessary medical care. Unless they're looking at a completely different bill, that particular complain is nonsense.

That leaves the elephant of abortion in the room. There are several points to be examined here. First, federal funding already doesn't cover abortions (save those which are deemed medically necessary) because of the Hyde Amendment over 30 years ago. If you wanted to overturn that, be my guest (I don't think it's politically possible because of the strange bargains necessitated by a federal republic form of governance). So if you were poor enough to qualify for Medicaid, you aren't losing anything from this restriction anyway. And that is the precise group of people I'd be most concerned about having increased access to elective abortions because there is already a decreased means to support children on a limited income supported by state assistance funds as well as the one group of people who were never going to be receiving assistance anyway as they weren't insured by employers or by private insurance. Two, the Senate bill is far less restrictive than Stupak was in the House, giving states opt-in/opt-out clauses (it's still a restriction I could live without personally, for the record). Three, a stronger case should have been made months ago with the stimulus package provision subsidizing birth control for people on unemployment/state assistance. That would have made the staunch opposition to abortion limitations from these bills seem at least ideologically consistent and fair-minded (where the sponsorship and support of these limitations, in addition to the ridiculous media opposition to the birth control subsidies, does not seem fair-minded and sensible at all). Four, abortion is still divisive enough that a few influential votes in Congress needed to pass something modestly related to a woman's health, as determined by a body mostly composed of men, are sufficient to block expanding access to middle-class and lower-middle class women and to continuing blocking access to poorer women. Five, stronger opposition to state rollbacks of access, such as parental consent laws, zoning regulations, any other tricks in the book to force closures of abortion clinics and access to other forms of birth control more generally are far more likely to expand access than federal subsidies are. There are already substantial portions of the country where abortion may be legal, but it doesn't exist legally. Federal subsidies may give people an ability to pay for the abortion itself when they wouldn't have been able to, but they're not going to give most women or families an ability to travel across state lines or from some rural part of a western state into the nearest major city in order to seek that out.

The one substantive objection which I (and Ezra) agreed with was the objections to the "Big Pharma" compromises, both the continued absurd protectionism and the continued monopolies over developed end products. I have some misgivings in relation to removing the re-importation system simply because many drugs in other countries are heavily state-subsidized (or directly price controlled), but I don't share the official state misgivings of "they are not safe" or that it would require more regulatory work or whatever else is our supposed problem and even accounting for state subsidies, say by enacting a reasonable tariff to pay for them, the market imbalance we have would be greatly improved by introducing some competition. Besides which, if we're going to grant these exclusive monopolies to drug companies as well as offer them the benefits of state-sponsored research grants and other corporate welfare methods, it doesn't seem fair (in a market sense) for drug companies here to turn around and complain about foreign competition doing more or less the same thing.

One other final note, there's a lot of push back that this bill is a giveaway to insurance companies and other medical providers. I think of the two, medical providers won a lot more than insurance. This was never a bill which seriously complained about medical care costs themselves or sought to address their rising costs. It was always a bill about expanding access to insurance so more people could pay for medical care with somebody else's money (which is what a risk pool of insurance is). The demonization of greedy insurance companies has been amusing, but it isn't at all a real world examination of why we have such expensive health care. People are, I suppose, right to complain that they're getting a large and captive market in which to "compete", with a few stipulations about how they can compete. But really most of that complaint ought to be directed at monopoly hospitals and government prices as dictated through medicare/medicaid warping the marketplace into some horrid abomination. Health insurance has never seemed to me like a particularly profitable industry and of course, it isn't (3% is a razor thin profit margin, basically if you are running a corner gas station you're worse off but that's about it). At least not in comparison to something like automobiles, oil, banking, or farming. All industries which have historically received far more state support or state manipulation to protect market shares rather than protect markets. If people want to complain about health insurers getting all these profits, they should get in line when there are other corporatist measures. And they definitely shouldn't be so quick to assume that it is the insurance companies that are driving the price increases rather than merely being beneficiaries of price increases caused by something else, such as increased market control by providers, medical licensing, distortions in specific medical field availability caused by price controls, and non-transparency in health care prices AND for the costs of insurance itself. There's plenty of blame here to go around and if consumers (patients) aren't willing to eat the sandwich they're making, I don't know what to tell them.

Put some more mustard on it (require more value in QALYs) or make a different sandwich next time (vote in new people) would be all I could advise.

As a side note, I personally still oppose the current bill and more or less the entire framing of this as "reform". But I'm finding people on the opposite end(s) of the ideological spectrum from me to have far less sensible objections and to sound suspiciously like the Republicans they are stubbornly and partisan-ly opposed by rather than raising major economic or even ideological complaints about both the processes used to devise the plans and the end product, which is annoying enough to both follow as a news item and to vent the annoyance in blog form.
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