On the question of whether health care is a market commodity or a human right, conservatives tend to come out on the commodity side, when they address the issue at all. Not so in reacting to Obama’s tentative application of cost-benefit analysis to publicly-funded end-of-life care, however:
I don’t know how much that hip replacement [for my terminally ill grandmother] cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life—that would be pretty upsetting.
This statement has produced a firestorm of criticism, to say the least. If I am understanding that criticism correctly, and I may not be, the right is arguing that raising the issue of cost in relationship to government-funded health care is a sign of a vicious, Nazi agenda. If so, then it seems to me that those critics do in fact believe that access to today’s state-of-the-art medical technology is an entitlement that the government cannot withhold on a cost or any other basis. This is a perfectly defensible position. It is just contrary to the right’s usual pronouncements and should be made explicit.
Likewise, when Limbaugh et al. use the term “rationing” as a self-evidently fatal rebuttal to any health care reform proposals, they also implicitly embrace the idea of health care as an entitlement.
Of course, the issue would not come up if health care were fully private—a solution that we are unlikely to achieve. And I do not mean to defend any of the emerging Democratic health proposals, none of which I purport to understand. Obama’s demonization of insurance companies is typical Democratic demagoguery; his notion that the government can act as a fair competitor to private providers is ludicrous; and his failure to call forcefully for deregulation of the health insurance market makes a mockery of his goal of offering consumers greater choice at lower cost. But I don’t think that raising the question of what health care is owed when taxpayers are footing the bill should be off limits; the question does not require any particular answer.
There is probably a mix of reasons, but the reason the “death panels” talk resonates with me is not that I believe in entitlements, it’s that I believe in a free market in health care. Health care is necessarily a matter of life and death (at the extremes, anyway), and socialized health care mean socialized life and death decisions – death panels. It’s not that I want to live in a fantasy world where everyone is entitled to infinite health care. It’s that I don’t want the decisions to be socialized.
It really does make a very big difference who gets to make the decisions. Consider an analogy with reading.
In a free market with free speech, I get to choose what I read or don’t read, to the extent that I can afford it. If a government – if a panel of experts – gets to choose what I read or don’t read, that’s indoctrination and censorship all rolled into one, and it’s a long way toward totalitarianism. In both cases, a choice is made, but it really does make a very big difference whether the choice is made socially or by the individual.
One might argue that health care is unlike literature in that the best treatment for a given illness is not subject to individual taste. That may be, but consider that we have a free market in food and nutritional requirements are not subject to individual taste either. Even where demand is uniform across the human species, a market for that uniform product is preferable to a government monopoly for a variety of reasons. We know that in a monopoly prices go up and quality goes down. We know that in a government-mandated monopoly the incentives are so fundamentally screwed up that government has no choice but to regulate the monopoly in order that it provide something resembling market quality. But we also know that government regulation of a monopoly is hardly a fix, especially where the industry (and hence the monopoly) is often able to capture the regulatory authority.
the mainstream conservative movement doesn’t have to address the tension here between the the logic of the market and allocation of resources by price signal and the rights-based principles of the religious right in this case. the electorate doesn’t punish philosophical incoherency at all (the early disagreements between russell kirk & the more libertarian segments of the old right illustrates that *intellectually* the circle has not been squared, but most people don’t need too much intellectual rigor in the first place).
constant, three points/questions
1) people over 65 relying on medicare are already socialized right? (i don’t know the details of end of life treatment, so willing to be enlightened)
2) obviously the insurance company has some input in the cases of most people who are getting various treatments. though again, i don’t know the details of this.
3) in the case of the uninsured under 65, there is medicaid, but even if there isn’t medicaid there are public charges and charity cases and mandatory treatment in emergency rooms, so in these cases the choice may also be out of your hands.
from what i understand a disproportionate (some say most, but i haven’t confirmed) amount of medical expenditure is “end of life.” i think in some ways this is outside of the bounds of normal economic calculation. there aren’t any trade offs, you die, or you don’t. in the foxhole at death’s door we’re all materialists who believe in extinction of self 😉
“… his notion that the government can act as a fair competitor to private providers is ludicrous…”
Please explain why this must be so. The Post Office hasn’t driven Fedex and UPS out of business. Most conservatives think that, with vouchers, private K-12 schools can compete with the public schools and don’t object to a “public option”. Hell, they compete without vouchers. The private health insurers spend a lot of money in Washington to get what they want. They will be well represented at the table. All the rules insuring fairness can be negotiated.
Why anyone believes our current health care system is a free market is beyond me. It is utterly controlled by liability, litigation, and insurance, which are in themselves a form of government control. Insurance companies are pretty indistinguishable from these ‘death panels’ people are ranting about, and the whole litigation side of things is a direct function of government regulation. Fear of being sued leads drug companies, hospitals, doctors, etc. to heap on layers of insurance and to do unnecessary procedures, which when you look at how many layers it creates adds up to a whole lot of money on each transaction going to something other than the care of the patient.
Our medical system is screwed. We need to either remove the stifling layers of government mandated litigiousness and allow it to go back to free market, or just let the government handle it while we pay for our own unnecessary procedures.
Charlie: The reason the government can’t be a fair competitor is that when times get tough, a company goes out of business or scales back, a government controlled entity just asks for funding and takes the money from your pocket by force.
The only reason these government controlled entities don’t out-compete their corporate counterparts entirely is that the government pretty much sucks at doing everything. They aren’t hungry like a private organization; they don’t have the same need for success or fear of failure.
It’s funny, but Obama brought up this very same question the other day, and tried to justify his government insurance option as being no danger to the industry:
“My answer is that if the private insurance companies are providing a good bargain, and if the public option has to be self-sustaining…then I think private insurers should be able to compete. They do it all the time. I mean, if you think about it, UPS and FedEx are doing just fine, right? No, they are. It’s the Post Office that’s always having problems.”
Doesn’t that just make you want to hand over some more taxes to create a government program?
I don’t call health care a right but I think it is something that a good government should help its people obtain. The fact is, we don’t send off sick people to die in the woods which is what a purely private, purely free-market system would allow. Instead we have Medicaid & Medicare and other state-sponsored programs (plus some charities) to cover patients that can’t get full coverage.
Are private health insurance companies looking at data for treatment effectiveness? You betcha: Pretty much the same data the government has. The helps guide private insurance’s treatment decisions (plus some PR and etc.) as it also should for Medicaid and Medicare.
I agree with Heather’s assessment: The “Death Eaters” (i.e. those that swallow the “death panels” BS rhetoric), seem to think they can have it all: Infinite access to treatments at a finite cost. Private plans *already* ration and make decisions about what treatments are available to their customers. I would be upset if a government managed plan didn’t also rely on available research to determine which treatments work best (if at all). It’s reasonable to expect that a government funded program to at least try optimizing treatment options. I’d just expect the government plans to be a bit more transparent than private plans.
Are there many people with private plans in the over 65 group? I don’t think so. At best, most only carry supplemental insurance.
“… when times get tough…”
Times are pretty tough right now and though the Post Office is ” always having problems” I don’t see any bailouts for them. They have to raise their prices and suffer the market consequences. Isn’t that fair?
You are right about it not being a free market. The only health insurance I can afford was selected by my employer. I had two choices- take it or leave it. The cost to me for the insurance is hidden as are the prices for the medical care itself. Too many middlemen between buyer and seller.
Heather, your “problem” is that you are bothered by intellectual dishonesty and logical inconsistency–how quaint! Apparently you did not get the bulletin that these traits are no longer disqualifiers in modern conservative thought. Indeed, they are perfectly welcome so long as they are believed to aid “the cause”, whatever that may be.
In short, modern conservatism has no higher fidelity to the concept of truth than modern liberalism has long displayed. Hooray for us!
David Hume,
Those look like three points, addressed for some reason to me. Were you asking me a question or challenging me on some point? I’m not sure what it is. If you want me to comment on the current system, some of which you described, my comment is that I prefer movement in the direction of a free market as opposed to movement in the direction of a more complete takeover of medicine by the government. The CEO of Whole Foods wrote a specific list of proposals in the WSJ Opinion Journal which I like very much as progress in the right direction.
Argon:
“Private plans *already* ration and make decisions about what treatments are available to their customers.”
Individual plans do but you can choose a plan. And yes, this does matter, a lot. To re-use my reading analogy, when you buy a book the author “rations” what you receive (there are only X pages and no more in the book you buy), but you get to choose whether to buy a shorter or longer book. It’s qualitatively different from a situation in which a state-appointed panel of experts rations how much and what you can read.
“I would be upset if a government managed plan didn’t also rely on available research to determine which treatments work best (if at all). It’s reasonable to expect that a government funded program to at least try optimizing treatment options.”
As long as you think that the government plan is merely another option, this is fine. But if you fear that the Democrats are trying to socialize health care, then this is not fine, for reasons I’ve laid out.
“I’d just expect the government plans to be a bit more transparent than private plans.”
I would argue that is unrealistic.
“Are there many people with private plans in the over 65 group? I don’t think so. At best, most only carry supplemental insurance.”
Probably, but all this really shows is that nobody is going to turn down free services (i.e. services which are already paid for through taxes wheher you accept them or not). It doesn’t really demonstrate the superiority or inferiority of anything, which I think is what you’re trying to argue, no?
David Hume:
“the mainstream conservative movement doesn’t have to address the tension here between the the logic of the market and allocation of resources by price signal and the rights-based principles of the religious right in this case.”
I’m not going to try to defend the “mainstream conservative movement” because I don’t really know what millions of people are thinking. I can really only tell you what I’m thinking. Since you mention market allocation in a way that, in context, suggests it is fundamentally the same as the rationing that Rush Limbaugh decries (and I haven’t listened to Rush Limbaugh – again I can only tell you and defend my own understanding of the idea of “rationing”), I’ll take the opportunity to dispute this.
“Rationing” has various meaning, and granted, some people say that “rationing” is an appropriate name for what happens in a market every day. However I would like to point out that this is not how “rationing” resonates with me and, I think, with a lot of English speakers. First, let’s examine a dictionary to see if there are any definitions present which explain the special resonance that “rationing” has for me.
Merriam Webster defines “ration” as “a food allowance for one day.” Let us say, “an allowance for one day”. Let us finally say, “an allowance” (of which the periodic allowance that children receive from their parents may be the most familiar to some). It is a certain fixed amount, not under the control of the individual. It is, typically, on the modest side. Historically, rations are associated with privation, specifically with the privation associated with war. Food rations are also associated with centralized control over distribution. Look up “war time rations”. I’ll quote from one page describing it:
“During the war, and also for several years afterwards, there were many food shortages. People were only allowed so much of some particularly scarce foods. This was partly because it made things fairer for everyone, but it was also because the rationing was a lot better for us.”
“Every member of every family would have had a ration book and it gave precise details of the amounts of certain types of food that you were allowed during one week”
All this feeds into what “rationing” really means to an English speaker hearing it.
Consider another English word, “quota”. A “quota” is in many ways a good synonym for a “ration” – in a system of war rationing we might equally say you are given a certain ration, a certain allotment, a certain quota of food. If someone like Rush Limbaugh were to decry “quotas” (such as racial quotas), I hope it would be less of a temptation to argue that they’re being inconsistent because the allocation of resources by price signals is an example of “quotas”.
Now, “quota” has more innocuous meanings depending on context, much as “ration” does, but there is, perhaps, less forgetfulness about all that it can mean.
Charlie: The Post Office has little to worry about from prices or competition. Is it fair that they are the only ones allowed by law to deliver non-urgent letters? I’m surprised they haven’t sued e-mail providers yet. I cut the Post Office more slack than other such agencies because at least they arguably have a constitutional mandate, but their ability to stay in business is a direct result of their government immunity from the Sherman Antitrust act.
Steel Phoenix – to add the drama of history to your point about the Post Office:
“The American Letter Mail Company was started by Lysander Spooner in 1844, competing with the legal monopoly of the United States Post Office (USPO) (now the USPS) in violation of the Private Express Statutes. It succeeded in delivering mail for lower prices, but the U.S. Government challenged Spooner with legal measures, eventually forcing him to cease operations in 1851.”
Constant:
“Individual plans do [ration and make decisions about what treatments are available] but you can choose a plan.”
I can take the employer-provided plan or leave it. If I leave it, I pay substantially higher costs for the same coverage and run the risk of being denied coverage because of ‘pre-existing conditions’ or being priced out of an affordable plan should I get sick.
Given that I’m currently healthy and have no good way to predict what health problems are likely to befall me in the future, it’s hard to choose a particular plan on the basis of what they are or aren’t going to cover. Furthermore, these coverage policies change. Sure I can jump between insurers if I don’t get sick (and change my personal physician), but I fall ill, I’m stuck.
So no, my current “choices” are not realistically broad. As Heather noted, one cannot get infinite service for a finite fee. One cannot get around limited resources. Personally, I don’t object to *rational* rationing or limitation of services but I *expect* the process to be transparent (which it is not in the private sector currently). Assuming the government plan remains simply an option, at least it sets a lower bound to what for-profit services should provide.
“So no, my current “choices” are not realistically broad.”
They would almost certainly be narrowed even further in a more fully socialized health care system. Meanwhile, for my part, I recognize and suffer under the limitations that you describe, and I advocate movement in the direction of a freer market in health care. I mentioned and endorsed the recent proposals of John Mackey, the Whole Foods CEO, as good recommendations that would move us toward a freer market in health care.
But I don’t think that raising the question of what health care is owed when taxpayers are footing the bill should be off limits; the question does not require any particular answer.
That’s right. The problem is that introducing the government in the manner the bill was suggesting would give the government a say in how your body is maintained. The “death panels” are the most noticeable end of this wedge. So they’re getting a lot of play. Once they’re in, the usual suspects would move on to other obvious targets, like smokers and fatties. Then the health fascists would start on exercise, or they might go after video games and television–using health care expenditures as a justification. In fact, you can probably work in just about anything by tying it to the nation’s health.
Also, some conservatives have noticed the dissonance, and they’re using it against the liberal claim that health care is a “right.” If it’s a right, why set up a panel to ration it?
Constant: “They [options for health insurance providers] would almost certainly be narrowed even further in a more fully socialized health care system.”
Narrowed, but perhaps providing more reasonable coverage and mobility between plans. The current system has been narrowing through business consolidation and profitability is maintained, in part, by cornering the market.
I agree with some parts of Mackey’s plan but don’t believe that they are sufficient to provide coverage to all, ultimately be more flexible, or necessarily drive down cost. For example, he says nothing about companies not covering those with pre-existing conditions or how health plans work to eject members and sub-pools who become sick. What Mackey’s plan will do is largely continue the split between the haves and have-nots of medical coverage. It will do nothing about the ultimate consolidation of insurance companies to a small number. It also assumes that consumers know how they’re likely to become ill prior to choosing a plan. But if they knew that, then wouldn’t they also be in a higher risk pool and consequently pay more for the plan that better covers their illness?
The fact is, if health insurance is going to be reasonably affordable and its costs equitably spread across people in a nation, everybody has to get into big pools and the risks have to be evenly spread across them. Again, this is something Mackey’s proposal does not address. It may be a libertarian dream to allow companies to cherry-pick their risk pools but realistically, that’s a political non-starter. I’ve been fortunate to work for companies large enough to force insurance companies to group all employees in a big pool. Many people are not so lucky.
It’s so odd where various political groups have landed on this issue. Republicans are mortified at the thought of harming Social Security or Medicare, but seem to think that any other kind of socialization is the beginning of death panels. Democrats want socialization, but aren’t willing to propose it.
I see the least functional system as being somewhere near what we have now. We’ve been talking about insurance as if it is an individual issue for each policy. At the point where everyone is mandated to have insurance for everything, what’s the point? Why not just cut out the middle man and make it a tax? Anything the government mandates, it should provide. They need to either keep their hands off or socialize it, these public/private partnerships are sucking the lifeblood of the country.
Just as Democrats spent 70 years increasing the power of the presidency, and of the federal government and were appalled by what George W Bush did with all that power when he got a hold of it, there are some issues it may be fun to point out to the advocates of ObamaCare.
1. If there is a public option, that means the government will pay claims and via the CPT code, drug codes, etc. know what they are for.
a. Do we REALLY want a permanent government record of all the women who ever had abortions?
b. Do we REALLY want a permanent government record of all the people who ever got birth control, and when?
c. Do we REALLY want to make reporting of ‘reportables’ to law enforcement computerized and efficient? These range from gunshot wounds (almost always reported) to allegations of domestic violence (which may just be the doctor sees a bruise on someone’s back and are seldom reported), having certain diseases, etc.
d. do we REALLY want computerized medical records subject to the same review all insurance companies conduct wherein the government can see if the doctor says we are using illegal drugs, engaging in risky sexual practices, or doing other things that they think mean we’re not taking care of ourselves properly?
e. Do we really want the government to hear all about whatever idiotic psychiatric or other diagnoses incompetent doctors enter into our charts – or even the valid ones – and then see what they do with the information? E. g. a recent doctor charted I drink 2 tumblersfull of scotch daily when i told her I drink 2 beers a week and maybe a scotch and soda, maybe not, in addition.
2. Do we really want the government caught between the rock and hard place of protecting our medical confidentiality and sharing the information above with local and state and federal law enforcement agencies? E. g. some state that has a parental notification law decides to go check with the parents of all the girls who got abortions whether they were notified or not?
3. What about the issue of organ donation? Everyone whines there are not enough donors. The government could pay to have everyone tissue typed and have it in their charts so they know who is a desirable donor….. then what happens?
4. Palin’s death panels. Of course, that could NEEEEEEEEVER happen here! NEEEEEEVER. At least not as long as we have a wonderful CARING and COMPASSIONATE guy like Obama in charge! (try not to puke, please). Ask all the democrats if they think President Cheney would be able to behave and not establish death panels to control costs so he didn’t have to raise corporate taxes on responsible companies like Halliburton and see what they say. Remind them of all the stuff Dubya did using all that federal power Democrats created over the years.