rationing

Why Pragmatism cannot win the Healthcare Debate

The debate over healthcare has raged for generations.  It has toppled at least one Congress, and threatens to topple another.  Through all of this, the pragmatists have been largely victorious, which means: They have sold us out again.  Healthcare remains a difficult issue for politicians, because of economic and moral questions that must be factored into any debate.  The first failure of 'pragmatists', and the worst, in fact, has been their unwillingness to deal honestly with the American people.  This has led to the abominable side-show of senior citizens, demanding in sincere indignation: "No government Healthcare! Keep your hands off our Medicare!"

From the moment one sees this abortive reasoning put forward, one very quickly becomes aware of the fact that somebody, somewhere in this argument, hasn't been playing it straight all these years with the American people.  To the assembled multitude, I shall now endeavor to do so, and almost nobody will like it, but none will be able to claim I've been anything less than truthful.

There are a few concepts we must cover before we can even begin to untangle healthcare.  The real question in healthcare, in the US, is not about the quality of the care, but instead how it is to be funded.   No other place on the planet offers so many healthcare options.  There is no place else on Earth to go if you cannot be made well in the US.  One can cite some exceptional procedure or treatment here or there, but these are merely the exceptions that prove the rule.  Let us not linger on the care itself, but instead turn to the meat of this issue, as it is and has been for all of the life of its public debate.

Healthcare will be rationed.  This is an explicit fact.  You can run circles trying to disprove it, but by any measure, healthcare, like toilet paper, or gasoline, or food, is rationed.  The question is, however: "Rationed how?" Or, "By what mechanism?" or "According to what standard?" Herein lies the real argument, the true crux of the matter, and it is a tempestuous thing for politicians, because it leaves them no wiggle room. For 'pragmatists' this is certainly uncomfortable ground.

Up until the advent of the 'Great Society' programs of the late 60s, the mechanism for rationing had remained what nature decreed: The free market.  The free market allocates resources in answer to only two questions, and they are interesting to consider: Who is providing a supply, and who is demanding how many units of care?

My argument, to which I will return in due course, is that this had been the most thoroughly moral thing about American healthcare financing until it was supplanted.  However, let us first examine the mechanisms then created in order to set aside the natural rationing provided by the free market.  Medicaid and Medicare were created to provide the mechanism for re-rationing some portion of the available care to those to whom the natural market would not provide it: The elderly, beyond their earning years and unable to afford it, just when they would need it most, and the poor, who couldn't afford it much at all.  The argument was successfully advanced that the rest of us should dedicate some portion of our earnings to pay for the care of these two classes.  More, the argument was successfully made that we should be compelled to do so.  Herein lies the ugly nature of government programs:  Coercion is the prerequisite for their enaction.  This is another fact from which pragmatists readily flee.  They will say "some coercion is necessary," painting the matter in terms of a necessary evil.

Suffice it to say that the concept of a 'necessary evil' is a deadly contradiction in terms, and while I shall leave that subject for another day, it is necessary that you understand the premise behind my argument here: If a thing is necessary, it means there was no other alternative.  In the absence of alternatives, the only available course of action becomes amoral; questions of morality are only in play where choice is possible. No choice? No morality. No morality? No evil. This then leaves you with a solitary and much easier question: Is there no alternative, in fact?

So here we have the moral plea of leftists, and other statists, along with their 'pragmatic' friends at the center stripe: "What should be done about the poor, the elderly, and the infirm?"

This, they leave you as your sole choice, but what have they craftily ignored? They have established a premise that in the name of morality, something must be done.  Really? According to what moral standard? By whose moral authority? The answer? By theirs.

You see, it was never asked if there was any moral authority to club you over the head for your wallet, or at least threaten to, on behalf of somebody who needed a bandage, an aspirin, or a hip replacement.  No, it was presumed from the outset that you exist solely to serve the needs of your fellow man.  Presumed by whom? Why, them, of course.

It would not have been so bad had they only decided to brow-beat you, to implore you like the ringing bell of a Salvation Army's kettle Santa, but instead, they took up arms against you, and leveled the guns of government and said: "Pay, or else. Besides, you'll feel better about it."

This is the same ploy that is being used now, as they push for some form of entrenched governmentally-redirected healthcare cost shifting.  The question isn't whether we should have some form of universal care, but only what particular form it should take.  In the end, they are still going to redistribute the wealth of some Americans at gunpoint, to the advantage of some others.

From there, it's a lose-lose for freedom, and the American people at large.  It is the avoidance of this question that makes the so-called 'pragmatists' dishonest.  It is their sell-out on the first moral premise that dooms us to failure.  By accepting the statists' view of that first premise, the outcome becomes one of inevitability and certainty.  They will get their way, with the help of the pragmatists, and it will be their morality that defines it.

Once you've let them get away with any claim to your wallet, by whichever moral standard, you've thrown open your wallet to all comers, with you as the beggar for your own means.

This is where the rubber meets the road in the debate over healthcare financing, and it is here we must fight it.

I know the Left likes to ridicule anyone who mentions Ayn Rand or Atlas Shrugged. They especially like it when conservatives or Republicans say something about "Going Galt".

It seems to me that one reason for this is a (deliberate?) misunderstanding of what we -- or at least, I -- mean when we say that.

By "Going Galt", it seems to me, we (mostly) mean that someone will not take that next step, make that investment of time, effort, thought, or money, to make their mark in the world and make a difference.

Like Rand's great philosopher Hugh Akston who became a short order cook in a roadside diner, rather than using abilities to their utmost, someone who "goes Galt" might simply choose to do something else, rather than take the extreme Galt/Wyatt/Mulligan option of completely removing themselves from the reach of the looters and the moochers.

In that light, I think Obamacare is going to cause us more problems than many have been imagining. . . .

I have heard from a surgeon whom I trust and respect (though I don't know his source for this information) that much more than half of all surgeons are 55 or older.

Given the basic premise that people do things based on the incentives involved, and given the further premise that Obamacare (or, if it fails, the next incarnation of it) will reduce the financial and professional incentives to become a doctor, my friend believes strongly that we will be in for medical rationing simply because we will not be able to find enough doctors, regardless of what happens due to gov't bureaucratic manipulations.

My friend spent 14 years -- FOURTEEN YEARS -- after college training to become a doctor, then surgeon, then getting his specialty skills.

What makes people think that we will be able to find "volunteers" to go through such a rigorous and lengthy program, all the while incurring massive amounts of debt for the cost of their schooling and training, just so that they can be asked to work 36-hour shifts* for whatever salary a bureaucrat determines they are worth?

My friend loves his work. He does it for the satisfaction he gets from it.  (Now.) But when asked if he would have gone through everything he went through solely for the satisfaction of the job, he says no.  The potential to make a good living for himself and his family was definitely part of the attraction to the career choice in the first place.

There are other jobs he could have loved and been accomplished in performing, while paying well.  Plus they would have afforded him much more time to spend with his family as his children grew up, rather than having to spend significant portions of not just days but nights as well away from home and on call.

The point I want to leave you with is that we can expect to lose men such as him from the medical profession if we insist on making them gov't cogs rather than free actors, capable of making what they can in a market which rewards them for their dedication, efforts, sacrifices, and skills.

Beware what you wish for, Obamacare supporters.  You might just get it . . . and then the supply of producers whose efforts you have appropriated will dry up, relieving you of the burden of looting them.

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* Yes, I know the 24+ hour shifts don't last forever.  And that they are concentrated in the early years of training, but does that really make anyone think that people will jump at the chance to perform such arduous tasks for the pittance the DC paper pushers are willing to fork out?  Really?

Let’s put aside our right-leaning suggestion box for a moment and put the challenge straight to the left as follows… (Warning: intellectual honesty check.) Will your bill:

1. Control Costs? If you have any third-party payer system, you’ll have a situation in which people overconsume. Because they have no incentive to be bargain shoppers, they won’t shop for bargains. Costs will continue to go up. Subsidized healthcare ensures people will continue consume more of what they don’t have to pay for directly. That’s the major driver of costs in healthcare. How will you deal with this problem—which is the main problem (not “administrative costs”?)

2. Avoid Using Price Controls? Bureaucrats determining prices will, as it always has, mean gross distortions (that whole supply and demandt thing). In the absence of real prices, resources don’t get allocated properly, because prices are a way to deal with dispersed, complex information. This is the problem we saw in the Soviet Union and it’s a major problem for the Canadian system. Will your system use price controls?

3. Avoid a Special Interest Bonanza? Any subsidized, government-provided reform will mean healthcare becomes a Freddie and Fannie phenomenon. Private companies that serve the government insurer will become special interests. They will game the system and rape it, as they have in so many other spheres of our life when colluding with government. Their prices will go up (unless controlled) and their profits will remain private. Losses will get covered up by continued subsidies and cost-shifting through higher taxes. This may also mask the cost-spiral (for a while). Eventually, heavy rationing will ensue or taxes will go through the roof. Is this bill healthcare corporatism?

4. Avoid Rationing Healthcare (Limiting “Access”)? If the government really wants to control costs, it will have to ration care. The problem is, we need a system in which individuals ration their own care, not bureaucrats with little or no connection to the individual. I ration my own healthcare (by shopping with my HSA dollars) and I prefer to keep it that way, despite the protestations of leftish types who believe they can make better decisions about my healthcare than I. Rationing means quality goes down and access gets limited.

5. Avoid More Deficit Spending? President Obama seems to be betting on energy taxes (cap and trade) to pay for what would amount to massive increases in government spending on healthcare. If the cap and trade bill doesn’t pass, will the government be able to pay for healthcare reform by simply cost-shifting to the wealthy? Or will taxes go up for everyone and big time rationing happen? The American people are at their end with the record deficits. Are you willing to push the envelope?

If your healthcare bill can’t pass this simple 5 question test, it’s not a good bill.

This week the Congressional Budget Office projected enormous cost increases under the current congressional plan for national health care. It was promoted as saving taxpayers money, but the CBO estimates a cost over $1 trillion and it is likely to raise the tax burden for many Americans to close to 60% of their already dwindling incomes, as government bureaucrats balloon the cost of what is already the most expensive health care system in the world. The devastating financial impact of ObamaCare for the nation and every citizen is now overwhelmingly clear. But just in case you still harbor any illusions about how disastrous current proposals for national health care would be, I thought it was time to revisit the other cost — the cost in human suffering and loss of life under socialized medicine.

A key element of the cynically misnamed Affordable Health Choices Act, which is the plan currently being rushed through congress to meet deadlines and criteria set by President Obama, is rationing health care using Comparative Effectiveness Research (CER) methodology where government bureaucrats would set up schedules by which treatment would be allocated based on statistics and cost to benefit ratios rather than the interests and needs of the specific patient. Decisions on care would be matters of policy based on group effectiveness rather than on a case by case basis and doctors would have to abide by these decisions without regard to the welfare of the patient.

The impact of rationing in other nations where it has been introduced as part of the national health care system has been horrendous. It attempts to reduce the financial cost of the system by a trade-off which increases the cost in lives lost and individual suffering. Two nations with many similarities to the United States which have resorted to rationing health care are Great Britain and Canada. In both nations the human cost has been high and the results are easily quantified.The failure of rationing comes down to two basic problems — denial of treatment and very long wait times. Both of these can result in suffering and death for patients, especially those with critical and chronic conditions which are treated easily and routinely in the United States today, but which often result in death in Great Britain and Canada.One telling scenario of denial of care comes with cardiac patients. In the United States if you come into a hospital with an arterial blockage you are usually scheduled for an angioplasty or a bypass in a matter of days, because that is the best way to achieve a long-term solution to the problem. In Canada and Britain the common response is dictated by a shortage of surgeons and facilities, so you are given beta blockers to try to keep your heart functioning and sent away. If you're lucky you'll survive the months that it takes to get you scheduled for surgery or maybe come into the hospital in the middle of an actual heart attack when your chances of surviving the surgery are lower but they may actually operate. Or even better, if you live in Canada they may slap on a heart monitor and have an ambulance drive you to the US for treatment as they do with hundreds of cardiac patients every year. The sad reality is that many who are denied immediate surgical treatment for heart problems just die.In the US a coronary patient is four times as likely to receive surgical treatment as in Britain. In the US only 5% of Americans are made to wait more than four months for surgery. In Canada 27% wait four months or more and in Britain 36% wait four months or more. While the base rate of coronary disease in the US is higher than in other countries because of diet and lifestyle, the rate of survival for those diagnosed with coronary problems is much higher than in other countries because patients get the best and most appropriate treatment more quickly.

The same pattern holds true with cancer. Overall Britons and Europeans in general die at a higher rate from all forms of cancer than US citizens and the difference is dramatic in cases where early detection and treatment are important. For example, women with breast cancer in Britain have a 46% death rate as opposed to 25% in the US. Men with prostate cancer in Britain have a 57% mortality rate while in the US only 19% die and the death rate is declining rapidly because of early detection. It's the same with colon cancer. In Europe as a whole there is only a 8% survival rate, in Britain there's a 40% survival rate and in the US there's a 60% survival rate. With cancer of the esophagus only 7% survive while in the US 12% survive, although it's still one of the most deadly forms of cancer. Both long- and short-term recovery and survival rates for all forms of cancer are also significantly higher for US patients. Rationed care has limited diagnostic facilities like MRI machines and has created long wait times for specialist doctors. In fact, 40% of cancer patients in Britain never get to see a cancer specialist at all, and the National Health bureaucrats have denied basic tests like pap smears and ruled out powerful chemotherapy medicines as too expensive, all of which has cost lives. With diseases like cancer where early detection and treatment are vital,  resource rationing means a lot more dead patients.

The human cost of delay of care caused by rationing is particularly significant. One key element of this is the wait time to see a specialist who can provide the best treatment for specific ailments. In the US 74% of patients get to see a specialist within four weeks. In Canada only 40% get seen that quickly and in Britain only 42%. In many cases these delays can cost lives, but the cost of suffering has to be considered as well. In both Canada and Britain the wait times are even longer for conditions which are not life threatening, but can be very painful and seriously reduce quality of life. In Britain a hip or knee replacement can take more than five months and in Canada it can take as long as eight months. That's a very long time when pain is literally crippling.

An unsurprising irony is that as our congress looks at health care reform, activists in Canada, Britain, and a number of other countries are also looking at health care reform. The difference is that they are trying to figure out ways to introduce more choice and more market elements and reduce rationing at the same time we are plunging headlong into the same mistakes which they made a generation ago and which they now realize have left them with unacceptable failures in their systems with thousands of preventable deaths every year and millions stuck on waiting lists for essential treatment.

This is how bad it can get with government-run, single-payer systems, which may have a cost in lives and suffering, but do at least bring down the cost of health care. Imagine how much worse it could be with a combination of government bureaucracy and rationing and the high prices of private insurance and you have some idea of what ObamaCare will be like. It is likely to have all the flaws of socialized medicine while preserving most of the shortcomings of our current private insurance system, because the thousand-page bill which congress was considering is largely authored by lobbyists for the health care, pharmaceutical and insurance industries. It's like yet another bailout for these industries at a high cost in life, suffering and taxation to the American people.

Even the far left agrees that the health care plan currently being rammed through congress serves the interests of big insurance, medical and pharmaceutical companies while doing more harm than good to the average citizen. It rations and reduces the quality of medical care. It massively increases costs and forces small businesses and individuals to purchase insurance plans at inflated prices which they cannot afford or pay substantial penalties which they also can't afford. It passes many of these costs on to the public in huge tax increases. It doesn't solve the key problem of inflated insurance and health care costs and is projected to still leave 20 million people uninsured.

This may be the most monumental legislative disaster ever given serious consideration in the notoriously profligate halls of congress. This plan is not what the American people have in mind when they think of health care reform. It ignores their needs and sets their interests aside to pander to statist radicals and big business. The American people deserve better.

Chris Dodd's committee.: We "heart" rationing care.

No word on whether Senators will get "enchanced customer service" from the public insurance option.