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On the Third Hand: The Hunger Case

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The Manhattan Institute has sent me a link to a great commentary by Richard Epstein and David Hyman about why the Patient Protection and Affordable Care Act of 2010 (PPACA) — also known as “ObamaCare,” also known as “That Infernal Law” — will “end health insurance as we know it.”

Jerry Ellig of the Mercatus Institute, an arm of George Mason University, has posted another great article about PPACA, “Rushed Rules of Health Care Law Don’t Add Up,” about how poorly analyzed PPACA is.

Epstein, Hyman and Ellig are coming from the right and doing what the writers at The Washington Monthly — a Democratic-oriented magazine — used to do from the left in the late 1980s and early 1990s: Focus on making arguments based on facts and commonsense principles with broad appeal, grounded in the Bill Clintonian — and fundamentally Ronald Reaganian — idea that “The ideals that unite us are are more powerful than any differences that divide us.”

The Democrats, and some Republicans, including people at groups like America’s Health Insurance Plans, Washington, who came up with the basic ideas behind PPACA way back in the 1990s and early 2000s, seemed as if they were sincerely doing their best to take that noble idea to heart.

They came up with notions with bipartisan appeal such as, “We need a special health insurance program for children, because they have no power to decide whether they are free riders, or whether they go to the doctor at the right time or the wrong time,” and “We need better protections for patients who have disputes with insurance companies, and for patients who do their best to maintain credible health coverage and then become sick.” The result was the Orrin Hatch and Edward Kennedy sometimes ended up voting for the same bills.

Since then, the lobbying industry has expanded, because, let’s face it, money aside, it’s so, so much fun to go to Washington and belong there. It’s a blast to walk through congressional office buildings and know where in the maze in the basement to go to lunch. It’s really great to go in the Capitol itself and see interns and junior staffers pretending that they’re bored with it all. 

My guess is that they all get along just fine with the lobbyists from the opposing side and go out to eat nachos together. But, because they are so smart and motivated and having so much fun, and they think of themselves as being engaged in gladiatorial contests of immense public importance, they get us all riled up.

Many people tend to blame the riling up on money, or corruption, or space aliens who’ve taken control of Washington and built a vast, subterranean network of tunnels that extends from Washington to Denver and sometimes becomes a seismically impressive nuclear battleground. My sense is that, especially in the age of the Internet, the people who have the most impact would probably continue to do what they do, roughly the same way, if no money were involved at all, just as poets continue to write poetry and independent filmmakers continue to make films, even though little or no money is ever likely to be involved.

The problem is that the most visible Republicans — certainly not insurance industry people — tend to make it sound as if we should indeed start a Hunger Games-type civil war against the Democrat infidels, before the Democrat infidels take away our guns and start the war first.

The most visible Democrats seem to have given up on the old Washington Monthly-style, consensus-building efforts and wandered into a hall of anecdotal mirrors.

During the PPACA congressional debates, Republicans were quietly delivering wonderful, precise, fact-based critiques of the weaknesses of PPACA. Meanwhile, on talk radio and talk TV, the main arguments seemed to be that President Obama was a Marxist Kenyan KGB Manchurian candidate who wasn’t his mother’s son and was keen on setting up death panels.

Democrats would respond by bringing out an endless parade of sick people, and relatives of dead people who used to be sick, to talk about horrible and expensive it is to be sick. Democrats also talked about how cruel and greedy the Republicans were, in an effort to gouge Republicans’ political eyes out as effectively as the Republicans were gouging Democrats’ eyes out. I don’t think the Democrats’ efforts were equivalent to the Republicans, but only because the Democrats were so easily distracted. They would try to destroy the Republicans as human beings, but then notice more bright shiny anecdotes about sick people and go fly away to pick those up out of the research rubbish pile.

Of course, the real faults with the bills that formed the rickety foundation of PPACA have nothing to do with whether Obama is a Marxist Kenyan, and hardly anyone in all of America, including the most conservative, tough-minded libertarian or the most luxury-loving health insurance company executive, disagrees with the idea that it’s horrible and expensive to be sick, or intentionally wants to make life harder for sick people.

But the system is doomed, and will change, no matter what happens at the Supreme Court in the next few months, because the system is doomed, because it doesn’t work. The question isn’t whether sick people — even poor, irresponsible, irritating sick people — should or should not be able to get decent care when they are sick. The question is how we do what we want to do, and what we can actually do. It’s fine to say that all people should get great care, no matter how poorly they’ve prepared or how much they’ve paid in taxes. It’s another thing entirely to achieve the goal, while, simultaneously, achieving other essential goals, such as maintaining a vibrant economy, protecting ourselves against enemies and crooks, and educating the young. 

We keep rolling a giant potato made of the gap between needs and resources around the economic system. Sometimes the need gap potato grows and sometimes it shrinks, but it’s always there. If we pretend it’s not there, it just gets bigger and bigger till it forces us to notice it by hitting us on our heads.

The Hunger Games movie is about people who compete for riches and glory based on luck and survival skills. Because of the need gap potato, the U.S. health care system is now about people who compete for getting health care without falling into poverty based on how well they take care of themselves, where they work, how street smart they are, and how persistent and lucky they are.

I have three college degrees, have fine health insurance and write about this for a living, and I have no idea how to get a checkup not to be billed as a sick visit without filing a fraud complaint that will probably somehow backfire and get me locked away in Gitmo. I don’t feel as if I have any reliable protection at all against any illness more serious than a cold.

Consulting firms have predicted that the end was near for the health system as we know it ever since I got to National Underwriter Life & Health in 1996. Employers have been struggling to keep coverage in place through all these years, and, generally, it seems as if the percentage of employers with group health plans has held reasonably steady. The mantra is that, “The commercial insurance division suffered in-group attrition this quarter due to layoffs, and, in some cases, businesses closing down, but the penetration rate among employers that continue to exist is about the same.”

But even a lot of the small, hardy, thrifty employers that have managed to hang on since 2008 are now on the verge collapsing. Three small employers have tried to hit little broke W-2′d me up for desperation loans since November. Turning the federal legislative clock back to 2009 isn’t going to help small group health coverage penetration and the small businesses’ brokers. All that can help those businesses and brokers is if the credit card companies suddenly ease up and raise the credit limits from the suffocating levels where they are today. It’s hard to believe that many small business owners who are scrounging for a few hundred dollars to pay the rent will hang on to group health coverage in a no-PPACA world.

Individuals mostly can’t qualify for coverage or can’t afford it. People who qualify for public health programs often can’t cope with the red tape. One of the small employers that hit me up for a loan should qualify for Children’s Health Insurance Program (CHIP) coverage for her son. But she’s self-employed, and, to sign up for CHIP coverage for her son, she has to provide a business financial statement from a Certified Public Accountant. How many people who qualify for Medicaid and are on the verge of being evicted from their apartments can afford to get a financial statement done by a CPA?

Doctors are miserable and upcoding patients’ bills with fraud-indictment-provoking enthusiasm because they’ve lost all financial hope. The hospital system my family has been using and many, many more have gone the same crazed upcoding route.

We could try to solve our problem by turning our health care system over to Europe, but European countries have their own need gap potato problem.

Many European countries with much larger government health care systems do actually have much better health care systems than ours. People in the Netherlands get much better, more systematic care than U.S. people generally do from doctors who are readily available in the evenings and on weekends. But European countries are about to have to change their systems, too, because most of them fund their social welfare systems on a pay as you go basis. Their baby boomers are starting to retire, and younger workers have found that the opportunity to earn good, income-tax producing pay has gone bye bye. 

Some would say that the current situation is the obvious outcome of government interference in the health care market. Sure. Obviously. But the alternative seems to be to get something like what we have in the dental market. The dental market is a lot freer than the medical market and in some ways works great. No government-imposed shortages there. But half of Americans get no care at all, or primitive or sporadic care.

Someone will say, “Well, charitable institutions and generous people will somehow take care of the heart failure and the diabetes of the people who have any curb appeal whatoever.” But, is that true? What of all the current unmet need for dental care even among cute, cuddly children? And how easy is it for poor, ugly, boring poor people to get dental care? Judging by the mouths of the lower income people in my area, not so easy.

I haven’t read The Hunger Games books. No one in the movie explains how the situation that led to the events that occur in the movie really came about. But a system in which only about half of the people get much health care seems as if it could be material for a prequel.

Giving too much emphasis to equality, even of opportunity, is bound to lead to disturbing, efficiency-lowering results. Bill Gates and the people who started Google deserve to be filthy rich and have giant houses. But a country in which inequality was so bad that half of the people got the kind of health care that poor people in Haiti or Nigeria now get would probably not be good for the insurance industry. The countries where a few people control most of the income and wealth are not known for their booming life and annuity markets. Kidnap insurance, maybe. Armed guards and personal servants, sure. Charted Life Underwriter holders who walk clients through needs-based planning questionnaires? Not so much.