Health care principles and problems

View 707 Tuesday, December 27, 2011

I am weary of saying that I am not an apologist for Newt Gingrich, then writing as if I am; but the headlines give me little choice. I have long said that Newt would not have been my first choice for President, but he is an old friend, and he would be a far better President than our current one. The nomination ought to be based on rational discussion, not on headline gotchas. There is a sense in which the future of the Republic depends on this principle. The Internet Age followed rapidly on the TV age which followed the Radio Age, and all of those had enormous effects on the way we choose our national leaders. Now we have Facebook and Twitter, and instant polls, and what gets lost in all this is any rational discussion of issues.

As for example the Wall Street Journal front page headline” Gingrich Applauded Romney’s Health Plan” (link) which begins “Newt Gingrich voiced enthusiasm for Mitt Romney’s Massachusetts health-care law when it was passed five years ago, the same plan he has been denouncing over the past few months as he campaigned for the Republican presidential nomination.”

Way down in the page 4 continuation it says

At the same time, the essay cautioned that the Massachusetts plan may not work. It warned that the state has an "exhaustive" list of health-coverage requirements that prohibit insurers from offering basic plans with high deductibles. It predicted that state residents earning little more than $30,000 a year—the threshold for an individual to qualify for subsidized coverage—would be "in jeopardy of being priced out of the system." Instead, the newsletter said, "we propose that a more realistic approach might be to limit the mandate to those individuals earning upward of $54,000 per year."

It also gave a nod to the concept of making it easier for Americans to purchase insurance across state lines, an idea widely backed by Republicans as a mechanism to make coverage cheaper through competition.

A follow-up August 2006 newsletter from the center called Mr. Romney’s plan "the most interesting effort to solve the uninsured problem in America today." It praised "a Republican governor working with a Democratic state legislature to find a bipartisan reform that is based on market-oriented principles." (link)

The entire article comes closer to a rational presentation, but the entire front page is not. Nor, despite the argumentation posing as a front page news article, is it clear that Mr. Gingrich’s position on the Romney plan for Massachusetts is not consistent with principled conservatism. I would have thought that the notion of state’s rights and allowing the states to experiment with solutions to very sticky problems was almost the essence of the Constitution of 1787.

Certainly the conservative position on health care is that it is not a national “problem” to be “solved” by national action. Whether or not any government actions can “solve” whatever is meant by the problem of health insurance, I for one am glad of the Massachusetts experiment. Like X projects in aerospace, it is an experiment that gives us some data rather than models and theory; and I cannot think that Gingrich’s “approval” of the Romney plan is somehow indicative of any betrayal of conservative principles. If some kind of universal health insurance program is going to work anywhere, it should work in Mass., a wealthy and highly educated state able to afford it if anyone could.

Any discussion of conservative principles and health care has to begin with some facts. One of those facts is that the courts have in essence nationalized a form of universal health care: they have decreed that emergency rooms cannot turn people away for lack of insurance or other means to pay for the treatment they demand. Moreover, there is, I think, a general consensus among the American People that the spirit of this mandate is acceptable: people should not die in hospital waiting rooms while trying to prove they can pay. Of course that seldom happens, and often the treatment demanded is not urgently needed, but we are agreed that people ought not be denied emergency care.

That simple principle works with some populations with strong moral and ethical principles that include limits on what they think they are entitled to. It works in many American communities to this day. It may work in Massachusetts for all I know. It does not work in Southern California, where eleven hospitals have closed their emergency rooms, and the once world class trauma center network we had is nearly forgotten. The hospitals close their emergency rooms because they can’t afford to keep them open: the alternative would be to close the whole hospital. (Another alternative, triage in the waiting room doesn’t work and subjects the hospitals to crippling law suits. The Courts in essence won’t permit it.)

And that is the essence of the “health insurance problem.” Insurance is not welfare, and requiring equal premiums for all insured – granting the ‘right’ to insurance for those with pre-conditions at the same premium as those in good health – is not insurance at all. The obvious strategy for those with crippling pre-conditions is to buy the insurance, while for those in good health it makes sense to buy no insurance at all until symptoms appear, then rush out and buy it. Given that rational economic strategy of the customers, the obvious rational strategy of insurance companies is to declare bankruptcy, and for their executives to get into some other line of work, possibly as welfare administrators.

As Mitt Romney has repeatedly said, in Massachusetts they had about 8% population without health insurance. Everyone else was satisfied with what they had. The plan, which was passed by a Democratic Party controlled legislature, attempted to deal with that situation and provide for the 8%. In theory it wouldn’t affect anyone else. How well it works is worthy of study, but it is the business of the people of Massachusetts, not mine. In Los Angeles County we have had eleven emergency rooms close down, considerable stress on those remaining, and the loss of our once renowned Trauma Network. I don’t know what the situation is in Boston. Were I in the health care business I would pay more attention.

The real question is, who is obliged to pay for what? If an elderly uninsured person has a heart attack and requires emergency care, who is obliged to pay for it? What is my personal obligation? And for that matter, if I have a heart attack, should you pay for it? (I will quickly acknowledge that when I did have medical problems, I had no lack of free expert advice from readers and subscribers, for which I am extremely grateful; but I think that is a different matter. None of that was compelled.)

That is really the essence of it all: who should be compelled to pay? Should the physicians and technicians be compelled to render their services for free? That seems unfair. It is also unlikely to produce a good supply of highly educated and qualified physicians, nurses, and technicians. And yes: I do understand that the supply has in the past been artificially limited (or at least that this is contended) in order to keep the price of those services artificially high, so the compulsion is not so monstrous as it seems – but that leads off to another question about who is compelled to pay for medical and technical training, the costs of such education, and the monstrous quality of the school system. And we haven’t time to deal with that.

We don’t even have time to deal with the question of “who must be compelled to pay and for what?” – yet that is the essence of the “health insurance” problem. When I was young the matter was simple enough. You paid for your own medical services, and if that proved to be beyond your means you sold property, or borrowed money, or did whatever was required; or you didn’t pay and the doctors gave you what service they thought you might deserve of their charity. There wasn’t much medical insurance as such. There were charity hospitals, mostly run by Christian religious organizations.

Health Insurance became widespread largely because it was a way for employers to compete for good workers during a labor shortage in a time of wage controls: the business could deduct the insurance payments as a cost of doing business, while the insurance benefit was not taxed as income for the laborer. The result was widespread insurance among the employed, and that led to the situation of establishing one’s insurance status when being admitted to hospital – and that led to the horror stories of people dying in the waiting room while filling out forms. And that made health insurance a political problem.

But the political problem never really addressed the question: Who must pay for what? What are you obligated to pay for my health problems?

Once we establish that principle we can look at mechanisms for dealing with it; and having a cold look at this first principle should once and for all establish a simple fact: it is not a federal problem. It may be a state problem: Massachusetts chose to make it one for the people of that state. That will depend on the ethical and moral principles of the people of that state: and given the relentless war on religion, that may be an interesting picture. Perhaps the answer is simple: a relentless drive for entitlement to the masses at the expense of the productive. This has happened before through history. The Framers of our Constitution hoped to avoid this at least on a national level by limiting the power of the federal government: but leaving matters to the states means that states will approach such matters in different ways.

I have no definitive answers here, but it does seem to me that before we talk about the mechanisms of “solving the health insurance problem” we deal with the more fundamental question: “who must pay for someone else’s health care?” and on what moral or ethical principle is that obligation based. Until this is answered we have only the simple principle of “democracy”: You have it, and we want it. Republics fall when that becomes the basis of government, and the rich turn to a protector, usually a ‘friend of the people”. The result is seldom to anyone’s liking, as we say with the Soviet experiments.

Of course that kind of democracy usually does produce a ruling class.

I do understand that politics takes over from rational discussion. When that happens the trumpets of leadership become uncertain. The personality substituting for Rush Limbaugh, for example, is today in near despair, while desperately proclaiming Newt Gingrich a liar for his comments on Romney’s Massachusetts health care. After all, didn’t he approve it? But it’s a bit more complex than that. Newt is wrong to impute to Romney a desire to impose the Massachusetts plan on the nation. I don’t recall Romney ever wanting to do so. He has, correctly, defended the state’s right to the experiment.

Newt is correct in denouncing Obamacare and saying that the Massachusetts plan must not be imposed on the United States. He was correct when he said it was an interesting experiment. He is playing politics when he attributes to Romney a desire to impose this on the nation. I certainly would not have advised him to do that. I will say that Mr. Gingrich has been far less negative in his campaigning than his Republican establishment enemies have been.

Newt thinks a lot and he says what he thinks. It was true when I was associated with him and it is true now. He generally surrounds himself with smart people who are not afraid to tell him he’s wrong, and he tends to enjoy those discussions. This is a very good practice for a legislator. It is less so for a commander in chief, but it is not a fatal flaw for a president. The President of the United States is not the Emperor. His whimsical decrees do not have immediate effect. The most important requirement for President is a dedication to the Constitution. That, I think, applies to every one of the Republican candidates.

Reagan once told us as a general rule to nominate the most conservative electable candidate. That was good advice then and it still is.