Borrowed Thoughts on the Obamacare Ruling

I'd been holding back on posting on the Supreme Court's upholding of the Affordable Care Act, both because it's too hot to think around the Darwin house at the moment, and because I'm a non-expert on constitutional law and found most initial responses dispiritingly knee-jerk. Around Facebook (which since I'm reading Alistair Horne's history of the Algerian war, I'm picturing as a kind of French flash-mob of political opinion) the general consensus among my mostly conservative friends seemed to be that this was the day on which the US Constitution died. Given some of the amazingly bad Supreme Court decisions in our history (Dredd Scott, Roe v. Wade, Buck v. Bell, etc.) a ruling that congress can fine people (if we call it a tax) for not buying health insurance doesn't exactly strike me as rating among the top travesties.

Other conservatives (and apparently some progressives) have spun the ruling instead as some sort of a long term conservative victory in disguise (since it explicitly reject the ability of congress to require people to buy a product via the Commerce Clause.) Although I do think that, at a political level, it keeps the presidential race in November simpler to have Obamacare intact as a weapon to attack the administration with (given that it continues to be unpopular) rather than having it off the table or its most unpopular provisions removed, I don't think it's possible to spin this as a conservative victory. Clearly, the Democrats won on a large new social program being ruled an acceptable expansion of state power.

As if often the case at such times, Ross Douthat sums it up well, so I'll mostly quote his piece today entitled accurate, "Yes, Liberals Won":

There was a widespread and bipartisan impulse, in the wake of yesterday’s health care ruling, to cast John Roberts’ exercise in political finesse as a potentially significant long-term win for conservatism. Variants of this case were made by George Will and Jay Cost on the right, Jonathan Chait and Tom Scocca on the liberal side of things, and many others besides....

I would find this perspective considerably more persuasive if I could envision how, exactly, this war of “slow constriction” is supposed to play out. Does anyone really believe that a Roberts-led Court is likely to revisit the constitutionality of the major post-New Deal social programs? That it’s going to overturn child labor laws and minimum wage laws, or shutter regulatory agencies? Whatever precedent was set yesterday, that kind of genuine counter-revolution seems highly unlikely.

Likewise, does anyone believe that a host of new Obamacare-style programs — crucial to liberalism’s ambitions, but vulnerable to constitutional challenge — are likely to pass Congress in the next decade or two? If we were entering an era in which an aggressive, ascendant liberalism were poised to push through more sweeping social legislation, then Roberts’ line in the sand might matter enormously for a whole series of looming debates. But the state of our finances (and our politics) makes it much more likely that the Obamacare contest will be remembered as a last lurch forward for welfare state liberalism than the first of many attempted government expansions like it. The manner in which liberals won yesterday could theoretically cost them opportunities to further expand the administrative state, but they probably weren’t going to have those opportunities anyway.

In an intellectual sense, the logic of the health care mandate may indeed have been “pregnant with rampant statism,” as Will puts it. But in terms of practical politics, the health care bill was itself the most statist act that’s likely to pass Congress over the next decade at least, and maybe in John Roberts’ lifetime. And by upholding it, Roberts handed liberals a victory in the scope-of-government war that matters most to them, while at worst setting them up to lose some less important skirmishes somewhere down the road.

On a side note of particular interest to Catholics, there seems to be some confusion out there on which "mandate" the Supreme Court upheld in this ruling. The mandate in question was the individual mandate (the rule that if you don't have health insurance from some other source, you're required to purchase health insurance or else pay a fine for not doing so) not the HHS mandate (an administrative ruling from the department of Health and Human Services which stated that many Catholic run organization are not in fact "religious organization" which can potentially be exempted from the requirement to provide their employees with contraceptive and "morning after" coverage as part of their Obamacare mandated health care plans.) There are a number of lawsuits that have been filed against the HHS mandate insisting (I believe correctly) that it is a restriction of the freedom of religion. These lawsuits, however, have not yet wended their way through the courts to a final ruling, and it will doubtless be some time before they do. Although, clearly, if the Supreme Court had thrown out the whole of Obamacare, this would have averted any need to fight the HHS mandate, the ruling yesterday was not a ruling against the specific freedom of religion question in play there, it was on an unrelated issue.

Our Representatives At Work

This is absolutely hilarious. [HT: Donald at TAC]

In a new report, the Congressional Research Service says the law may have significant unintended consequences for the “personal health insurance coverage” of senators, representatives and their staff members.

For example, it says, the law may “remove members of Congress and Congressional staff” from their current coverage, in the Federal Employees Health Benefits Program, before any alternatives are available.

The confusion raises the inevitable question: If they did not know exactly what they were doing to themselves, did lawmakers who wrote and passed the bill fully grasp the details of how it would influence the lives of other Americans?
...
But the research service found that this provision was written in an imprecise, confusing way, so it is not clear when it takes effect.

The new exchanges do not have to be in operation until 2014. But because of a possible “drafting error,” the report says, Congress did not specify an effective date for the section excluding lawmakers from the existing program.

Under well-established canons of statutory interpretation, the report said, “a law takes effect on the date of its enactment” unless Congress clearly specifies otherwise. And Congress did not specify any other effective date for this part of the health care law. The law was enacted when President Obama signed it three weeks ago.

It doubtless says a lot about how people of all ideological stripes feel about their representatives in congress these days that the comments on the New York Times website were universally of the, "Ha, they deserve it," persuasion.

Health Care Predictions

In the debate over the now-passed health care reform bill, a great number of statistics were brought out as to why the US desperately needed a bill like this: Numbers of bankruptcies supposedly caused by high medical costs and lack of insurance. Numbers of people who supposedly died each year because of lacking health insurance. Infant mortality rates, etc. With the bill now passed, Megan McArdle is curious to see those who supported it make some firm commitments as to what the results will be over the next five years:

1) Ezra Klein is confidently predicting that it will save hundreds of thousands of lives.
2) Nick Kristoff expects miraculous improvement in our national life expectancy.
3) Michael Moore thinks this will stop people from getting thrown out of their homes in a Medical bankruptcy.
4) At least one of you must be willing to claim massive improvements in infant mortality, after you've cited those statistics to me over and over.

These sorts of things should all be pretty easy to measure, and McArdle goes on to make her won eight predictions in regards to the effectiveness of the bill:

1) Conservatively, Ezra's arithmetic implies a reduction in the death rate of people between 18-64 of at 20,000-45,000 a year. Let's take the low bound--20,000 deaths a year--and assume that we should see that, or something close to it, by 2020. That's about 3% of deaths in the relevant age group, which would show up as a very noticeably kink in the death rate. For comparison purposes, the entire fall in mortality between 1980 and 2000 was about 2.7%.


Contra Ezra, I am predicting that this will not happen. I'm about 75% confident that you will not be able to discern any effect from the health care reform among the statistical noise. But I am 95+% confident that the effect will not be as large as 3%.


2) I'm pretty sure that Kristof read the table he was drawing from wrong--he was looking at life-expectancy at birth, but he interpreted the data as if it was about adults in the 1940s. Still, age-adjusted mortality fell about 15% in just 10 years, an achievement that hasn't been matched since. If Kristof is right, and this had more to do with health care access than antibiotics, we should be able to get a similar improvement this time around--especially since we're already seeing terrific reductions, with a 10% decline in age-related mortality just between 2001-6. Hell, both Ezra's numbers and Kristoff's imply that we should be able to knock down the death rate by at least 20% between 2014 and 2024, when we add their improvements to the existing trend.


I do not think that there will be a noticeable kink in the trend line around 2014. The death rate jumps around quite a lot, so there may be a big drop (or increase) in 2014, neither of which would be meaningful. By 2025, however, I'm skeptical that we'll see a major inflection in the trend.


3) David Himmelstein claims to believe that the majority of all bankruptcies are related to medical issues, and that this is a strong argument for national health care . . . i.e., he claims to believe that medical bills rather than income loss are the main causal driver here. That's the data Michael Moore is citing. I will make a bold counterclaim: the bankruptcy rate after 2014 will not fall by half. It won't even fall by a quarter. This is among the easiest effects to measure, as if the people citing these statistics are right, we should see a sharp and immediate reduction in bankruptcy rates in the first year, with the full effects evident by 2018.


4) Infant mortality should be no greater than that of the Netherlands by 2018. Again, I predict that this will not happen, and indeed, that infant mortality rates may not fall at all.

[read the rest]

Somehow, however, no one seems eager to take up this task from the other side. Indeed, Ezra Klein writes to McArdle insisting that he not be pinned down to having predicted any measurable results for the bill.

Of course, this is partly the result of the traditional political tides: Before a bill passes, supporters promise the moon if it passes. After is passes, they start under-promising in an effort to make sure that they don't get caught with "it didn't work" accusations during the next round of elections. Of course, all this is made even trickier when the authors of a bill intentionally frame it so that it doesn't take effect until after two more election cycles, thus taking advantage of the collective ADD of the American voting public. Democrats may have believed that the bill would save tens of thousands of lives a year, but they didn't believe it enough to want to save those lives between now and 2014 more than they wanted to be spared the effort of explaining themselves in the 2010 and 2012 election cycles.

This isn't a strictly a liberal phenomenon either. Wise Republicans would be hesitant commit to any specific number for increased federal tax revenues because of a tax cut and get no more optimistic than predicting that the tax revenue trend of the previous ten years would continue over the next ten years without a noticable long term impact. Still, given that this program will become one of the top ten line items on the federal budget, it is disheartening that its supporters are not even willing to commit to its having any measurable positive effects at this point. One is left wondering, if its effects will be so small as to be lost in the statistical noise, what exactly are we getting for our $200 Billion a year (plus even more in individual and business expenditures on insurance premiums?

Life Under Health Care Reform

Time being scarce the last few weeks, I'd originally planned on writing a post of this format about one of the Senate bills, but since the House bill (HR 3962: Affordable Health Care for America Act) is currently the one in the news, I'm focusing on that. The purpose here is to try my best to cut through the hysteria and hype coming from both sides and take a realistic look about what changes we would notice as US citizens if the House health care reform bill becomes law.

The first thing to keep in mind is that nothing much happens until 2013. This could probably called the "keep incumbents from being hurt by this act, especially Obama" provision. Whether the long term effects of the bill are good or bad, change often causes pain and confusion at first, and one of the key ways of getting legislators on board for the bill is to assure them that they're unlikely to be immediately booted out of office by voters upset about their premiums. This kind of cynicism is hardly unique to this one bill or to either party -- it just is what it is. So take the below as a discussion of how thing would be under HR 3962 in the period 5-6 years from now, assuming that is passes and there are no changes made between now and then.

The bill provides several new regulations on insurance companies and on you, which you'll notice quite clearly.

1) You will be legally required to purchase insurance. If you don't (and unless you fit criteria for financial hardship as defined in the bill) you will be fined either 2.5% of you income, or the average cost of the plans in the lowest tier of the health insurance exchange. So, if you make 40k/yr, you would be fined $1000. If you make 60k/yr, you would be fined $1500. If you refuse to pay your fines, you'll be treated exactly like any other tax evader (which means you can potentially be sent to jail.) The Senate bill specifically exempted non-payers from being sent to jail, but the House bill fails to differentiate those who refuse to pay health care fines from those who refuse to pay other taxes, so it is believed that standard tax evasion rules would apply. There will also be penalties placed on employers who do not offer their employees health insurance.

2) Health insurance companies will not be allowed to turn you down for coverage because of any pre-existing conditions you may have, nor will they be allowed to refuse to cover care related to those conditions.

3) Health insurance companies will be required to charge all people the same for the same plan -- not charge people with existing health problems more and vastly limits the amount that insurers can charge more to insure older people.

4) Provides subsidies for most American citizens if they are buying individual health insurance, in order to make complying with the individual mandate more affordable.

So what happens to you? Well, if you've one of the roughly 80% of Americans who currently health insurance through your employer: nothing much. If your employer wasn't providing coverage to some of its employees before, and decides to comply with the employer mandate rather than paying the relevant fines, it may seek to recoup the costs of expanding health coverage by increasing the share of your health benefits you have to pay for. Given that the average employer provided family health care plan currently costs about $13,000/yr, it's likely that there's a lot of room for your employer to push more of that cost in your direction. (And when it comes to cost savings, most of us would prefer that to layoffs.) In Massachusetts, which passed similar health care reform in the past, employer plan premium have been rising at almost twice the national average rate over the last few years. If the cost to you of your employer's insurance plan increases to beyond 12% of your annual income (for example: $400/mo for a family making 40k/yr) you would be eligible for subsidies from the government, but otherwise you would be on your own.

If, on the other hand, you currently do not have health insurance or have individual health insurance, you would be greatly affected by the bill. You would become eligible to buy your insurance through the national insurance exchange (and if you didn't buy coverage, you'd be fined, see above.) Among these plans would be the much discussed "public option", which would essentially be the same as a private health insurance plan except that it would be administered by a government agency. Adoption of the public options plans is not expected to be high, as the CBO estimates that their premiums will be higher than the average of the private plans in the exchange offering the same benefits.

The plans on the exchange are not necessarily cheap, but you will know pretty clearly what level of coverage you are getting as the plans will have to meet government defined levels of coverage. If you feel daunted by researching what an insurance plan does or does not cover, this might be a major benefit. If not, it might reduce flexibility for you. The average "basic" exchange plan for an individual is expected to cost $5,300 per year, the average for a family of four is expected to be $15,000. In addition to these premiums, you could expect to pay about 2,000 a year in co-pays and deductibles as an individual, or $5,500 as a family. (Obviously, if you get very little care, this would be less. My own family has deductibles similar to the exchange levels on our employer-based health care plan, and our total out of pocket last years was under $1000.)

However, you also receive a scaling set of subsidies in order to offset your costs, depending on how much money you make. Here are a few examples (these are directly from the CBO subsidy analysis):

A single person making $20,600 would pay an annual premium of $900 ($75/mo) and would pay no more than $600 in out of pocket expenses for the year. If he didn't buy insurance, he'd pay a fine of $515.

A single person making $38,300 would pay an annual premium of $4,300 ($358/mo) and would pay no more than $1,800 in out of pocket expenses for the year. If he didn't buy insurance, he'd pay a fine of $957.

A family of four making $42,000 would pay an annual premium of $1,900 ($158/mo) and would pay no more than $1,200 in out of pocket expenses for the year. If they didn't buy insurance, they'd pay a fine of $1050.

A family of four making $66,000 would pay an annual premium of $6,300 ($525/mo) and would pay no more than $3,700 in out of pocket expenses for the year. If they didn't buy insurance, they'd pay a fine of $1650.

These subsidies are currently designed to scale according to the enrollee's income, not according to the cost of the plan, so from what I can tell customers would be cushioned initially from any drastic increases in the cost of coverage (such as Maine, Massachusetts and other states passing similar regulations have experienced). However, that might potentially change if the cost of the program spiralled rapidly out of control due to the increased cost of providing insurance under this model.

In this regard, it might almost be a benefit to have the public option in play, as it would make it much harder for people to claim "it's all because of insurance company profiteering" if the public options premiums continue to run higher than private plan premiums as the CBO projects.

A few useful sources, though not everything in this post is derived from them alone:

The CBO analysis of the House bill.

The official summary of the House bill. (This copy of the file is at the Heritage Foundation, but the actual file is the one the House Democrats put out.)

CBO analysis of subsidies.

Who Says No

People at various points in the ideological spectrum have pointed out it's a little odd to see conservatives objecting to the idea of the government deciding what medical procedures ought not to be covered, when they're apparently okay with insurance companies deciding what procedures ought not be covered, or with people not being able to afford procedures because they lack good insurance. However, it strikes me this difference may actually make a fair amount of sense, both for some pragmatic reasons and some emotional/ideological ones.

Pragmatically:

There are lots of insurance companies, and when polled people often rate their own pretty high. So many people may not expect to ever have problems with their own insurance companies refusing to cover something vital. However, people (conservatives especially) don't tend to trust the government very much, and there's only one. So people who hear about insurance company problems can tell themselves (rightly or wrong) "It won't happen to me." But if the government decides to block something, everyone knows it will effect him.

With insurance companies paying for care, one can always try to use public shame (driving away customers) or lawsuits, or government regulation to make them provide some service you think they owe you -- however if the government is making those decisions people are probably more skeptical of their ability to appeal to the government to get the government to reverse its decision on something. (Most people have experienced this with disputing a cop's version of a traffic stop, or trying to get an appeal through the IRS. It's not easy.)

Whole Foods Health Care

Whole Foods is headquartered here in Austin, TX, and I know a fair number of people who've worked there. The general consensus seems to be that it's a good company to work for (so long as you're comfortable with the "crunchy" culture) with especially good benefits for a food retail chain. So I was interested to see a piece in yesterday's WSJ by Whole Foods CEO John Mackey advocating an approach to health care reform more similar to the benefits Whole Foods provides its employees. Although Whole Foods is seen as a progressive employer, Mackey's suggestions are more along the lines of what innovative libertarians and conservatives have suggested for health care reform. (If the GOP scores a tactical victory in staving off the many bad ideas in the current health care reform proposal, one hopes they will exert themselves to actually bring something to the table this time, perhaps along these lines.) Extracting his main proposals:

Here are eight reforms that would greatly lower the cost of health care for everyone:

I Really Hate This Part...

If I've seemed a bit reclusive on all the recent fuss over the health care bill, town hall meetings, etc., it's because the debate over the current reform package has now entered the phase of American politics that I really don't like. There's an early stage in which ideas are discussed and bills are drafted. People try to put coallitions together, compromises are discussed, and various groups push their policy recommendations. That's the realm I find interesting, and in my small corner of the blogsphere, I enjoy participating, in a strictly informal fashion, in the debate.

But then there's a point when an actual bill (or bills) are on the table, and the democratic melee is let loose. Over the last week I've been reading Alessandro Barbero's The Battle: A New History of Waterloo, and in light of that it strikes me that there's a certain Napoleonic-battle aspect to all this. A month or two ago we were staring at maps and discussing the merits of different formations, but now everything is shrouded in smoke while innumerable combatants in this democratic struggle (most of whom, on both sides, honestly have a fairly rudimentary understanding of the overall debate) slug it out until we find out which side will hold the field and which will break and run.

In a democratic republic, this is a necessary part of our political process.

Excessive Health Care Profits

In the health care reform debate, we often hear about how huge amounts of money that could be going to provide people with treatement is being sucked up by insurance company profits instead. This kind of thing always makes me wonder, since in my experience a competitive market place will usually drive profit margins down pretty low. So I thought it would be illustrative to look up how much money the top private insurance companies make, and then determine their profit margins and profits per enrollee.

The following information is publically available on Google Finance. Revenue figures are annual ones for the year ending 12-31-2008. The total revenue, income before tax and income after tax figures come directly from each companies public financial reports. The enrollee figures are potentially slightly more approximate, since there I googled for the most recent press release which showed total enrollment for each company.


It struck me as interesting that it was Humana, with the lowest profits per enrollee in 2008, which just posted a healthy profit increase for Q2. Wellpoint and Aetna have suffered membership declines in the last quarter.

In no case is the company making more than $100 per enrollee per year in profits. Given that most insurance plans cost a good $4000-$6000 per year, the amount of what we pay for insurance that goes to "lining insurance companies' pockets" would seem to be fairly small.

Catholic Health Care: Our Lady of Hope Clinic

As Catholics, and other Americans, continue the debate over national solutions to help the uninsured, Our Lady of Hope Clinic in Madison, Wisconsin is helping treat the uninsured one person at a time. Long time reader Steve Karlen is the development director for the clinic, which opened in April of this year. OLHC has a unique model, based on Dr. Kloess and Dr. Johnson's desire to provide outstanding primary care through a structure designed in accordance with Catholic principles of solidarity and subsidiarity.

Like the increasingly popular private practice or closed practice model, OLHC accepts up to a set number of patients, which due to OLHC's non profit model are called benefactors. The limit is set at 600, which has not yet been met, so the clinic is still accepting memberships. Benefactors receive unlimitted primary care through the clinic with no additional charges or co-pays beyond the annual benefactor fee -- which is set at a 1200 dollars with various discounts which can apply for couples, children, or younger patients. (This pricing is comparable to other closed practice/concierge-style doctor's offices.) Like a closed practice, benefactors can make same day appointments any time and have direct access to their doctors via phone and email. They are expected to carry insurance for specialist, prescription and hospital care -- however benefactors can often save money overall on health care by switching to a high deductible plan for care not covered by the clinic.

How to Get There from Here

There's been much discussion of late about what other country's health care apparatus the US should consider emulating, and in such discussions France is often mentioned. Now, all cheerful ribbing against the French aside, their health care system is not nearly as "socialized" or nearly as afflicted by treatment denials and waiting lists as those of the UK or Canada. It is also rather more like the system that the US already has, in that it is a hybrid public/private system, though in their case there is a guaranteed base level of coverage everyone has through the government (funded via a hefty payroll tax -- not unlike Medicare) which most people supplement with private coverage. Most doctors are in private practice, and 25% do not even accept the public plan, just as some practices in the US do not accept Medicare. However, everyone does have that minimum level of coverage, and the French spend a lower percentage of their GDP on health care than the US (11% versus 16%) which when you take into account that France's GDP per capita is a good deal smaller than that of the US (which is the polite, economist way of saying it's a poorer country) works out to the US spending about twice as many dollars per person on health care, while still not having universal coverage.

So what are we waiting for? Why don't we go enact the French system here right now? Why doesn't Obama put on a jaunty beret, dangle a cigarette coolly from the corner of his mouth, hoist a glass of wine, and just say, "Oui, nous pouvons."

A Case Study on Costs and "Basic Health Care"

One of the elements of discussion about health care from the perspective of Catholic Social Teaching that often bothers me is when someone states, "Basic health care is a human right" and then goes on to insist that this means we need a system by which the maximum range of health care paid for by the best insurance in the modern US is available to everyone via a government single payer system. (The which leaves aside the practical matter that virtually no single payer systems cover as much as cushier US private insurance plans do.)

Modern medicine has brought us incredible benefits, which we rightly want to make sure that everyone in society is able to share. But modern medicine has also make it possible to throw large amounts of money at a problem to achieve a return which is statistically pretty small. Should this be considered "basic healthcare"?

When we sit down to ask ourselves, "Why can some people not afford health care coverage in this country," it seems to me that one of the reasons is that we've raised our standard of "basic" so high that it becomes hard to afford.

We've been experiencing an applied study in this as we sort out our options in regards to BabyDarwin being breech. 3-4% of pregnancies are breech. BabyDarwin is in what is termed a Frank Breech position, which means his bottom is down, and his feet are up near his head. This is, according to most of the reading we've done, by far the safest form of breech positioning, and some medical authorities maintain that it's basically as safe to deliver a baby in a Frank Breech position as it is deliver a baby who's head down. Others maintain it's slightly more dangerous. The only actual numbers I was able to find were in the Wikipedia (with all appropriate provisos):

Umbilical cord prolapse may occur, particularly in the complete, footling, or kneeling breech. This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix. When the waters break the amniotic sac, it is possible for the umbilical cord to drop down and become compressed. This complication severely diminishes oxygen flow to the baby and the baby must be delivered immediately (usually by Caesarean section) so that he or she can breathe. If there is a delay in delivery, the brain can be damaged. Among full-term, head down babies, cord prolapse is quite rare, occurring in 0.4 percent. Among frank breech babies the incidence is 0.5 percent, among complete breeches 4-6 percent, and among footling breeches 15-18 percent.

There are also some other dangers that are more of an issue in other breech positions or with a premature baby -- in that if the legs and torso are delivered first and are much smaller than the head (which is usually only the case with premature babies -- at full growth the torso is large than the head) then the baby may be partly delivered while the mother is insufficiently dilated, and then the head gets stuck. This can cause damage to the head, loss of oxgen, and a range of injuries resulting from trying to pull the baby loose.

Because of the 0.4% versus 0.5% difference in risk between standard postion and Frank Breech, and because "breech" in general has a bad name as a result of the other issues (with premature babies and with other positions), the verdict we're getting is pretty much that if we can't get BabyDarwin to turn, we'll have to go the c-section root, because no doctor around here is willing to deliver a breech baby naturally. (And the home birth midwife is clearly not willing to touch it with the proverbial ten foot pole.)

We have solid insurance, so the c-section root will actually cost us less out-of-pocket than what the homebirth route (not covered by insurance, and unfortunately already paid for). But the overall health care cost issue is significant.

Googling around for costs on a c-section I'm seeing a "list price" in the ballpark of $20,000 (though I'm sure the insurance company manages to get it for less.) The prices I'm seeing for a normal vaginal delivery in a hospital are around $6,000. The home birth cost was $2,100 (though that was with an early payment discount -- and before they raised their prices, so apparently "list" is now $3,600.)

The difference in risk between normal delivery and c-section in our particular case is apparently around 0.1%. So comparing a c-section and hospital delivery, we as a society are spending just shy of $28 million on doing 1999 unnecessary c-sections in order to avoid one natural delivery that would have resulted in serious problems. Looking at the difference between a c-section and a home birth at list price, that difference grows to $33 million.

We're justly hesitant to put a dollar value on a human life, and obviously, if you're the 1 out of 1000 who sees your child die or severely injured as a result of the difference in risk between normal positioning and Frank Breech, knowing that the chances were low would do nothing to console you. However, aside from the question of how many lives could be saved if that $30 million were used in some other way than getting c-sections for all breech babies, there's another element to the incentives at play here.

This is primarily an academic discussion for us because we're middle class and well insured, and so we have no problem at all affording the c-section if we can't get the baby turned. (And no problem affording the multiple ultrasounds and consultations and such involved in trying to get the baby turned.) But imagine that we were poor an uninsured. Because the incentives and regulations for our medical system are built around the assumption that everyone worth thinking about has the deep pockets of an insurance company behind him, we'd still be faced with no doctor of midwife being willing to provide a normal delivery, so we'd be stuck going into $20k of debt that we had absolutely no way to pay off in order to get a c-section that we probably didn't need.

As it stands, our medical system is built around the assumption that cost is no object. And doctors are very heavily penalized based on any "avoidable" injuries or deaths that occur on their watch. The result is that instead of providing good, high quality "basic" health care, and using extreme (and expensive) measures only when necessary, we often require extreme measures "just in case". This makes it far, far more difficult to provide "basic" health care to all.

I don't know enough about health care to provide specific policy proposals, but just working through this example it seems clear to me that we are not discussing enough variables when it comes to making sure that "basic health care" is available to everyone. Instead, the only debate going on in our political arena is on how to provide everyone with the level of health care which is often provided under comprehensive insurance policies -- a level which we probably cannot afford to provide to everyone, and which is determined as much as a matter of tail-covering as medical need.

Why Conservatives Oppose "Universal Health Care"

Zach of Civics Geeks has a good post in which he addresses a question posed by Matt Talbot of The Hopeful Populist. In a post entitled "Calling All Conservatives", Matt asks:

What alternative do you propose to universal health care, on the European model? Whatever the problems there, everyone is guaranteed basic care, no one there is bankrupted by medical bills, and everyone seems (by and large) happy with it.

How, as a Catholic, can you oppose that?

Just...explain to me why it would be so horrifying to just have universal health care in the United States. Yes it would cost money, and yes, taxes would go up - but so what? Isn't working people not being bankrupted by hospital bills ever again worth a few more percent at tax time? Isn't a society where everyone can go to a doctor when he's sick better than a society where he delays going because then he won't eat or won't be able to buy gas, or can't pay his car payment or whatever?...

The reply, "we ought to care for each other in the community" sounds good - heck, I even agree with it. But the price of modern health care is too much for that kind of community-provided care. I have no idea what an MRI machine costs, but I can't imagine my local parish can fork over than kind of cash....

Not, perhaps, the most temperately phrased question, but one that deserves a good answer. Zach's answer is a good and honest one, he lists off nine reasons ranging from the legal to the economic to the moral why one would be hesitant about "universal health care". I encourage you to read his post. But always being one to gild the lily (or at least to run on at length) I thought I'd add my own thoughts as well.

I'd like to start off by taking the last claim first. Is modern health care so insanely expensive that it's simply unreasonable to expect that a community could pay for its health care bills? Well, our parish is made up of 3,000 families. A large parish, perhaps, but far, far smaller than your average insurance pool. From dealing with small business insurance a while back, I can tell you that $500/mo is a fairly normal-to-low all in cost for insuring a family. So let's say that our parish became a community medical collective and assessed every family to pay $500/mo to meet everyone's health care costs. Let's also say that the parish absolved 1/3 of the families from paying anything, because their incomes were too low. So 2000 families each paid $500/mo into the parish medical fund. How much does that work out to? One million dollars per month. It's amazing what a large number of people all chipping in together can add up to. (As per Matt's rhetorical question: My friend Google tells me that MRI machines cost about one million dollars. A parish could buy one every month.)

But I don't realistically expect to see parish-based health care cooperatives any time soon, so let's leave that aside and answer the more general question: Why are conservatives down on "universal health care" according to the European model? And can one be so as a Catholic?

I think there are a couple main reasons:

1) The need for personal responsibility in providing for others.
In his post, Matt throws around lots of worries that people will be bankrupted in paying for doctor's bills, that people who are sick will have to decide whether to see a doctor or make their car payments, etc. Let's look wider for a moment in order to understand the principle we're bumping up against here. Why do we pay rent or mortgage? Why do we pay for our cars? Why do we pay for clothes and food and books and computers and game systems and beer? Is it fair that someone should have to choose between paying his rent and his car payment? Should he have to decide between his mortgage and food? Why do we pay for things? Why don't we just get all that we need?

Well, there's a practical reason: Fully collective organizations of society have not, historically, worked well at all except in the case of small religious communities.

But there's also a reason rooted in human nature: The natural state of man is one in which he works in order to provide for himself, his family and his community. At a biological level, we are descended from primates that lived in small social groups, and survived on the basis of group members foraging for food and sharing food with their dependants. At a religious level, when Adam and Eve were expelled from the Garden, God told them that from that point on they would live from the sweat of their brows. In both senses, we are meant at a very deep level to provide for ourselves and our families through our own work -- and even though we now live in a far more complex economy our senses of health, self-respect and well-being are directly tied to toiling in order to provide for ourselves and our dependants.

Money is how, in a complex economy with extensive specialization and trade, we pay for each other's time and labor. And so, paying for things with money that we earn through our labor is how we are at a fundamental level meant to provide for ourselves and those who depend on us.

What are the necessities of life? Food, shelter, clothing, medical care, education.

If our purpose and happiness in life consists of providing the necessities for ourselves and our dependants, we should want to see the connection between our labor and the provision of these necessities be as direct as possible. Toiling to provide these for the ones we love if not something that keeps us from being human, it's what makes us human.

Now I am not a radical individualist or libertarian. Most certainly, this does not mean that those who cannot at some point afford shelter should be homeless, that those who cannot afford food should starve, etc. As I kept reiterating above, one of our main duties in life is to provide the necessities for ourselves and "our dependants" and "those we love". As Christ taught us in the story of the Good Samaritan, we are called to love all those around us who are in need. We are social animals and social creatures, and as such we have the natural and moral duty to care for those in our communities who are in need. We absolutely need to have provisions for providing food, housing, clothing and medical care to those who cannot at this time provide it to themselves.

However at the same time, all those who are in any sense able bodied (and able minded) have not only a duty to avoid being a burden to others unnecessarily, but a human need to provide for themselves through their own work. So while we have a human duty to help those currently unable to provide for themselves, we also have a need as a society to help as many people as possible provide for themselves rather than relying upon help. We have a duty to avoid incenting dependency.

Now some readers may be frothing to rejoin: "But what about our current system? People don't pay for health care now. Massive, impersonal insurance companies do." This is true, but only in a sense. After all, the fact that my money resides in a massive impersonal bank (in which it is directly deposited by my employer, and which cashes the checks which I write to pay my bills) does not mean that I do not in fact earn my money and use it to pay for things. Similarly, I know that by holding the job that I currently do, I earn as a form of compensation a certain level of heath coverage, which I provide to my family as the head of my household. Many people do indeed pick our specific jobs and stick with them because they know that the benefits they can thus provide to their families are more valuable than the higher salaries they might be able to get elsewhere.

However, I do agree that our current system is overly indirect. And indeed, I think that some of the inflation of the cost of basic care is the result of that indirectness. As such, I would strongly favor a change to a system in which we pay for basic care more directly (either our of pocket or through small community health care pools -- no larger than a parish) and where we carried insurance only for large medical expenses. However the fact that our current system is very much imperfect does not make me want to adopt a European-style system, which would be a move in the opposite direction from what I believe we need to go in.

2) The need for checks and balances to prevent abuse.
People often complain about insurance companies denying coverage for certain people or certain procedures. That is unquestionably a problem. However, all honest analysts agree that a completely government run system would also involve denying coverage for a number of high expense/high risk procedures. The difference is that under a government system the fox is in charge of guarding the hen house.

I recall hearing a while back about a woman who was approached by Michael Moore for his documentary Sicko. He wanted to interview her about how her insurance had refused to pay for a procedure for her husband. She called the insurance company and said: "Remember that procedure you turned us down on? Michael Moore wants to interview about my experience. Are you sure you don't want to reconsider?" The insurance company, whose profitability relies in part in maintaining a positive public image, caved and paid for the procedure. Similarly, the government routinely (indeed, sometimes unwisely) steps in and rules that certain procedures must be covered by insurance.

All this works because people can switch insurance companies, and because the government regulates insurance companies from an outside perspective. Those checks and balances would be lost in a government run program. The result would probably be (as is currently found in the differences between health in the US and in countries with socialized medicine) that people would get better routine and preventative care under a government system, but those with truly serious illnesses would have worse outcomes than under the current system.

3) Hesitance to make irrevocable change.
Once people start to get something "free" from the government, it's nearly impossible to ever scrap the system and move to a different model. No matter how bad the government system is, it's "free" (as in paid invisibly through paycheck withhold and probably mostly by people richer than you), it's there, and no one wants to deal with the inherent uncertainty of privatizing.

As such, any suggestion of going to a European system for US health care is a suggestion of heading down a one way street. We won't get to change our minds without a total fiscal melt-down or political collapse.

It is, thus, a change I am very, very hesitant to make lightly. I'd happily commit lots of my own personal money or government taxes to a program designed to provide basic healthcare only to those who can't pay for their own first. That would meet the immediate need, without committing us irrevocably to a path about which I have grave doubts.

By proposing instead a full switch to a European-style system, progressives do themselves no favors when it comes to building bridges. (Which is, incidentally, probably why none of the viable Democratic candidates proposed such a program -- no matter how much they might have personally preferred such a move.)

How to Pay for Health Care, a Conservative Answer

When one expresses skepticism at instituting government run health care in the US, one is pretty quickly asked: "Well the current system is obviously broken. What do you think we should do about it?"

There is a temptation, for someone like me, to reply that the whole world is broken, and what is anyone going to do about that other than trying to treat those around him as well as he can? But questions are seldom totally without answers, so the question stuck in my head and simmered there for a while.

The result is not necessarily intended to be an enactable answer -- which is fine since no one has made me king. But it is intended to provide some sense of the sort of characteristics a good solution ought to move towards, at least according to the principles that I have in mind.

General Principles

• Little though we enjoy it, it seems to me important that people pay for what they get. This can be done according to their means, and perhaps their means may be very small, but I think that our human dignity and our sense of responsibility for what we do both requires that we achieve things, as the story of Adam and Eve puts it: "with the sweat of our brows".


• Big organizations almost always seem to turn into slow, beaurocratic, unresponsive organizations eventually.


• If we have a moral duty to make sure that our fellow humans receive all reasonable medical treatment that they need in order to preserve life and dignity, it seems to me that moral duties are best carried out by small groups and individuals, not massive impersonal organizations.

Current Difficulties

• Going to a government-run system creates the ultimate set of hidden costs. With paycheck witholding, we often have little visibility to how much we pay in taxes anyway. The same criticism can, to an extent, be leveled against employer-provided medical insurance, though at least there we have options.


• In a world where people's behaviors can often be predicted by models that assume selfishness, it seems likely that a government paid system would result in a slowing in R&D and investments in new facilities. Assuming what I've read to be correct, the UK has a serious problem with aging medical infrastructure, and Canada's approach to keeping costs under control has been to announce to doctors that they are now paying less for the same work than they used to.


• By its nature, employer provided actuarial insurance makes it the most expensive to get coverage for the people whose need is greatest, and makes it most difficult of all to insure those who cannot work through age or infirmity -- who often are also people who need medical care. Currently we deal with this through a government run system -- which is slated to become impossibly expensive very soon as the baby boom generation retires.


• Compated to other elements, this is a rather pragmatic issue, but it seems to me that our malpractice lawsuit/insurance mess must add a huge additional load to our system, not only because some doctors have to pay over a quarter of a million dollars a year (per doctor) in malpractice insurance (and then pass that cost on to their patients in the form of higher fees) but also because the fear of malpractice suits results in lots of additional tests and procedures being done "just in case". I assume that any government-run healthcare system would shut down the malpractice industry (or at least cap it) and so it seems only fair to assume that the same should be done in any non-governmental solution.

Solution
It seems to me there has to be some sort of system for having the community as a whole help those who cannot afford all the medical care they need, yet at the same time a human and practical need to keep said community down to a small enough group that it remains a personal and human institution with minimal overhead. What I would thus propose is that households (probably defined in roughly the same way as they all for income tax) organize into independant groups -- let's call it a "medical community" if that doesn't sound too Orwellian. You'd need a minimum size of about 1000 households in a group and a maximum size of perhaps 5000. If a group got over that size, it would be required to split.

The medical community would charge a monthly fee per household (perhaps with a couple of levels for single vs. multi-person) which would go into the community pot to cover medical expenses. When you went to the doctor, got a presciption, etc. -- you would provide the information for your medical community and might also pay some sort of co-pay. (It seems to me that co-pays are important to incent behavior. For instance, in our current insurance we pay $25 at the doctor's office, $50 at the after hours care, and $250 at the emergency room. However little one may want to pay the $25 at the doctors office, the incentive to take care of things in a timely fashion rather than waiting and landing in the emergency room.) The rest would be covered entirely by the medical community.

Membership in a medical community would be mandatory, and communities would not be allowed to exclude members because of age or medical condition. Each community would have one or more full time administrators whose job would be to oversee the bill paying and provide reporting to the community memebers on a monthly basis. Each community would be able to formulate its own rules on what was covered and to what extent. In most ways it would work best if communities were regional, but I think it might also be important to have them based around culture or belief system as well. For instance, a specifically Catholic community might refuse to pay for abortions, sterilizations, birth control, etc. Being in a like-minded community would also help people from being under pressure that related to their beliefs -- say pressure not to have "too many kids".

At the end of the year, if there was money above a certain threshold left in the community coffers, each member would recieve a refund check. When there were unusually large expenses to help a certain member, others would be kept appraised, especially if an extra assessment were required. However, even with only 2000 families, some pretty expensive care becomes affordable. (Say two kids out of the community need special medical care that runs to a million dollars each -- that works out to $83/household/month for 12 months.)

There would be a difficult balance to maintaining a proper ownership sensibility. On the one hand, you want people not to get care they don't need, get generic drugs when possible, etc. in order to have money left and get a refund at the end of the year. On the other hand, you don't want people so hounded on these issues that they forgo needed care.

For those who are truly poor, I think the best approach (rather than throwing them into a vast government paid system) would be to have the government provide a credit to the community equal the to monthly dues for families unable to pay. There might also be a provision where if the head-of-household (or one of several) loses his/her job, that families fees are waved until they regain employment, and the community is able to get a credit from the government.

Another thing that might be a positive would be having "excessive cost" insurance that a community could buy from an insurance company, so that if one household in the community had medical costs of over a certain very large amount (say $250k) in one year, the excessive cost insurance would pay the rest. The rules on excessive cost insurance would have to state that the only factor in the rates would be number of people in the community.

Problems With The Solution
In many ways, I think a community-type solution like this would provide the most humane approach to making sure that all were able to receive needed medical care, while not centralizing health care so much that it stiffled competition and took the positive aspects of market forces out of American health care.

However, community also has downsides. While feeling like you own your money tends to make you more responsible with it, there are always those who take advantage of others and also those who week to keep others from getting what they need.

Also, while I think it's important to have a small enough institution so that you know where costs are going ("The Jones family was in a terrible car crash. Keep them in your prayers and have someone organize bringing meals to them for the next week." "Samir's son has been diagnosed with Leukemia -- we're going to see if we can get him into Children's hospital and we'll keep everyone up to date on how it's going.") small entities are often in danger of being badly run. Each community would need a competant board, and one or more competant (read well paid and professional) administrators -- despite anyone's instinct to cut costs by doing it themselves on the side.

I'm sure there are other things that I'm not thinking of as well which will jump right out to readers.

I'm curious as to the reaction to this kind of idea both from those who favor government health care and those who (like myself) are very much against it.

Diseases Make People Sick

I wonder if one can say with without sounding like some sort of complete Scrooge...

There's a turn of phrase which has been bothering me a lot lately, and given that many predict health care will be a big issue in the coming election, I suspect I'll be hearing it a lot more.

"I think there's something wrong with a world where parents have to watch their child get sick because they don't have health insurance."

I understand what people mean to say, but: Not having health insurance is not itself a health problem. Indeed, 95% of the time, not having health care is not a health problem. The trick is, the other 5% can really get you.

Most of the time people are healthy. Our kids haven't been to a doctor for anything other than yearly checkups and vaccinations in about a year and a half. (And the last time we actually did take a kid in, we were told, "Yep. Looks like a virus. Get her plenty of rest and fluids.")

Now, I don't deny that not having health insurance is scarry, and at times costly. When we first moved to Texas, we found ourselves between coverage for a couple of months, during which time everyone got massive cases of strep throat and sinus infections. Just that cleaned us out a good $500 worth of money we didn't have, though what had really worried me was what would happen if we got in a massive car wreck or something and racked up tens of thousands in medical bills. (On the flip side, the $500 in actual medical bills was about the same as I was having witheld every month from my check to pay for insurance at the job I'd left in California.)

So my point is not necessarily to say that not having health insurance is no big deal. But I do think that it represents an emotional and unhelpful way to discuss the problem to imagine that simply being without health insurance itself makes people sick or makes people die.

Health insurance is one way, in our modern world of powerful but expensive medical care, to pay for health care. And paying for medical care is sometimes necessary when someone is sick or injured. However, it's the medical care which is sometimes necessary to health, not the insurance. Thinking inside the box of, "Lack of insurance equals sickness and death" limits our collective ability to consider all possible solutions to the "health care crisis".

Insurance has never made anyone healthy, nor does lacking insurance make people sick. Insurance is just a method of paying for things.