As this book was written a massive health care reform overhaul law was pushed through Congress on completely partisan lines and is being “marketed” to a skeptical public by the Obama Administration. They insist that once you understand all the details you‟ll love it. The principled conservative predicts it is certainly destined to further transform, but unfortunately distort, the health care delivery system. To the principled conservative, government has already done just about everything possible to distort the market while politicians and advocacy groups have marched forward to proclaim that the “system” is broken. At the same time we recognize that purchasing health care, either via direct cash outlay or insurance or some combination thereof, is a very personal and basic human concern. It is appropriate for public policy to be directed at this issue as opposed to consumer choices that are relatively unimportant to policy makers (i.e. the type of television or computer you choose to purchase). But let us look at the history of greater government involvement in and funding for health care. The Medicare system enacted in 1965 is one of the main liberal arguments for government intervention in health. Proponents accurately assert that seniors have more security in health care than they did before. And even conservatives tend to like a program that is open to all and does not exclude or punish those having the bad judgment to earn more money in their working years than others. But the Medicare program costs a ton of money, far above original projections, is huge budget drain, and is going broke. It remains to be seen whether the promised universal coverage will actually reduce Medicare costs, since one of the ways of reducing costs is always to pay providers less—which of course reduces provider participation and access to doctors. So, naturally, Obamacare puts tens of million more Americans on Medicaid, a system that has failed for 40 plus years mainly because it pays providers far below market rates.
As is the case in Medicare and Medicaid and any government-financed health care reform, the only way to control government spending on health care is to heavily regulate and ration care. This also means having government involved in dictating how medicine is practiced. It is not the doctor or hospital that will approve payment for a procedure or test, but a government agency or authorized entity. But this intrusion has become common-place because of Medicare and private health insurance company practices. Doctors have, so to speak, been screwed for years as third party payers, Medicare, and others dictate how they practice medicine. Add to that the defensive medicine practiced because of the fear of lawsuits, one might ask what sane person would want to be a physician in this day and age? Obviously, someone who cares about healing people and is prepared to fight whatever red tape (and there is a hell of a lot of it) thrown in their way. Physicians thought they had found a gold mine in the early days of Medicare with cost-based reimbursement (whatever you charged, you got reimbursed). But as the program‟s costs grew, the federal government asserted a more active and intrusive role in determining how physicians are paid via the Resource Based Relative Value System. The principled conservative would naturally assume that a payment scheme created by the federal government under subcontract to Harvard University would be a monstrosity. And it is. Every year physicians‟ groups rush up to Congress to beg them (they prefer to say, lobby) not to further reduce Medicare payments based on this complex formula.
The principled conservative likes choice but faces the reality that most Americans cannot hope to save enough money to pay for catastrophic hospital costs in case of an accident or major illness. In addition, over time patients with health insurance have been insulated from the true cost of health care. The third party payers (insurers) have provided a service that has possibly permanently damaged and certainly de-personalized the patient-doctor relationship. So where do we go from here? For starters, we fight against the federal government imposing a “one size fits all” insurance. Health needs differ dramatically by age, personal circumstances, and personal behaviors. The main reason that every citizen should have some type of health insurance is to insure against catastrophic costs resulting from lengthy hospitalization or medical treatment. But we are realistic and pragmatic. We are not saying turn back the clock to the days when folks paid their doctor out of pocket and negotiated directly. We are not calling for an end to all private and government-funded health insurance programs. We are saying fix the clock so that it tells time accurately. And that requires a willingness to innovate in products, individual choice, and autonomy. It also includes doing some major tinkering to the current government-funded health insurance programs (Medicare, Medicaid, and CHIP-Children‟s Health Insurance Program).
The health care issue is complex so it‟s no surprise that opinion poll after opinion poll generally find a wide consensus for “health care reform,” but widely divergent opinion on the actual new health care reform law.
Probably a slight majority are deeply skeptical that it is the right type of reform. The principled conservative would offer the following overarching guidance: individuals must always be allowed to pay from their own resources for services and treatments (including drugs) that they desire and their physician recommends regardless of what is covered by their insurance plan or approved by any government agency or authorized entity analyzing “effective treatments.” We must point out that health care systems in countries like Britain and Canada that promise universal care actually achieve universal rationing—with the wealthier coming to countries like the U.S. when they cannot get the care or timely surgery desired in their own country. Yes, we are rightfully scared about big brother. Did you know that England even has its own rationing institute called the National Institute for Clinical Excellence, or NICE? Oh the irony, those NICE people get to tell you that further treatment for grandmother just isn‟t something that society can afford, sorry. They routinely deny access to cutting edge cancer drugs. Naturally the academics love it because they sit around a table and get to decide what care can be afforded for “the people.” Lovely! Canada is similarly sorry. They use the U.S. system as a safety net when their DMV-styled waiting time get too long, which is typical as new (and costly) technology is not available in the numbers and locations we expect in the U.S.36
Amazingly, in America, you will commonly hear health care “experts” bemoan market innovations like
“concierge medicine” or physician-owned hospitals. God forbid that practitioners would target their services to consumers in an efficient manner that their patients like. Here, suddenly the committed social engineer becomes committed to the status quo philosophy that if waiting is good in health care, more waiting must be even better!
Remember, the principled conservative supports innovation and technology. If consumers prefer concierge medicine with actual doctors making house calls again and physician-owned hospitals focusing on better customer service, let the market decide. Obviously, big health insurance companies and big government have distorted choices. But we must understand that to micro-manage and socially engineer health care via government is an exercise in utter folly. Yet the new health care reform law is based on the premise that a panel of experts can predict exactly how many specialists are needed in the future. There is a 15 member Workforce Commission charged with this task. These will certainly have to be very smart people, possibly philosopher-
kings. They will certainly attack with full gusto the current mantra of the social engineers that more primary care physicians are needed versus specialists. But it is not so simple and the primary care doctor mania represents a flawed assumption for several reasons. First, since when have patients simply followed a healthier lifestyle because their primary care doctor so advised? Banking on preventive measures and resulting savings in the “system” is extremely wishful thinking. Second, science is getting more complex (just consider genetics) so wouldn‟t we want more highly trained specialists who know all the nuances of their focused area? If you have the misfortune to contract a serious and complex disease, the first thing your primary care doctor (and you) will want to do is find the best specialist or assemble the best team of specialists.
Hence, the principled conservative want to promote choice in health plans and delivery of care, while giving consumers more control of how to spend their basic health care dollars. Insurance should be more focused on catastrophic loss, not paying for every last dollar of services. Why the obsession about prohibiting co-pays or cost-sharing? This helps people understand that the service costs money; unless you believe that the government owes everyone 100 percent free health care, then there is a proper measure of personal responsibility. And individuals cannot expect the “health care system” to fix all their problems if the individual doesn‟t take care of him or herself. A cost differential (including higher insurance premiums) may be a better incentive to start exercising rather than simply listening to counseling (or hectoring) by a doctor. The prevailing policy strategy appears to be perversely the opposite at present, as the health care reform law allows an insurance plan to vary their rates based only on age, geographic location, family composition, and tobacco use. What about other risk factors and personal choices: illegal drug use, excessive drinking, obesity, poor diet? So, for the greater good comrade, you are to get no reduction in your premiums for staying in shape. We are not asking for intrusiveness in private matters; we are simply saying that insurers have a right to assess risk and make pricing decisions based on that risk.
Hollywood hypocrisy over health care
Since many leftist celebrities like to extol the virtues of a socialized medical system, it is ironic that they would probably vigorously oppose federal government regulation of the movie industry in the following areas: movie studio;
Under such constraints, who would ever expect any movie to get made? Yet in health care we have many of the above features in our current and newly “reformed” system. The amazing thing is not that the system is broken, but that high quality care is still delivered despite these government interventions.
But let us not just focus our barbs at the air-head Hollywood star. This attitude of “do to them as we would never have done to our industry” is also prevalent among the many lawyer-legislators that would balk at such restrictions on law firms. For example, efforts to limit contingency fees in order to discourage frivolous medical malpractice lawsuits and ambulance chasing is nearly always shot down in lawyer-dominated legislatures (with, of course, generous political support from the plaintiff ‟s bar).
Today we find ourselves burdened by a system of onerous controls on doctors. On yet another issue, Ronald Reagan was presciently correct. Once physicians gave in to government intrusion via Medicare, they lost the freedom of practice in their profession. Since the federal government is paying for a huge portion of overall health care via Medicare and Medicaid, as Reagan predicted they tell doctors how to practice and how much they‟ll get paid. Between government insurance programs and the crunch of the private health insurance industry, is it any surprise that some physicians throw their hands up and say “ok, just pay me as an employee to work in a hospital or clinic so I can practice medicine.” But alas, such freedom is only that of the servant.
Someone will tell them how to practice and second guess their clinical decision-making. If “reform” means transforming doctors into tightly controlled bureaucrats, this is one area that perhaps a return to the concept of patient-centered services via house calls and personal attention may not be such a bad idea. It is also amusing and ironic that the proponents of reform rarely ever wish to take their own children or grandchildren to a government-funded public health clinic.
So the principled conservative has a simple principle here—stop stupid socialistic health care ideas. We must work to identify and publicize the many stupid policies in the new health care reform law, and work to repeal or reform it. We like competition in Medicare, so don‟t give up on it. This means reversing the liberal assault on Medicare Advantage plans. We do not want to necessarily make health insurers rich. We definitely want to make doctors rich, as they deserve it. We are not adverse to an industry if it operates legally and ethically and profitably. While there always will be bad players within any industry, to issue a blanket condemnation of an industry such as pharmaceuticals is an exercise in utter stupidity, especially given the development of life-saving or life-extending drugs. These developments are far more important to the quality of health care, saving of lives, and extension of the average life span than a year‟s worth of friendly “watch your weight ” tips from your doctor.
Let‟s get to the heart of what bugs the progressive socialist about the health insurance and drug industries. Is it wrong or unethical to turn a profit in health care? The principled conservative, who supports capitalism, says of course not. Naturally, there will be legitimate debate and differences of opinion as to whether a particular regulation creates a fair and reasonable playing field or otherwise. But we never question the profit motive.
Even not-for-profit health care organizations have to be in the black or they will go out of business. Not-for-profit just means profit is not the primary purpose, but the organization‟s purpose is not to lose money either. If so they would be called a “for loss” organization, and none of those exist very long for obvious reasons.
Amazingly, to pay for the “reform” law, health insurers and medical device manufacturers will face hefty new annual taxes in the billions, industry-wide. Put your mind around this concept for a moment. In order to allegedly help you purchase health insurance and presumably have access to the latest medical technology (of which medical devices are critical) to improve your health care and hopefully improve your quality of life and extend it, the government is going to tax the shit out of those very products. Does that make any sense? To a social engineer perhaps, but not a principled conservative.
Interestingly, we cannot count on industry to necessarily stand up for capitalism and free markets if they think they can make money from government intervention/corporate welfare. Hence, the health insurers gambled that if the health care reform law makes everyone buy their product, that is worth the extra federal meddling in their business. Plus, it will probably lead to a consolidation in the industry, with only a few big insurers left and the potential smaller competitors crushed by the federal intervention in the market. Yet, if they really thought it through, they would realize what a long-term disaster it will be. And of course if the Founding Fathers knew that a federal cabinet secretary would be lecturing a private business about how they set their prices, they would not only roll over in their graves, they would come back as zombies and take their revenge!
The other charge often made is that this product (health care or health care insurance), is different, the market is different, the market doesn‟t work, etc. The principled conservative would say that‟s just plain wrong. The markets always work better than government planning, if you just give them a chance. And by work better, we mean in terms of timeliness, quality, and competitively priced services and products.