Public Option Alternatives

The public option has had a difficult time making its way through Senate Finance Committee mark-up sessions.  In the past week, two separate proposals for including a public option in health care reform were nixed.  Rejection of the plans, one proposed by Senator Charles Schumer of New York and the other by Senator John Rockefeller of West Virginia, is said to be indicative of a further adoption of the middle-of-the-road approach.  Still, some are optimistic that because Obama has the de facto final say on health reform legislation, he will work hard to include a public option; others debate whether the President is willing to compromise the public option for overall reform.

Instead of approving of Schumer’s or Rockefeller’s proposals, the Senate Finance Committee voted to include a proposal by Senator Maria Cantwell of Washington.  Cantwell’s amendment is said to be a compromise between Democrats and Republicans on the public option.  The plan, which would be federally-funded, would be available to those individuals who earn too much to qualify for Medicaid but are below 200% of the federal poverty level.  At present, an implementation cost analysis for the plan is still unavailable, but Cantwell says that the plan, which also give states the power to negotiate down the price of insurance, would be able to cover 75% of the uninsured population.  The plan would mirror the current health care system of Washington State.

Though many important Committee members like Sen. Baucus have approved of such an amendment, others like Senator Olympia Snowe of Maine have voted against it.  Keep in mind, Snowe has been labeled “the key to health reform.”  For Snowe, a public option would only be provided in states in which 95% of the population is deemed to not have access to “affordable” insurance through an Insurance Exchange.  Senator Tom Carper of Delaware has proposed a similar plan; however, his version leaves it up to the states to decide what it deems best for its constituents.  Under Carper’s version, states would get to choose between opening up state-funded health care plans for government employees to all residents, or creating a health insurance provider or a co-op to compete with private insurance companies.

The proposals of Carper, Cantwell & Snowe have their respective positives and negatives and are subject to, and seemingly born of, the political process. They smack of compromise.

What will it take to get any one of these proposed bills passed during the full Senate vote? The ongoing divide between liberals and conservatives on the issue of providing a public competitor to private insurance companies has created a fissure which has echoed through the common landscape now for months. But we are getting close– as the NY Times  put it– “tantalizingly close,” to sweeping Health Reform.  Floor debate will ensue shortly. Predictions abound. But in the words of Lamar Alexander, the number 3 Republican in the Senate, “There is nothing predictable about the Senate floor.”

Compromise. President Lyndon B. Johnson, key to passage of both Medicare and the Civil Rights Act famously declared: “I’m a compromiser and a maneuverer. I try to get ’something.’ That’s the way our system works.” As evidenced by the two aformentioned Johnson successes, however, Johnson also knew when to expend enough political capital to make that ’something’ meaningful. I would suggest we stand at the precipice of one of those times.

Principles for the Homestretch

House and Senate leaders will soon have to reconcile several different versions of health reform bills. The bills are complex, but some simple principles should guide the process of integrating them into a final product. As the press reports on a whirlwind of proposed laws, we need to ask of any particular proposal: Does it . . .

1) Increase productive competition in health care? Everyone talks about “increasing competition” among insurers and providers, but there are many ways to compete. Hospitals and doctors can game the reimbursement system. Insurers may not directly discriminate against the sick, but can find other ways to keep high-risk patients out of their plans, as even the most market-oriented health policy experts realize:

[T]o avoid patients with costly, complicated medical conditions, health plans could include in their networks relatively few doctors who specialize in treating those conditions, said Mark V. Pauly, professor of health-care management at the University of Pennsylvania’s Wharton School.

Both the Netherlands and Switzerland have already experienced problems in this area, even though the Netherlands has implemented risk-adjustment methods (which attempt to deter such “cherrypicking” and “lemondropping”) far more serious than anything proposed in current bills in the US. As Karen Pollitz has repeatedly argued, we’re going to need a much greater investment in insurance regulation to make any reform bill work.

2) Make it easier for uninsured or underinsured individuals to buy coverage? Many of the proposals for allocating and awarding subsidies for coverage sound exceedingly complex. We’re hearing about serious limitations on access to exchanges, subexchanges, burdensome “free rider” provisions, etc. Any particular provision may sound good in the abstract, but taken as a whole they could become an obstacle course that makes obtaining insurance coverage a miserable and exasperating experience for those supposedly aided by reform. During the second Bush administration, hundreds of thousands of children eligible for subsidized health insurance were not enrolled because states failed to make enrollment convenient enough for time- and cash-strapped parents. As Liebman and Zeckhauser remind us, “we must design systems for mere mortals, not the people who inhabit the models of traditional economists.” What seems easy to one of DC’s privileged elite can be very hard for an overworked mom or minimum wage-earning service worker.

I believe that the main reason a solid 2/3 to 3/4 of the country supports a public option is because it is a straightforward, transparent way to provide a backstop of health insurance for everyone. If Congress both rejects a public option and makes subsidies for private insurance as complex as the tax code, health reform risks becoming a model case of government failure. Last week’s negative votes on Rockefeller’s strong and Schumer’s weak public options could easily become a “you broke it, you bought it” moment for centrist Democrats and Republicans on the Senate Finance Committee.

3) Fairly distribute the burdens of reforming the health care system? This is the tax and finance question, and it promises to generate some epic battles on Capitol Hill. However the Senate Finance proposal ultimately evolves, it will be in tension with a House of Representatives that sees progressive taxation as a foundation for financing reform. The Baucus proposal to tax “high end”/Cadillac/”gold-plated” health plans may seem progressive, but it promises to gradually engulf even normal plans. While David Leonhardt offers some good economic arguments for such a tax, policymakers should be guided by Leonhardt’s observations on the propriety of taxing those at the very top of the income scale, who have disproportionately benefited from economic trends and tax cuts of the past decade.

4) Provide incentives for long-term cost-saving and preventive medicine? Comparative effectiveness research is a crucial tool for focusing pharmaceutical research on drugs that save lives. We have a shortage of primary care doctors vis a vis specialists. Reimbursement systems are too easy to game. Insurance markets are concentrated and need more competition and transparency. Any bill that ignores these problems (or fails to empower HHS or another agency to address them) can’t lead to truly sustainable universal coverage.

The health reform fight has been bruising, disappointing, and frustrating for many who care about health policy. Many unwise assumptions are already baked into leading bills. In the Senate, ostensibly Democratic lawmakers are promoting what are essentially Republican ideas and granting enormous subsidies to industries that may well betray them at the next electoral cycle. Nevertheless, there remain many opportunities for improving the final product at the beginning of the end of the legislative process.

Implementing Reform: Children with Special Health Care Needs

The public option took a hit on Tuesday, as the Senate Finance Committee rejected amendments adding it to the Chairman’s Mark of the Baucus bill. As I have written previously, a public plan could improve care for the most vulnerable, including those with chronic illness, who tend to struggle for appropriate care under commercial plans. If the public option is dropped, the implementation of the resulting private plan-based system, including enforcement and regulatory design at the federal and state levels, becomes that much more critical to the task of assuring access to appropriate care.

The bills build on the benefits design of the private insurance market, as did Medicare and SCHIP before them. Those programs adopted familiar, private-sector benefits design and payment methods for political and pragmatic reasons: powerful stake-holders were comforted, and implementation was simplified. The bills build on this lineage. The Baucus bill, for example, requires all plans offered by the insurance exchanges to provide:

preventive and primary care, emergency services, hospitalization, physician services, outpatient services, day surgery and related anesthesia, diagnostic imaging and screenings (including x-rays), maternity and newborn care, pediatric services (including dental and vision), medical/surgical care, prescription drugs, radiation and chemotherapy, and mental health and substance abuse services that at least meet minimum standards set by Federal and state laws.

Pretty standard stuff. But describing a slate of covered benefits, and ensuring that that care is properly delivered by private, mostly for-profit firms, are different things entirely.

Take the example of children with special health care needs (”CSHCN”). The Maternal and Child Health Bureau of DHSS defines CSHCN as “…those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” The Catalyst Center at Boston University identifies these children’s health conditions as including:

chronic illnesses such as diabetes, sickle cell anemia, cystic fibrosis, and heart disease; developmental disabilities such as mental retardation, sensory impairments, and autism spectrum disorders; emotional or behavioral health needs including ADHD and mental health conditions; and physical disabilities such as cerebral palsy, spina bifida, or muscular dystrophy.

Simply providing “health insurance” to children with these conditions is no guarantee that they’ll receive appropriate services. A 2002 study by Harriette Fox and others for HRSA reported that insurers have interpreted contract terms to exclude categorically some conditions such as mental retardation or “inorganic disorders.” Others have limited medically necessary services such as speech therapy or habilitation therapy because they are not curative or restorative, but merely needed to maximize a child’s ability to function.

These contract terms and their interpretations have not often been challenged by state departments of insurance, because those terms and interpretations have the power of custom and industry practice behind them. These customs and practices, however, can deny care that children desperately need to live socially integrated and healthy lives. Amy Davidoff and coauthors in 2004 examined the difference in children’s coverage experiences when covered by Medicaid on one hand, or by private plan-mimicking SCHIP on the other, with respect to denial of access to needed services, including medically necessary ancillary services. They reported that,

Medicaid-eligible children tend not to face these concerns, in part because Medicaid explicitly covers medically necessary services not covered by private insurers. To the extent states pattern their SCHIP programs on private insurance and not Medicaid, the children lose that benefit.

The Baucus bill adds to Medicaid’s strength in this regard. At Title II, Subtitle B of the Chairman’s Mark (after the acceptance of an amendment from Senator Debbie Stabenow), a new Medicaid state plan option will permit states to offer, for children with at least two chronic conditions or one serious and persistent mental health condition,

Comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support; and referral to community and social support services, if relevant…

What of families covered by the private competitive marketplace of health insurance or SCHIP? The bills speak in general terms of the power of federal and state regulators to ensure adequate and appropriate coverage. This enforcement power should be used to ensure that coverage applies to chronic and disabling conditions as it does to run-of-the-mill medical/surgical cases. Future posts will examine some of the specific enforcement language, which will be key to the realization of the promise of reform to CSHCNs and others with chronic and disabling conditions.

Parsing “Populism” in Resistance to Reform

Today the NYT leads with a story on a growing resistance to the individual mandate to purchase health insurance. The mandate is a key part of virtually all the reform bills now being discussed. A “growing group of lawmakers are pressing for state constitutional amendments that [they believe] would outlaw” the mandate in their states. Law professors have a dim view of the effort:

“States can no more nullify a federal law like this than they could nullify the civil rights laws by adopting constitutional amendments,” said Timothy Stoltzfus Jost, a health law expert at Washington & Lee University School of Law.

Mark A. Hall, a law professor at Wake Forest who has studied the constitutionality of mandates that people buy health insurance, said, “There is no way this challenge will succeed in court,” adding that the state measures seemed more “sort of an act of defiance, a form of civil disobedience if you will.”

Even Randy E. Barnett, a Georgetown Law professor who has written about what he views as legitimate constitutional questions about health insurance mandates, seemed doubtful. “While using federal power to force individuals to buy private insurance raises serious constitutional questions, I just don’t see what these state resolutions add to the constitutional objections to this expansion of federal power,” Professor Barnett said.

What I find so depressing about the new Orval Faubuses of health care is their failure to address funding mechanisms for purchasing health that would make the mandates much less onerous. As I blogged earlier this summer, the House Tri-Committee Bill tries to shift the burden of paying for health care from the already strapped lower-middle class to wealthier citizens who have disproportionately benefited from globalization and other economic trends. At that post, attorney David S. Miller commented:

A mark-to-market tax on the publicly-traded securities of the highest-income and wealthiest individuals would achieve [even more progressivity]. This proposal would also raise significantly more revenue than the [proposed House] surtax, would not require any increase in tax rates, would affect far fewer taxpayers, and would be more in line with the consensus view that the tax base must be broadened. It would also level the playing field between wage and income earners (who are currently subject to tax at ordinary income rates on all or virtually all of their economic income) and with investors (who defer tax indefinitely on appreciation and, when taxed, pay it at reduced long-term capital gains rates).

Unfortunately, the ballyhooed Baucus Bill appears to be far less redistributive than even the House Bill (which I have criticized for failing to distinguish between the merely well-off and the truly wealthy–a very important distinction in an era of fractal inequality). The new state resistance to a mandate should be seen as less a defense of the middle class than it is a sad example of classically self-defeating resistance to equitable distribution of social benefits and burdens.

Health reform financing must rely not merely on redistribution from the healthy to the sick, but also from the rich to the rest. A just society is committed to the universal destination of human goods-–especially those essential to the preservation of human life. Perhaps we will eventually reach a point at which taxation of those at the top to provide for the care of those at the bottom truly threatens the well-being of our economy. But when “the increase in incomes of the top 1 percent of Americans from 2003 to 2005 exceed[s] the total income of the poorest 20 percent of Americans,” we’re a long way from that point on the Laffer Curve.

Reform Rodeo

1. The HITECH Act’s Breach Notification rules are now in effect. As is noted in the article, many are questioning some of the limitations in the act– which may reduce the Act’s impact on protecting privacy.

2. Eugene Volokh’s blog discusses the constitutionality of an individual mandate.

3. A persuasive article from Fortune Magazine describing how Baucus’ Finance Committee bill will raise taxes on the middle class, and in dong so violate the core tenets of the Obama administration.

4. A nicely compiled listing of the amendments that have been put forward during the Finance Bill’s mark up.

5. A FiveThirtyEight post questions those who presume that health reform is inevitable, raising some sobering thoughts.

6. Under the Obama administration, The FDA has provided a black box warning for the anti-nausea drug Phenergan, presumably in light of the Supreme Court’s recent rejection of the drug manufacturer’s claim that federal regulations preempt state court’s from suing drug manufacturers for defective warnings.

7. In case you missed it: A post from Health Reform Watch by Professor Timothy S. Jost on Health Care Cooperatives was cited by Jacob S. Hacker in an article over at the New England Journal of Medicine’s web site. Hacker’s article, “Poor Substitutes–Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option,” is well written and well read.

Reform Rodeo

1. Sen. Baucus, releases the Finance Committee’s public option-less, co-op-based draft bill that will be marked up later in the month (full draft in PDF here, Baucus’ interpretation of it in today’s WSJ op-ed) .

1(a). Ezra Klein opines about how “BaucusCare” should be improved, and in doing so provides a good overview of some of the draft’s key provisions.

2. The New York Times has a nice primer on one of the most discussed possibilities reforming health care: health insurance exchanges. It is definitely worth following the link the Times provides to the FEHB online comparison tool to see how easy it is for federal employees to shop for health insurance.

3. The Kaiser Family Foundation has released their annual report (summary in PDF format here, full report in PDF format here) the shows the changes in employer health benefits.

4. The Robert Wood Johnson Foundation summarizes a New England Journal of Medicine poll which finds that a majority of physicians support a public option.

5. The Health Care Blog has a nice run-down of HHS’s effort to retake control of EHR certification from CCHIT–and what the not-for-profit CCHIT is doing in response.

6. In Case You Missed It: Professor Nathan Cortez in The Health Care Blog on “Immigrants, Health Reform, & Lies” — originally posted here on HRW.

Amusing Ourselves to Death, Health Care Edition

As health insurance reform hopes entered a downward spiral in August, a squad of Monday morning quarterbacks blamed Democrats for mismanaging the debate. Turning his attention from the finance to the insurance industry, Matt Taibbi is particularly withering:

There [are] now so many competing ideas about how to pay for the plan and what kind of mandates to include that even after the five bills are completed, Congress will not be much closer to reform than it was at the beginning. “The president has got to go in there and give it coherence,” [former Labor Secretary Robert] Reich concluded.

But Reich’s comment assumes that Obama wants to give the bill coherence. In many ways, the lily-livered method that Obama chose to push health care into being is a crystal-clear example of how the Democratic Party likes to act — showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia.

There are some aspects of the Senate HELP Bill that bear out Taibbi’s cynicism, and I expect more in the Gang of Six’s handiwork. But Taibbi misses the forest of reform for the trees of venal interest group grabs that are embedded in any modern legislative process. (Can he really say that even Baucus’s bill, the worst proposed so far, is so bad that it’s worse than the status quo?)

And can we please back up a bit and consider how industry giveaways develop “off-camera?” Professor Timothy Jost, one of the most authoritative, knowledgeable, and diplomatic voices in the health reform debate, has this to say about the media coverage of health insurance this summer:

I have explained how the bill works at a number of public meetings in recent days and have uniformly met the same response, “no one has laid this out for us before”. The media has done a terrible, an abysmal, an inexcusable, an unethical job of covering reform. They have completely abdicated their job of informing the public in favor of becoming an entertainment industry. The media have attended only to the politics, the controversy, the nuts, and the absurd, and have done almost nothing to let the public know what is at stake and what the legislation does. Consequently, the American people uniformly confess to being confused.

What could bring clarity? Paul Krugman, indispensable in so many other areas of contemporary political debate, offers this frame. He proposes Obama say the following:

“We’re going to make sure that every American has access to the same insurance deals big employers get. We’re going make sure that no American can be denied coverage at a reasonable rate because of previous medical history. And for those Americans who find it hard to afford essential insurance, we’ll provide financial aid.”

“Now, there are a few things we’ll need to do to make this work. We’ll have to require that all large employers either offer coverage to their workers or pay into a fund that helps them get their own insurance. We’ll sign people up for insurance now, even if they’re healthy, because it’s not fair to others if you wait until you’re sick to join the system. And we’ll keep the insurance companies honest by offering people the choice of buying their insurance directly from a public plan.”

“Let me be honest: this won’t come free. But this plan will give Americans the fundamental security of knowing that for the rest of their lives they and their families will have the health insurance they need, insurance that they can’t lose.”

Krugman also addresses the thorny issue of the public option, arguing that it’s crucial to balance an individual mandate to have health insurance with an option to join a public plan. It should be easy for America’s “vast middle class” to see the benefits here, if Obama can break through the carnival of death panel-talk that the media has seized on this summer.

Risk, Reward, and Rationality in the Health Care Debate

I agree with Andrew Koppelman’s analysis of resistance to health insurance reform. But Red America’s implacable opposition to the plans now debated in Congress has deeper ideological roots in a love of risk. As Thomas Edsall has observed, “A problem for Democrats … is the long tradition in the US of … venerating risk … and of a deep commitment to untrammeled individualism.”

Even more frustrating for Democrats, the left’s hard-won victories to reduce risk have left many people assuming that they can’t gain much from reform. Consider four “backstops” that leave many people unworried about losing insurance:

1) Bankruptcy: Republicans worked hard to water down bankruptcy protections during the Bush years. Nevertheless, these laws still protect many consumers. As health law expert Timothy S. Jost writes, “Ultimately, the federal bankruptcy code must also be seen as our federal catastrophic health care program.”

2) Medicare: Thanks to LBJ and an overwhelming Democratic majority in the 89th Congress, the elderly already have access to federal health insurance, and are wary of any coverage expansion that could drain resources from the program. Here the GOP’s anti-spending and family values wings have formed a pincer movement that has whiplashed Democrats. First, fiscal conservatives used CBO’s dubious cost estimates to demand “real savings” to pay for reform. Dreaming of bipartisanship, Obama’s technocrats seized on the Dartmouth studies to argue that up to a third of all medical spending, including Medicare, is wasted, and that reform of the delivery system could rationalize that spending. At that point the GOP’s “family values” wing associated reform with death panels, rationing, and “pulling the plug on grandma.”

3) EMTALA: Can a relatively well off person “rationally choose” to be uninsured? As Jost notes, as of 2004, “many of the uninsured are in fact reasonably well-off—8.4% are from households that earn $75,000 or more per year.” To the extent this group is calculating the costs and benefits, it’s likely counting on the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) to force hospitals to “screen and stabilize” those who come to their emergency rooms. Of course, once you’re stabilized, the duty to care is over, but few people think very clearly about what it is like to slowly (and stably) die of cancer while the only effective treatments are too expensive to pay for.

4) Medicaid: Finally, we come to another element of the social safety net many people think they can fall back on: Medicaid. Benefits aficionados know that only the categorically eligible can rely on it. Some reform proposals would replace the “numerous statutory and regulatory pathways for establishing eligibility” with a simple income test. But for now, those among the populace who just assume that Medicaid covers all the poor may believe they would have little to gain from reform even if they did face crippling medical bills. (They’re probably also unaware of Medicaid’s pitifully low reimbursement rates–but more on that later.)

None of these so-called backstops will help everyone, all the time. But one can imagine a risk-loving, red-blooded American wanting to roll the dice on them rather than endure the type of bureaucratic assessments and applications that will gradually poke and prod the uninsured making between 133% and 400% of the poverty level toward buying their own coverage on an exchange. Indeed, under the Senate HELP Committee’s proposal, a family making 400% of the poverty level could be responsible for paying up to 12.5% of their income in premiums, for insurance that leaves them liable for paying $11,600 in out of pocket expenses. That’s a worst case scenario of paying 26% of income for health care–better than bankruptcy, but potentially tantamount to the same thing in a country where the bottom half of the population has virtually no net worth. (And that cost-sharing estimate assumes the medical component of the CPI does not increase.)

The really appealing goal of reform–a strong public option that would be part of an exchange open to all–appears to be more of a bargaining chip than a firm commitment for the Obama Administration. Strategically, if your goal is to get “something” through Congress, this makes a great deal of sense: Republicans and some waivering Democrats think a public option smacks of socialism. But as a political matter, it is draining support for reform. People can understand a public option, and building support for it might have been as decisive to Democrats’ fortunes as FDR’s reformulation of the American social contract in the 1930s. Sadly, Obama’s technocrats appear more attracted to wonk-talk like “bending the cost curve” than the forceful moral case for collective responsibility for health. Only the President can correct that course. It takes an ideology to beat an ideology.

X-Posted: Balkinization.

Catholic Doctrine and the Public Option

I claim no expertise in Catholic doctrine, nor for that matter theology; but I have studied them some in relation to law and social justice and as a matter of personal edification. Recently, I have heard of protestations within the Faith against the spectre of the Public Option and “socialized medicine” as such. Again, as I claim no expertise, I’ll just present and lend some analysis to what lies before me; I speak only for myself.

I consulted my copy of the Catechism of the Catholic Church, Second Edition (revised in accordance with the official Latin text promulgated by Pope John Paul II), Libreria Editrace Vaticana. According to the Apostolic Constitution Fidei Depositum, On the Publication of the Catechism of the Catholic Church, “The Doctrinal Value of the Text,” this Catechism is “a statement of the Church’s faith and of catholic doctrine, attested to by Sacred Scripture, the Apostolic Tradition, and the Church’s Magisterium.” The Catechism is also said to be “a sure and authentic reference text for teaching catholic doctrine and particularly for preparing local catechisms.” According to the Apostolic Letter, Laetamur Magnopere in which this Catechism of the Catholic Church is Approved and Promulgated by John Paul II, it was “prepared by an Interdicasterial Commission” presided over by then Cardinal Joseph Ratzinger.”

The Catechism

Part Three, Life in Christ, Article 3, Social Justice, Section II, “Equality and Differences Among Men.”

• 1936 On coming into the world, man is not equipped with everything he needs for developing his bodily and spiritual life. He needs others. Differences appear tied to age, physical abilities, intellectual or moral aptitudes, the benefits derived from social commerce, and the distribution of wealth.[1] The “talents” are not distributed equally.[2]

• 1937 These differences belong to God’s plan, who wills that each receive what he needs from others, and that those endowed with particular “talents” share the benefits with those who need them. These differences encourage and often oblige persons to practice generosity, kindness, and sharing of goods; they foster the mutual enrichment of cultures….

One might think that access to medical care for a sick man, regardless of “the difference” in “the distribution of wealth,” would be essential to “developing his bodily… life.” In addition, it seems plain within the text that despite (or perhaps because of) these “differences,” each should “receive what he needs from others.” There is no provision for pre-existing conditions; no provision which mandates that only the best capitalists’ health needs be met.

As for the prospect of a government constituted by the people and for the people providing en masse for these needs, it may be of some help to look to Part Three, Life in Christ, Article 3, Social Justice, Section I, “Respect for the Human Person.” This section precedes the section quoted above by about a page.

• 1930 Respect for the human person entails respect for the rights that flow from his dignity as a creature. These rights are prior to society and must be recognized by it. They are the basis of the moral legitimacy of every authority: by flouting them, or refusing to recognize them in its positive legislation, a society undermines its own moral legitimacy.[3] If it does not respect them, authority can rely only on force or violence to obtain obedience from its subjects….

If this acknowledgment of certain inherent rights precedent to social structure sounds familiar, it should: as part of the promise which is the Declaration of Independence we are told that all men “are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness” and that it is “to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed.”

Importantly, according to catholic social justice doctrine, the basis for the moral authority of power (i.e. governance), and thus its legitimacy, is contingent upon its being in accord with the dignity of human beings. Therefore, the failure to reach such an accord in a society’s legislation calls to question the legitimacy of that society’s rule; the legitimacy of such rule being “undermined” in direct proportion to such failures.

As for an example of that which is required by the dignity of human beings/ legitimacy of rule, it may prove to be of some help to look again to “Equality and Differences Among Men.”

• 1938 There exist also sinful inequalities that affect millions of men and women. These are in open contradiction of the Gospel:

• Their equal dignity as persons demands that we strive for fairer and more humane conditions. Excessive economic and social disparity between individuals and peoples of the one human race is a source of scandal and militates against social justice, equity, human dignity, as well as social and international peace.[4]

I would suggest that supplying affordable access to health care to all within this country is the essence of striving for “fairer and more humane conditions.” And that respect for the dignity of mankind, upon which rests “the basis of the moral legitimacy of every authority,” not only allows for such proposals as a Public Health Care Option, but, it would seem, demands it.

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[1] 41. Cf. GS 29 Sect. 2 (footnotes are from the text of the Catechism, but appear here renumbered due to format. The original footnote number appears immediately after this document’s footnote number-in this instance, the original is “41.”

[2] 42. Cf. Mt 25:14-30; Lk 19: 11-27.

[3] 36. Cf. John XXIII, PT 65.

[4] 44. GS 29 Sect. 3.

Is it Unconstitutional to Mandate Health Insurance?

Is it unconstitutional to mandate health insurance? It seems unprecedented to require citizens to purchase insurance simply because they live in the U.S. (rather than as a condition of driving a car or owning a business, for instance).  Therefore, several credentialed, conservative lawyers think that compulsory health insurance is unconstitutional.  See here and here and here. Their reasoning is unconvincing and deeply flawed.  Since I’m writing in part for a non-legal audience, I’ll start with some basics and provide a lay explanation.  (Go here for a fuller account).

Constitutional attacks fall into two basic categories:  (1) lack of federal power (Congress simply lacks any power to do this under the main body of the Constitution); and (2) violation of individual rights protected by the “Bill of Rights.”  Considering (1), Congress has ample power and precedent through the Constitution’s “Commerce Clause” to regulate just about any aspect of the national economy.  Health insurance is quintessentially an economic good.  The only possible objection is that mandating its purchase is not the same as “regulating” its purchase, but a mandate is just a stronger form of regulation.  When Congressional power exists, nothing in law says that stronger actions are less supported than weaker ones.

An insurance mandate would be enforced through income tax laws, so even if a simple mandate were not a valid “regulation,” it still could fall easily within Congress’s plenary power to tax or not tax income.  For instance, anyone purchasing insurance could be given an income tax credit, and those not purchasing could be assessed an income tax penalty.  The only possible constitutional restriction is an archaic provision saying that if Congress imposes anything that amounts to a “head tax” or “poll tax” (that is, taxing people simply as people rather than taxing their income), then it must do so uniformly (that is, the same amount per person).  This technical restriction is easily avoided by using income tax laws. Purists complain that taxes should be proportional to actual income and should not be used mainly to regulate economic behavior, but our tax code, for better or worse, is riddled with such regulatory provisions and so they are clearly constitutional.

Arguments about federal authority deal mainly with states’ rights and sovereign power, but the real basis for opposition is motivated more by sentiments about individual rights - the notion that government should not use its recognized authority to tell people how to spend their money.  This notion of economic liberty had much greater traction in a prior era, but it has little basis in modern constitutional law.  Eighty years ago, the Supreme Court used the concept of “substantive due process” to protect individual economic liberties, but the Court has thoroughly and repeatedly repudiated this body of law since the 1930s.  Today, even Justice Scalia regards substantive due process as an “oxymoron.”

Under both liberal and conservative jurisprudence, the Constitution protects individual autonomy strongly only when “fundamental rights”  are involved.  There may be fundamental rights to decide about medical treatments, but having insurance does not require anyone to undergo treatment.  It only requires them to have a means to pay for any treatment they might choose to receive.  The liberty in question is purely economic and has none of the strong elements of personal or bodily integrity that invoke Constitutional protection.  In short, there is no fundamental right to be uninsured, and so various arguments based on the Bill of Rights fall flat.  The closest plausible argument is one based on a federal statute protecting religious liberty, but Congress is Constitutionally free to override one statute with another.

If Constitutional concerns still remain, the simplest fix (ironically) would be simply to enact social insurance (as we currently do for Medicare and social security retirement) but allow people to opt out if they purchase private insurance.  Politically, of course, this is not in the cards, but the fact that social insurance faces none of the alleged Constitutional infirmities of mandating private insurance points to this basic realization: Congress is on solid Constitutional ground in expanding health insurance coverage in essentially any fashion that is politically and socially feasible.

Mark Hall
Professor of Law and Public Health
Wake Forest University School of Law

[UPDATE: 03/26/10 http://www.healthreformwatch.com/2010/03/26/are-the-attorneys-generals-constitutional-claims-bogus/]

The Lewin Group: Cited Often, Owned by UnitedHealth

In a recent Chicago Tribune article, “Health-care reform: Medical insurers poised to reap a healthy ‘bonanza,’”   the following paragraph concerning The Lewin Group caught my eye

One of the Democratic proposals that most concerned insurers was creation of a “public option” government-sponsored insurance plan. The industry launched a campaign on Capitol Hill, distributing arguments opposing the government option that often were grounded in a study published by The Lewin Group, a health policy consulting firm owned by UnitedHealth.

In an effort to stay abreast, I read a fair amount of opposition commentary–and “The Lewin Group” comes off the lips of Republicans and others opposed to the Public Option often enough. Although The Lewin Group connection with UnitedHealth has been made public by a number of sources, I’m not sure that it’s common knowledge. And perhaps, as always, when dealing with information–especially information doing duty as a foundation upon which Medical Insurers stand “poised to reap a healthy bonanza”–considering the source– and considering that the source of that information is owned by one of the nation’s largest insurers– may be worth a moment or two.

This description of The Lewin Group comes from The Lewin Group in their Testimony before the before the Energy and Commerce Committee, U.S. House of Representatives, dated June 25, 2009, and updated July 9, 2009

The Impact of the House Health Reform Legislation on Coverage and Provider Incomes

About The Lewin Group

The Lewin Group is a health care and human services policy research and management consulting firm. We have over 25 years of experience in estimating the impact of major health reform proposals. The Lewin Group is committed to providing independent, objective and nonpartisan analyses of policy options. In keeping with our tradition of objectivity, The Lewin Group is not an advocate for or against any legislation. The Lewin Group is part of Ingenix, Inc.,which is a wholly owned subsidiary of the UnitedHealth Group. To assure the independence of its work, The Lewin Group has editorial control over all of its work products. (emphasis added)

The Lewin Group was purchased by Ingenix (and thus UnitedHealth) in 2007, somewhat presciently in time for the Health Care debate. I do not doubt that The Lewin Group has a stated and formal editorial control over its work products; I do doubt that it looks to bite the hand that feeds it. And I would suggest that as an arm of UnitedHealth, despite Mr. Kellar’s claims above, self decapitation– at least in the corporate world– is less a “mystery” than it is an illusion.

A recent Washington Post article also noted The Lewin Group’s relationship to its immediate parent

Ingenix, a UnitedHealth subsidiary that was accused by the New York attorney general and the American Medical Association, a physician’s group, of helping insurers shift medical expenses to consumers by distributing skewed data. Ingenix supplied its parent company and other insurers with data that allegedly understated the “usual and customary” doctor fees that insurers use to determine how much they will reimburse consumers for out-of-network care.

In January, UnitedHealth agreed to a $50 million settlement with the New York attorney general and a $350 million settlement with the AMA, covering conduct going back as far as 1994.

Ingenix chief executive Andrew Slavitt said the Ingenix data was never biased, but Ingenix nonetheless agreed to exit that particular line of business. “The data didn’t have the appearance of independence that’s necessary for it to be useful,” Slavitt said.

This may give us some idea of where Mr. Slavitt’s bar for data’s  “appearance of independence that’s necessary for it to be useful” is set. But there is of course a possible difference to be had between “useful” and “valid” and “valid as used.”  Distinctions the video below, as well as the Chicago Trib article, may help to clarify.

It should be noted, however, that according to WaPo,

Lewin Group Vice President John Sheils said his firm had nothing to do with the allegedly flawed Ingenix reimbursement data. Lewin has gone through “a terribly difficult adjustment” since it was bought by UnitedHealth in 2007, because the corporate ownership “does create the appearance of a conflict of interest.”

“It hasn’t affected . . . the work we do, and I think people who know me know that I am not a good liar,” Sheils said.

Mr. Sheils also noted to WaPo that those who pay for studies also have the option of “burying” those studies:

But not all of the firm’s reports see the light of day. For example, a study for the Blue Cross Blue Shield Association was never released, Sheils said.

“Let’s just say, sometimes studies come out that don’t show exactly what the client wants to see. And in those instances, they have [the] option to bury the study — to not release it, rather,” Sheils said.

I wonder if UnitedHealth gets the in-house rate.

Reform Rodeo II

1. On the Public Option Developments:

The New Republic has an optimistic assessment of the recent developments which are said to have forced the Obama administration to adopt a more centrist strategy.

2. On Exercise:

An interesting article in Time Magazine describing the counter-intuitive results that exercise–particularly strenuous exercise–may have on weight gain. However, see this article in the New York Times, describing a Finnish study which found that strenuous physical activity–and not moderate physical activity–reduced the risk of a suffering from a number of different types of cancer.

3. On Treatment Guidelines:

The New York Times also has an interesting discussion of the difficulties of implementing national treatment guidelines that aim to help health care providers utilize best practices. (Note: The article may require a free New York Times account).

4. On Payment Reform:

A recent piece in the New England Journal of Medicine explores the implementation of alternatives to the fee-for-service model.

5. On Taxing Health Benefits:

Merill Goozner frames the taxing of health benefits, arguing as others have, that taxing health benefits may in fact be regressive.

6. On the Best Health Care In the World:

Ezra Klein has a nice discussion of (and link to) an interesting post by the Urban Institute where they explore the (un)truthfulness of claiming that the U.S. has the best health care in the world.

7. In Case You Missed it:

Professor Tim Greaney  in The Health Care Blog: “Market Entry by Health Care Cooperatives: Neither Quick Nor Easy” (Originally posted here on Health Reform Watch, then picked up by THCB).

8. In Case You Missed it:

Professor Timothy S. Jost in The Health Care Blog ,”Are Cooperatives a Reasonable Alternative to a Public Plan?”  (Originally posted here on Health Reform Watch, then picked up by THCB).

9. Wild card Pick: If you haven’t heard about the astounding medical applications of a pooch’s powerful snout, this short video (with an accompanying transcript) from National Geographic is definitely worth watching.

If You Give a Republican a Cookie…

Senator Charles Grassley (R-Ia), who is seeking re-election next year and is said to have wrested key concessions from his Democratic counterparts in the Senate– including, according to AP, “an agreement to back away from a government plan to compete with private insurers” –dipped his beak in the ignominious trough of the demagogue over the weekend. AP reports that Sen. Grassley

told an Iowa crowd he would not support a plan that “determines when you’re going to pull the plug on Grandma.” The remark echoed conservative activists who wrongly claim a House health care bill would require Medicare recipients to discuss their end-of-life plans with doctors.

In addition, with recent (perhaps hasty) speculation regarding the demise of a Public Option in Health Care Reform, The Wall Street Journal reports that “The number two Senate Republican said Tuesday replacing a public health care option with a nonprofit private cooperative wouldn’t win any more Republican support, saying they are essentially the same thing. Sen. Jon Kyl (R., Ariz.), said Republican objections were more fundamental than simply changing the name of a new national entity to compete with private medical insurers.”

Senator Kyle, who as Whip is said to speak for the Republican Party,  favors a more private market based approach to health care reform–utilizing such means as medical malpractice reform, allowing small businesses to join together to give them more negotiating clout with health insurers, and allowing health insurance to be permitted to be sold across state lines like other forms of insurance. In addition, Sen. Kyle is reported to support federal government encouragement of “individuals to save more for potential health care needs through tax-friendly accounts, which would reduce their reliance on costly insurance.”

Notably, in a 2006 report on the affect of the minimum wage on families in Sen. Kyl’s home state,  the Children’s Access Alliance of Arizona stated that “Arizona has the widest income gap in the nation. The average income of the top 5% of Arizona families is 14 times greater than the average income for the bottom 20% of families.” Also worth noting is that Senator Kyl voted against increasing the minimum wage in 1997, 2005 and 2007.

On Health Care Legislation, according to On the Issues.org, Sen. Kyle voted as follows:

• Voted YES on means-testing to determine Medicare Part D premium. (Mar 2008)
• Voted YES on allowing tribal Indians to opt out of federal healthcare. (Feb 2008)
• Voted NO on adding 2 to 4 million children to SCHIP eligibility. (Nov 2007)
• Voted NO on requiring negotiated Rx prices for Medicare part D. (Apr 2007)
• Voted YES on limiting medical liability lawsuits to $250,000. (May 2006)
• Voted NO on expanding enrollment period for Medicare Part D. (Feb 2006)
• Voted NO on increasing Medicaid rebate for producing generics. (Nov 2005)
• Voted NO on negotiating bulk purchases for Medicare prescription drug. (Mar 2005)
• Voted YES on $40 billion per year for limited Medicare prescription drug benefit. (Jun 2003)
• Voted NO on allowing reimportation of Rx drugs from Canada. (Jul 2002)
• Voted NO on allowing patients to sue HMOs & collect punitive damages. (Jun 2001)
• Voted YES on funding GOP version of Medicare prescription drug benefit. (Apr 2001)
• Voted NO on including prescription drugs under Medicare. (Jun 2000)
• Voted YES on limiting self-employment health deduction. (Jul 1999)
• Voted NO on increasing tobacco restrictions. (Jun 1998)
• Voted YES on Medicare means-testing. (Jun 1997)
• Voted NO on blocking medical savings accounts. (Apr 1996)
• Rated 0% by APHA, indicating a anti-public health voting record. (Dec 2003)

More extensive analysis of the votes may be found at On the Issues’ 18 full quotes on Health Care.

In a statement on Senator Kyl’s own website regarding Health Care, he notes that “The shortage of health care professionals is due, in part, to Medicare’s efforts to control costs.”

Senator Kyl has repeatedly opposed what he terms “government intervention” in the health care and health care insurance market, stating that it will invariably lead to bureaucrats standing in between patients and their doctors and what will ultimately amount to the rationing of health care.

Interestingly enough, on his website Sen. Kyl notes that in his home state of Arizona, “The average wait for a consultation with a gastroenterologist in the Phoenix area is now two to three months. Mesa hospital administrators report acute shortages of both orthopedic surgeons and neurologists, resulting in emergency room and inpatient consult delays.”

Senator Kyl does not seem to equate such waits or shortages with any form of market based “rationing” and states that the long waits for care at present are “partly due to exorbitant medical liability premiums and the lack of physicians willing to practice under the threat of lawsuits,” and, presumably,the above mentioned “Medicare’s efforts to control costs.”

Regarding Medical Malpractice as a means of Health Care Reform, Senator Kyl, as we’ve reported before, according to Bloomberg.com might be be best to look elsewhere. Regarding real Health Care Reform, for those who had entertained the notion of Bipartisan dialogue as a means to passing comprehensive legislation, they too might be best to look elsewhere. I would suggest, for now, while there are still cookies to be had, the House–where a substantial number of Democratic Representatives have insisted that they will not vote for any reform measure which does not include a Public Option.

Jost on Cooperatives: “Are Cooperatives a Reasonable Alternative to a Public Plan?”

[Ed. Note: Considering recent speculation that the Public Option may be "dropped" in favor of adoption of Health Care Cooperatives, this post by Timothy S. Jost which was originally posted to Health Reform Watch on June 15 , along with yesterday's re-post from Tim Greaney, should go some way towards answering some questions about Health Care Co-ops. As the clamor rises to understand the nature and implications of Health Care Cooperatives, this post from Professor Jost has been linked everywhere from NPR's Planet Money to  The Democratic Underground, the Patriot Room and all points in between. The point taken by most is that we've tried Health Care Co-ops before, and, for the most part, they've failed. For those of you who've missed the article, it is re-posted below as originally posted by Editor-in-Chief, Professor Frank Pasquale. You can access Professor Jost's bio by clicking here.]

In the last post, I introduced Timothy S. Jost and his case for a public insurance plan option. Jost has also recently addressed the new “middle ground” between a public option and the status quo: cooperatives. I’m honored to print his analysis below on our blog.

Are Cooperatives a Reasonable Alternative to a Public Plan?
by Timothy S. Jost

First, a word about history. We have tried cooperatives before. During the 1930s and 1940s, the heyday of the cooperative movement in the United States, the Farm Security Administration encouraged the development of health cooperatives. At one point, 600,000 mainly low-income rural Americans belonged to health cooperatives. The movement failed. The cooperatives were small and undercapitalized. Physicians opposed the cooperative movement and boycotted cooperatives. When the FSA removed support in 1947, the movement collapsed. Only the Group Health Cooperative of Puget Sound survived. Over time, moreover, even Group Health, though nominally a cooperative, has become indistinguishable from commercial insurers-it underwrites based on health status, pays high executive salaries, and accumulates large surpluses rather than lower its rates.

The Blue Cross/Blue Shield movement, which also began in the 1930s, shared some of the characteristics of cooperatives. Although the Blue Cross plans were initiated and long-dominated by the hospitals and the Blue Shield plans by physicians, they did have a goal of community service. The plans were established under special state legislation independent from commercial plans. They were non-profit and, in many states, exempt from premium taxes. They were exempt from reserve requirements in some states because they were service-benefit rather than indemnity plans and because the hospitals and physicians stood behind the plans. They were exempt from federal income tax until the 1980s. In turn, they initially offered community-rated plans and offered services to the community, such as health fairs. In some states their premiums were regulated and they were generally regarded as the insurer of last resort for the individual market.

Over time, however, the Blues lost their focus on community service and began to look more and more like their competitors. They abandoned community rating (which, realistically, they could not maintain when faced with competition from experience-rated commercial plans) and began to impose underwriting and cost-sharing requirements indistinguishable from the private plans. Although providers lost control of the Blue plans, the plans never took a leadership role in bargaining aggressively with providers, despite their market dominance in many states. Many of the largest Blue plans became for-profit, and those that remain non-profit are largely indistinguishable from commercial insurers. Although the national Blue Cross/Blue Shield association offers some coordination services to local plans, it has not resisted the move of Blue plans away from a community-service toward a for-profit orientation. Lacking a national focus on public service, state and regional plans have become indistinguishable from their commercial competitors.

Blue plans are not the only non-profit insurers that survive. Many church and fraternal organizations have their own non-profit plans. Although these plans often try to serve their communities, they usually have a small presence and little bargaining power in most communities in which they operate; tend to insure individuals and small groups, the most costly market; are often the victims of adverse selection; usually underwrite much like commercial plans; and tend to offer low value, high cost-sharing policies. They are not a model on which to build national reform. Mutual insurers are also in theory owned by their members. They also, however, are indistinguishable from for-profit insurers in most states.

What can we learn from this history? First, health care cooperatives are, in fact, an American response to health care reform. Cooperatives and non-profit insurers were there before for-profit commercial insurers entered the health insurance business, and we could try to revive the idea again.

But why would state or locally-run cooperatives be any more successful now than they were when we tried them before?

First, it is hard to imagine how they would get underway. Capitalization and critical size were problems before and would likely be problems again. Senator Conrad’s recent draft suggests that members of the coops would elect their boards, and that the coops would then obtain state licensure as mutual insurers, meeting state standards for solvency and reinsurance (with the help of federal seed money). But there is a chicken and egg problem here. Until the coops had members they could not have a board. Until they had a board, how would they meet licensure requirements? The state coops, moreover, would, under Conrad’s proposal be supervised by a national board, but the national board would be elected by the state coops. Again, the state coops would presumably not be able to get underway until the national board provided policy guidance, but the national board could not get underway until the state coops were formed to elect it. None of this makes sense.

Second, there is every reason to believe that small, state run coops would fail like their predecessors did in the 1930s and 1940s. Unless they reached the critical mass necessary to bargain effectively with providers, to accumulate reserves, and to compete with national private insurance plans, they would be doomed to failure. Even if they managed to succeed here and there, they would contribute nothing to a national effort to control costs, drive value, and make affordable care accessible.

Third, if state-run coops in fact, against all odds, became large, successful competitors for insurance business, what would keep them from following the course of the Blue and mutual plans before them? Without strong Congressional direction and a unifying national leadership, what could keep them focused on cost control, quality improvement, transparency, and service rather than simply becoming indistinguishable from their commercial competitors? How would they drive the delivery system change we need?

Fourth, how does setting up cooperatives on a state-by-state basis drive national health care reform? Each state currently can set up cooperatives if it wishes to, but none have done so. Why would states suddenly embrace this concept? And what assurance do we have that they would pursue anything like a common strategy? To approach this issue on a state-by-state basis is simply to surrender on national health care reform. A federal fallback plan to be implemented in the future is also unlikely to work. HIPAA contained a federal fallback plan for states that failed to implement reforms in the individual market, but it was poorly implemented and eventually abandoned. To revert to a state-by-state approach is to surrender on national health care reform.

What Would Make the Cooperative Concept Work?

In fact the cooperative idea in itself is promising. The proposed cooperatives look much like the social insurance funds of Germany and of other central European states. Those funds are governed by their members and do a comparatively good job of keeping health care costs in check. But they operate in a strong framework of national laws and under the guidance of national leadership.

The only viable strategy is Senator Conrad’s Option 2–a federal charter to license and regulate a national non-profit coop, with coop governance prescribed by Congress. Leadership could initially be appointed as directed by Congress to represent consumer, labor, and small business interests, and thereafter be elected by the membership. The federal government could provide seed funding to assure initial solvency, but thereafter the coop could be self-supporting. It would be financed through premiums, and compete on a level playing field with private insurers (although some account would have to be taken of the fact that private insurers, no matter what underwriting rules were imposed, would still dump high-risk insureds into the coop). Some administrative functions could be delegated to the regional level, much as Medicare Advantage or drug plans are administered at the regional level. Regional councils could also be elected by members, who could have a role in selecting the national board and an influence on national policy.

A national cooperative could perhaps compete effectively with national private insurers. It could perhaps bargain effectively with providers, including global pharmaceutical firms and national hospital chains. It is possible that it could drive creative national quality initiatives and provide national data on health care use. It would not be government-run insurance, the great fear of the American right. But it could perhaps provide a national solution for a national problem. It will not happen on its own, however. It will only work with concerted and probably long-lasting support from the federal government.

Health Care Reform, Ms. Palin Weighs In

Finally, after all this time mucking around with boring and complex health care experts, a voice from the wilderness has weighed in in terms we can all understand. “Evil.” Ms. Palin actually used the word evil to describe the Health Care system she has fabricated to be the Obama Plan.

Conjuring up pictures of a thumbs-down bloodstained and leering (but decidedly Wonkish) Obama/Caligula “death panel,” Ms. Palin recently informed her Facebook followers with this “Statement on the Current Health Care Debate,”

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course.The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

This woman was slated to be a heartbeat from the presidency; she looks to get closer. She has over 700,000 “supporters” on her Facebook page.

The statement starts thus:

As more Americans delve into the disturbing details of the nationalized health care plan that the current administration is rushing through Congress, our collective jaw is dropping, and we’re saying not just no, but hell no!

Without delving deeply into the merits of the argument (others have done so ably–there are none, this is make-believe coupled with demagoguery of the worst sort which also pretends that Private Insurers offer unlimited care at present– but for a very good point by point refutation you can look at any of these compiled over at Kaiser, or this fact-checker from ABC’s Senior White House correspondent Jake Tapper), might I suggest a certain logical inconsistency even within the make-believe of Ms. Palin’s view? In her opposition to a Government or Public Option, she seems left with an option in which a Private Insurance Executive, concerned as he must be with Corporate Profits, would be more likely to extend payment for massive health care expenses to Grandma and Baby Trig than the spendthrift “tax and spend” Democrats she consistently describes as “fiscally irresponsible.” One might imagine a slightly better chance with Howard Dean or Ted Kennedy than with a Health Insurance CEO that made $467,000 PER WEEK last year –and wanted to do so again this year. No?

If you read her post carefully ( I know, but perhaps you could humor me for a moment) what she seems to be saying is that in effect, the fiscal irresponsibility of the spendthrift Democrats in offering health insurance to all will itself lead to, and force, rationing. But the question then, of course, is this: rationing to whom and on what scale? Her premise it seems is necessarily that the absence of health care for some, at present, makes it possible for the unlimited healthcare of  many (i.e., in Ms. Palin’s make believe world, Private Insurers at present offer unlimited non-rationed Health Benefits to those who, at present,  have health insurance, but if the poor and uninsured are given access to healthcare, that will bankrupt the system and require limitations upon those who had formerly held unlimited access to care– or, in short, if the poor and uninsured get some, the presently covered will get less). How is that not rationing?

If rationing is the selective distribution of scarce resources via certain criteria–some form of merit or lack thereof–then rationing is exactly what happens under Ms. Palin’s make-believe model at present: the utilitarian calculus en masse. The distribution criteria, however, in Ms. Palin’s model, is money–which becomes a “death panel” in and of itself. A “communal standard” based on wealth. Simply put, in Ms. Palin’s world, she necessarily allows for that most efficient of instruments, the market, to decide who lives or dies.

Strangely enough, Ms. Palin’s world begins to look a lot like ours.

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