Jimm Webb's semi-reasonable, admittedly Unconstitutional plan for health-care reform
I watched another C-SPAN televised town hall today and they've done the country and those who care to pay attention a huge service by doing so. The narratives that the meetings are either infiltrated by unhinged, astroturf Republican sycophants shouting down Democrats or that ACORN or SEIU or other community organizations or unions have organized a massive, concerted counterattack both overstate the case. There are varying degrees of rancor depending on the position of the member of Congress and the political leanings of their constituents, and while there is anger and there are occasionally small groups of people shouting or a large portion of the audience booing, out of turn and in anger, for the most part these incidents result in brief delay in the proceedings, not any sort of effective "shouting down" of the opposition in the sense that those with opposing viewpoints are allowed to express them--they have the microphone--after a brief outburst. Similarly, while those who support the bills seem to be slightly more organized than those who oppose it--often a number of are carrying multiple copies of the same sign, and others who are in their camp have hand-made signs, all of which are held up when the anti-reform crowd cheers in an (ineffective) attempt to create a confusing visual image. References to Nazism have not been present in several meetings I've seen, and the most outlandish thing a supporter on the right said was to question whether Barack Obama was, in fact, a patriot. Jim Webb--whose town hall this view was expressed at--said this was beyond the pale of civil discussion, although permissible under free speech, but that he disagreed with questioning our President's patriotism. Overall the impression I got was that while there is a lot of anger that the idea that the protesters on either side are political pawns or crazy people was completely wrong.
Most opponents were concerned about the general contradiction of how we can save money by expanding care to millions of new people--the Democratic argument basically seems to be that the $1000 tacked onto most folks' health insurance premiums annually to provide acute, emergency care to people who have no general health coverage is equal to or greater to the cost of both insuring them all and also paying for the subsidies of the insurance premiums for all that seem like they must go up if the whole country basically adopts community rating--health insurance companies must charge people more or less the same rate within some relatively narrow band whether they are healthy or not--and furthermore those companies must accept people with pre-existing conditions. The math doesn't seem to work out; you're going to make insurance a lot more expensive for everyone, promise that the government will pay for the part that people can't afford, and put a lot more people into the program, those of whom are the horror stories that necessitate this reform are those who will cost the most to provide care for and/or are the least able to pay for their insurance.
Jim Webb's answers to the hard questions seemed to make much more sense than the Senior Democratic leadership--although to be frank, the partisan anti-health-care reform crowd didn't seem to buy his arguments--but his arguments provided some serious questions about the role of government. His good ideas, first of all, were that he would oppose specifics about proposed legislation that seem to violate the pledge to make this plan pay for itself. Specifically, he opposed the public option at first and if it were to be implemented later to increase pressure to drive down costs it would have to compete on a level playing field and not run at a loss subsidized by taxpayers; he recognizes that this simply continues the failed premise of entitlements like Medicare and Social Security and would lead to a massive budget shortfall in a short period of time. I wasn't quite sure what to make about his proposal that doctors be compensated differently, with the general idea being that the incentives be changed from procedures performed to overall outcomes of patients--an idea which both in theory and as Webb explicitly pointed out would steer more people into becoming GPs and would reduce the disparity in compensation between hot-shot specialists like brain surgeons and the doctors in the trenches of pediatric medicine and general practice. This seems like a necessary type of reform to do something about runaway costs of medicine, but unfortunately it takes a lot more work and years of schooling and skill and is generally something that in the free market would be compensated more richly to be a brain surgeon than to be a pediatrician. Social engineering to encourage the few people who want to be doctors to be GPs by changing the financial incentives so that even when the objectively measured amount of training and difficulty of performing brain surgery is greater by a fair amount than that to become a GP that the discrepancy in pay will be lessened seems like it will lead to a shortage of brain surgeons and therefore waiting and rationing of brain surgeries. And this would apply to all acute and semi-acute specialties where the U.S. truly leads the world... orthopedic and trauma and cardiac surgery, surgical oncologists cutting out tumors, oncology in general.
At least, though, Webb claims he would not vote for a bill that would increase the deficit and laid out specific ways in which the overall cost of health-care must be cut in order for him to believe that the bill will be paid for. He also proposed some unpopular revenue sources to pay for the inevitable short-fall in savings and the cost of the new program (in addition to the $200-$500 billion in cuts to Medicare in the several bills) such as taxes on those who have really expensive "Rolls Royce" health-care plans that cover virtually everything. As a believer in markets one would think that would create a massive niche market for insurance providers who provide the richest possible coverage that isn't taxed and would therefore generate less revenue than the government will predict, but at least he's thinking about it.
As a sidebar one thing he seemed somewhat less dismissive than most Democrats of including Republican ideas that are largely structural changes that are free to the taxpayer such as serious tort reform, truly pro-competition and anti-defensive medicine provisions in a final bill. He did say that 35 states had caps on malpractice awards, but seemed to fail that this was not the only way to reduce the massive malpractice premiums doctors pay. I've found the absolute demonization of insurance companies understandable, but have found the lack of any noise about trial lawyers or any movement by Democrats to throw them under the bus surprising. Loser pays rules, limits on non-economic damages, more stringent rules for what constitutes malpractice such as necessarily including some deviation from a well-defined standard of care could all drive down the massive cost of malpractice suites which manifest themselves both in insurance costs but also in the defensive medicine that doctors practice--this seems like pure common sense--Webb was not dismissive of it, but on the other hand, he was very, very far from promising that he was going to go back and take the word of the people to Harry Reid and make sure that every member of his party would have to vote up or down on including such reforms.
In general his business experience and experience successfully running Virginia's state government with a heavily Republican legislature was clear, and we would do well to elect more officials in every branch of Congress who have actually run things and understand--apparently contrary to many on both sides of government--that waving a wand and declaring something so by fiat is very different from getting in the trenches and making something work. One thing I wonder about, though, is that as a businessman why he doesn't ask why health-care costs are rising so much faster than inflation: how much of it is it due to waste, fraud, deceitful practices of insurance companies and pharma companies and other economic players in the industry and how much is it due to innovation, increased amounts of expensive care being given, and a general rise in the number of transactions where people willingly get effective, life-extending treatment from doctors? A novel proposal he brought up that I've thought about previously but which I've never heard a serious national politician bring up is to address through trade policy the fact that government-run health-care systems in foreign countries (including in the first world) generally have price controls in place and give U.S. Pharmaceutical companies a choice: sell us the drugs at a deep discount and take a small profit margin or we'll wait til they go generic or (in some cases in some countries) circumvent your intellectual property rights and you'll get no profit. That does not spread the burden of paying for massively disproportionately U.S. based pharmaceutical R&D across the industrialized world and is why drugs cost so much less in Canada than in the U.S.--the current model is to get the U.S. market to support the rest of the world by paying retail while they all get the drugs at just above cost. He deflated the can-do spirit of liberal questioners who asked why we don't do what Canada does and use the U.S.'s massive "bargaining power" to negotiate for better drug prices like every other country. Short answer: if there's no profitable market for big pharma, they'll stop producing new drugs. This is a very good idea, but why we can't institute the trade reforms to make the Europeans pay their fair share for drugs outside the scope of a massive overhaul of the entire U.S. system of how health-care reimbursements are paid is beyond me, though.
I still see serious problems with this much less drastic, much more acceptable plan that Webb outlines the broad strokes of, as opposed to HR 3200, though. First, one of the details he outlines for driving down costs is not only having community rating but FORCING those young people who have the money to buy health insurance but choose not to to do pay for a plan (or part of a plan since the plans they can buy in most states now are much, much cheaper than they would be under the Webb plan.) This seems blatantly Unconstitutional, and in the way that gets overturned by Supreme Courts, especially conservative ones, which unless one of the 5 conservatives dies or retires, we will have for the foreseeable future. I say "in the way that gets overturned" because there are many Unconstitutional laws--say Medicare and Social Security-- for which no Federal government mandate exists in Article 1, Section 8 of the Constitution but which give people free money. People generally don't complain about those. When you go from allowing people to make a choice as a free person in a free country not to buy something (health insurance) and live with the risk, such as it is, that you might go bankrupt and be a burden to society if you got hit by a bus, to forcing them to buy such insurance basically in an indirect and somewhat bizarre form of taxation to decrease the overall risk of an average person in the insurance pool to try to keep the premiums of the new insurance companies who are community-rated, allowing prior-existing-conditions, and denying less procedures, those people are going to be upset and ask where the Constitution allows the government to force them to buy something they don't want. Can you think of another good the government makes you buy? Car insurance, yes, but the whole problem with that analogy is that you don't buy a car and drive it around on your own property... you drive it around public roads. In other words, you're taking advantage of a government maintained road network to get to useful places, your driving affects others safety, you have to be licensed to drive on that network, and therefore increased regulation is permissible. Driving on publicly funded and maintained roads is a privilege, not a right. Living and choosing not to buy insurance, thus far in our country's history, has been.
In response to the specific question of what Article and Section of the Constitution Webb would cite to justify the government's takeover of the health-care choices of virtually all Americans in some sense--even if they don't immediately change the structure of coverage for most Americans--his answer was not only a red herring and a total dodge in a format where the questioner could not respond, it was highly insulting. He responded that since this law clearly cannot be justified by the Constitution and since Medicare and Medicaid and Social Security cannot either that he "assumed that the questioner wants Medicare and Medicaid and Social Security to be repealed." The questioner was not allowed to say if they would repeal those programs if they could or--in a rhetorical stance similar to one Webb used before saying that if we were starting over that he would not link health-care to employment--would do so ideally but in the real world recognize that this is unworkable. In addition to blind-siding this woman who asked a legitimate and fair question with no chance to respond, he demands of the questioner an ideological coherence that he exempts himself from. While the questioner must by virtue of asking what the Constitutional justification is of this law support the immediate repeal of every Unconstitutional social program written into law that is essentially Unconstitutional--the good Unconstitutional laws as mentioned above-- Webb can take the stance that since a previous government passed an Unconstitutional law every future government can do so, as well, and not have to answer to their constituents. By defying her to support the destruction of other programs--by which he presumably meant to say that since these laws that many people like aren't justified by the Constitution that we've come to a consensus that the Constitution can be ignored--he essentially openly defied his oath of office: to protect and defend the Constitution. I guess they should add a codicil "unless people get free money."
Our founders were clever in writing the Constitution and they anticipated the very dangers of Unconstitutional, popular laws like Medicare and Social Security. The power of the many who stand to gain is in theory checked by the fact that the power to create a national system of social insurance or medical coverage is, in fact, not among the powers listed to Congress and therefore is reserved to the states and ultimately the people. Unfortunately, previous generations of lawmakers have taken the easy way out and ignored their oath to defend and protect the Constitution. If we're ever going to get on the road to sustainable financial demands on our citizenry and paying off our debt, sticking to the powers enumerated by law and reforming the massive body of Unconstitutional but popular law--and not passing any new, Unconstitutional entitlement programs--would seem to be a good start.
Most opponents were concerned about the general contradiction of how we can save money by expanding care to millions of new people--the Democratic argument basically seems to be that the $1000 tacked onto most folks' health insurance premiums annually to provide acute, emergency care to people who have no general health coverage is equal to or greater to the cost of both insuring them all and also paying for the subsidies of the insurance premiums for all that seem like they must go up if the whole country basically adopts community rating--health insurance companies must charge people more or less the same rate within some relatively narrow band whether they are healthy or not--and furthermore those companies must accept people with pre-existing conditions. The math doesn't seem to work out; you're going to make insurance a lot more expensive for everyone, promise that the government will pay for the part that people can't afford, and put a lot more people into the program, those of whom are the horror stories that necessitate this reform are those who will cost the most to provide care for and/or are the least able to pay for their insurance.
Jim Webb's answers to the hard questions seemed to make much more sense than the Senior Democratic leadership--although to be frank, the partisan anti-health-care reform crowd didn't seem to buy his arguments--but his arguments provided some serious questions about the role of government. His good ideas, first of all, were that he would oppose specifics about proposed legislation that seem to violate the pledge to make this plan pay for itself. Specifically, he opposed the public option at first and if it were to be implemented later to increase pressure to drive down costs it would have to compete on a level playing field and not run at a loss subsidized by taxpayers; he recognizes that this simply continues the failed premise of entitlements like Medicare and Social Security and would lead to a massive budget shortfall in a short period of time. I wasn't quite sure what to make about his proposal that doctors be compensated differently, with the general idea being that the incentives be changed from procedures performed to overall outcomes of patients--an idea which both in theory and as Webb explicitly pointed out would steer more people into becoming GPs and would reduce the disparity in compensation between hot-shot specialists like brain surgeons and the doctors in the trenches of pediatric medicine and general practice. This seems like a necessary type of reform to do something about runaway costs of medicine, but unfortunately it takes a lot more work and years of schooling and skill and is generally something that in the free market would be compensated more richly to be a brain surgeon than to be a pediatrician. Social engineering to encourage the few people who want to be doctors to be GPs by changing the financial incentives so that even when the objectively measured amount of training and difficulty of performing brain surgery is greater by a fair amount than that to become a GP that the discrepancy in pay will be lessened seems like it will lead to a shortage of brain surgeons and therefore waiting and rationing of brain surgeries. And this would apply to all acute and semi-acute specialties where the U.S. truly leads the world... orthopedic and trauma and cardiac surgery, surgical oncologists cutting out tumors, oncology in general.
At least, though, Webb claims he would not vote for a bill that would increase the deficit and laid out specific ways in which the overall cost of health-care must be cut in order for him to believe that the bill will be paid for. He also proposed some unpopular revenue sources to pay for the inevitable short-fall in savings and the cost of the new program (in addition to the $200-$500 billion in cuts to Medicare in the several bills) such as taxes on those who have really expensive "Rolls Royce" health-care plans that cover virtually everything. As a believer in markets one would think that would create a massive niche market for insurance providers who provide the richest possible coverage that isn't taxed and would therefore generate less revenue than the government will predict, but at least he's thinking about it.
As a sidebar one thing he seemed somewhat less dismissive than most Democrats of including Republican ideas that are largely structural changes that are free to the taxpayer such as serious tort reform, truly pro-competition and anti-defensive medicine provisions in a final bill. He did say that 35 states had caps on malpractice awards, but seemed to fail that this was not the only way to reduce the massive malpractice premiums doctors pay. I've found the absolute demonization of insurance companies understandable, but have found the lack of any noise about trial lawyers or any movement by Democrats to throw them under the bus surprising. Loser pays rules, limits on non-economic damages, more stringent rules for what constitutes malpractice such as necessarily including some deviation from a well-defined standard of care could all drive down the massive cost of malpractice suites which manifest themselves both in insurance costs but also in the defensive medicine that doctors practice--this seems like pure common sense--Webb was not dismissive of it, but on the other hand, he was very, very far from promising that he was going to go back and take the word of the people to Harry Reid and make sure that every member of his party would have to vote up or down on including such reforms.
In general his business experience and experience successfully running Virginia's state government with a heavily Republican legislature was clear, and we would do well to elect more officials in every branch of Congress who have actually run things and understand--apparently contrary to many on both sides of government--that waving a wand and declaring something so by fiat is very different from getting in the trenches and making something work. One thing I wonder about, though, is that as a businessman why he doesn't ask why health-care costs are rising so much faster than inflation: how much of it is it due to waste, fraud, deceitful practices of insurance companies and pharma companies and other economic players in the industry and how much is it due to innovation, increased amounts of expensive care being given, and a general rise in the number of transactions where people willingly get effective, life-extending treatment from doctors? A novel proposal he brought up that I've thought about previously but which I've never heard a serious national politician bring up is to address through trade policy the fact that government-run health-care systems in foreign countries (including in the first world) generally have price controls in place and give U.S. Pharmaceutical companies a choice: sell us the drugs at a deep discount and take a small profit margin or we'll wait til they go generic or (in some cases in some countries) circumvent your intellectual property rights and you'll get no profit. That does not spread the burden of paying for massively disproportionately U.S. based pharmaceutical R&D across the industrialized world and is why drugs cost so much less in Canada than in the U.S.--the current model is to get the U.S. market to support the rest of the world by paying retail while they all get the drugs at just above cost. He deflated the can-do spirit of liberal questioners who asked why we don't do what Canada does and use the U.S.'s massive "bargaining power" to negotiate for better drug prices like every other country. Short answer: if there's no profitable market for big pharma, they'll stop producing new drugs. This is a very good idea, but why we can't institute the trade reforms to make the Europeans pay their fair share for drugs outside the scope of a massive overhaul of the entire U.S. system of how health-care reimbursements are paid is beyond me, though.
I still see serious problems with this much less drastic, much more acceptable plan that Webb outlines the broad strokes of, as opposed to HR 3200, though. First, one of the details he outlines for driving down costs is not only having community rating but FORCING those young people who have the money to buy health insurance but choose not to to do pay for a plan (or part of a plan since the plans they can buy in most states now are much, much cheaper than they would be under the Webb plan.) This seems blatantly Unconstitutional, and in the way that gets overturned by Supreme Courts, especially conservative ones, which unless one of the 5 conservatives dies or retires, we will have for the foreseeable future. I say "in the way that gets overturned" because there are many Unconstitutional laws--say Medicare and Social Security-- for which no Federal government mandate exists in Article 1, Section 8 of the Constitution but which give people free money. People generally don't complain about those. When you go from allowing people to make a choice as a free person in a free country not to buy something (health insurance) and live with the risk, such as it is, that you might go bankrupt and be a burden to society if you got hit by a bus, to forcing them to buy such insurance basically in an indirect and somewhat bizarre form of taxation to decrease the overall risk of an average person in the insurance pool to try to keep the premiums of the new insurance companies who are community-rated, allowing prior-existing-conditions, and denying less procedures, those people are going to be upset and ask where the Constitution allows the government to force them to buy something they don't want. Can you think of another good the government makes you buy? Car insurance, yes, but the whole problem with that analogy is that you don't buy a car and drive it around on your own property... you drive it around public roads. In other words, you're taking advantage of a government maintained road network to get to useful places, your driving affects others safety, you have to be licensed to drive on that network, and therefore increased regulation is permissible. Driving on publicly funded and maintained roads is a privilege, not a right. Living and choosing not to buy insurance, thus far in our country's history, has been.
In response to the specific question of what Article and Section of the Constitution Webb would cite to justify the government's takeover of the health-care choices of virtually all Americans in some sense--even if they don't immediately change the structure of coverage for most Americans--his answer was not only a red herring and a total dodge in a format where the questioner could not respond, it was highly insulting. He responded that since this law clearly cannot be justified by the Constitution and since Medicare and Medicaid and Social Security cannot either that he "assumed that the questioner wants Medicare and Medicaid and Social Security to be repealed." The questioner was not allowed to say if they would repeal those programs if they could or--in a rhetorical stance similar to one Webb used before saying that if we were starting over that he would not link health-care to employment--would do so ideally but in the real world recognize that this is unworkable. In addition to blind-siding this woman who asked a legitimate and fair question with no chance to respond, he demands of the questioner an ideological coherence that he exempts himself from. While the questioner must by virtue of asking what the Constitutional justification is of this law support the immediate repeal of every Unconstitutional social program written into law that is essentially Unconstitutional--the good Unconstitutional laws as mentioned above-- Webb can take the stance that since a previous government passed an Unconstitutional law every future government can do so, as well, and not have to answer to their constituents. By defying her to support the destruction of other programs--by which he presumably meant to say that since these laws that many people like aren't justified by the Constitution that we've come to a consensus that the Constitution can be ignored--he essentially openly defied his oath of office: to protect and defend the Constitution. I guess they should add a codicil "unless people get free money."
Our founders were clever in writing the Constitution and they anticipated the very dangers of Unconstitutional, popular laws like Medicare and Social Security. The power of the many who stand to gain is in theory checked by the fact that the power to create a national system of social insurance or medical coverage is, in fact, not among the powers listed to Congress and therefore is reserved to the states and ultimately the people. Unfortunately, previous generations of lawmakers have taken the easy way out and ignored their oath to defend and protect the Constitution. If we're ever going to get on the road to sustainable financial demands on our citizenry and paying off our debt, sticking to the powers enumerated by law and reforming the massive body of Unconstitutional but popular law--and not passing any new, Unconstitutional entitlement programs--would seem to be a good start.
Labels: ballyhoo, constitution, government, philosophy, politics
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