AAPS News - Volume 67, no. 8 - August 2011
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Some leftists are disturbed by Barack Obama’s failure to make a moral case for his signature legislation (ACA, the Affordable Care Act), writes John Goodman.
"How can there be a moral case for a 2,700-page bill that was shaped and molded by self-seeking interests, with no more regard for principle than one would find in a game of musical chairs?" he asks. It’s like asking for a moral case for the IRS code.
Economist Goodman states that ObamaCare is "self-evidently immoral." Even if you believe that some of us have a moral obligation to help others with their medical care, "what does that belief have to do with legislation in which costs and benefits are strewn about with all the care of a drunken sailor?"
What moral code justifies the following, he asks:
Forcing some people to pay more, and allowing other people to pay less, than the cost of their insurance
Giving people in health insurance exchanges up to 10 times as much federal subsidy as those of the same income level who get insurance at work
Forcing young people to pay two to three times the real cost of their insurance to subsidize older people with more assets
Taking from people who need crutches or wheelchairs or pacemakers to give to...well, who knows?
Common law, Goodman writes, is focused on the question of "who owes what to whom, given that we are all equal before the law and each of us has the right to pursue his own interests."
He challenges leftists to come up with a treatise on ethics that explains and justifies the what and why of forcible redistribution of wealth (http://healthblog.ncpa.org 7/6/11).
The Calculus of "Equity"
The promises of "healthcare reform" will fail, say supporters, if it does not "reduce disparities" in care. Appropriate data could allow consumers to choose plans on the basis of "providers’ track records in ensuring equitability of care" (NEJM 6/16/11).
Because of physician outrage, the Obama Administration put a "secret shopper" program on hold—for now. Fake patients would have checked whether doctors’ offices discriminated on the basis of type of insurance in making appointments. It is already known that they do: According to a 2008 survey by the Center for Studying Health System Change, only 4% of physicians decline to accept new privately insured patients, while 13% turn down new Medicare patients, and 27% new Medicaid patients (Avik Roy, National Affairs, summer 2011). For pediatric specialists, Medicaid acceptance is as low as 4% (NEJM 6/16/11).
To monitor, track, identify, and target the underlying causes of racial and ethnic disparities requires data. The HITECH Act requires physicians to record the race or ethnic background of at least half of their patients to receive incentives for implementing electronic records. Self-reporting is considered the gold standard, but imputing information based on surname or "geocoding" is proposed as an interim strategy (NEJM, op. cit.). There are no standards for percentage of genome needed to pass as a member of a particular group.
An acceptable, even required form of disparity is based on quality-adjusted life years (QALYs), plus intangibles including "social usefulness" and "reciprocity," which reward patients for past exhibition of approved values. The model is the British National Institute of Health and Clinical Effectiveness (NICE), which has an international division for exporting its methods to 60 countries, including the U.S. Rationing is the cornerstone of the new redistributionist system. NICE is a faceless bureaucracy "empowered to tip the scales of suffering and death based on a set of arcane formulas and value judgments to which the public has neither access nor meaningful input," writes Joe Herring (American Thinker 11/28/09).
Where Does the Money Go?
The first share goes to the top: for example, $10 billion to the Innovation Center, a real "gem" in the ACA, according to CMS head Donald Berwick. This "do tank" has the very special authority to report innovations that work to the Secretary of Health and Human Services, who can convert them into rulemaking without going back to Congress. We already know what "great care" is, states Berwick. The problem is that "payment systems aren’t aligned," we lack the information we need, "we haven’t been trained to work in teams," and "institutional structures are in our way." The Center will "make things move really fast" by "releasing energy around the country" and by "commissioning work" (Medscape Internal Medicine 6/16/11).
The federal government wants to "give" states up to $50 million each to establish Exchanges; actually, ACA gives HHS power to tap a limitless amount. Exchanges will not reduce premiums. Their purpose is "to distribute taxpayer money to insurance companies on behalf of individuals who qualify for subsidies," writes Dave Racer, thereby increasing dependency on government (www.alethospress.com).
Billions go to Medicaid managed care. One Arizona plan took in $652 million in 2010, and spent $554 million on "healthcare services." We have no idea how many chest xrays, office visits, surgical procedures, or drugs this bought. But nearly $100 million did not buy any care for anyone. Money was taken from taxpayers and redistributed to...well, who knows?
Honest Prices, and the Uninsured
In his column "Universal Health Care with No Mandates" (Forbes 6/23/11), Peter Ferrara "just takes off the veil and calls the uninsured what it is," writes John Dale Dunn, M.D. It’s a "phony issue, involving a concerted effort to make a crisis out of a series of anecdotes." Dunn notes that the real cost of uncompensated care is surprisingly low, partly because the uninsured are largely young and healthy. Also, there’s the unspoken reality that the real marginal cost of charity care is far less than the uncollected, grossly inflated chargemaster charges.
Hospital prices—when obtainable—are typically three to six times higher than the prices posted at www.surgerycenterok.com, writes G. Keith Smith, M.D. "An amazing thing happened here in Oklahoma City," he writes on the Center’s blog. An uninsured patient was given a fixed price up front—and it was exactly the same as the Center’s, except that the hospital’s did not include the surgeon and the anesthesiologist. This was a discount of $10,000 to $15,000—and the hospital still wanted the business!
RomneyCare Is Problem, Not Solution
Mitt Romney, "the guy whose turn it is to get the Republican nomination [for President]," writes Mark Steyn, is out defending his record. As Steyn sees the difference between their two plans, "Obama has a one-disaster-fits-all approach..., whereas Romney believes in letting a thousand disasters bloom." The cost problem in Massachusetts was not caused by "deadbeats using the emergency room as their family doctor," as Romney argued, "but by the metastasizing cost distortions of government intervention." Three years later, ER use is higher than ever, 70% of the newly insured are all but entirely subsidized by the state, costs are 30% higher than the national average, and Boston has the longest wait time in the nation to see a new doctor.
We need a credible alternative, Steyn writes. However Congress votes, we’re rubbing against the real debt ceiling— "the willingness of the world to continue bankrolling American debauchery" (Investor’s Business Daily 5/13/11).
The Myth of Medicare Efficiency
Still frequently cited is the misleading comparison of Medicare’s administrative costs of 3% with 15% to 20% for employer-sponsored insurance. Unlike private insurers, Medicare has off-budget help: the IRS and Social Security Administration collect taxes and premiums, and HHS provides accounting, marketing, and more. Most importantly, Medicare beneficiaries are sicker, so the denominator of patient care costs is higher. The per person cost of Medicare administration, even with the extra help, is $509, versus $453 for private plans (Avik Roy, op. cit.).
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"Rulers have become owners…. We are...their wards, pupils, or domestic animals. There is nothing left of which we can say to them ‘Mind your own business.’ Our whole lives are their business…. We seldom had fewer rights and liberties nor more burdens: and we get less security in return. While our obligations increase, their moral ground is taken away…. [The new society creates] membership in a debased modern sense—a massing together of persons as if they were pennies or counters." C.S. Lewis, quoted by Joseph Sobran
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