Sparrows and chickens
In 1958, Mao Zedong decided to free China from all disease by destroying the “four pests.” Mosquitoes, rodents, flies and the dreaded harbinger of death: the sparrow. He believed sparrows were responsible for low crop production since they could be seen eating grain seed. Over the next four years, Chinese peasants eradicated something like 600 million sparrows by banging drums all hours of the day, denying the birds a perch until they died of exhaustion. Mao didn’t realize that gain seed was only a small part of the sparrows’ diet, mostly they ate insects. Massive locust swarms plagued China for years, resulting in famine and millions starved to death.
In 1963, President Lyndon Johnson imposed a 25 percent tariff on potato starch, dextrin, brandy, and light trucks. He did this to punish France and West Germany for their protective tariffs on U.S. chicken. Over the years, everything but the light truck tariff went away, resulting in American manufacturer hegemony, high prices, and for decades nearly zero innovation among pickup trucks. Now that most quote-American-unquote brands are actually made elsewhere, Ford Motor Co. imports its Transit Connect as “passenger vehicles” from Turkey, shreds the interiors and rear seats in Baltimore, then magically turns the vehicles into light trucks.
The Cassidy-Graham plan to morph Obamacare into a state Medicaid block grant program is less terrible than Obamacare because it is not designed to be a perfectly engineered system. The law of unintended consequences will act much more quickly, and Obamacare will actually run as it was intended, and therefore fail faster, but not all at once. Therefore, we must support it, as imperfect as it is. We’ve tried all the other more well-thought-out government rollbacks, and failed politically. Therefore the sparrows must die, and the chickens must be taxed to find out what happens.
The perfect system
Obamacare was constructed to be a perfect national insurance market if all states participated in the exchanges. It guaranteed that every family would receive a minimum slate of health benefits, no matter what their position or economic situation. Everyone had to have insurance. By shifting the expense to employer-run plans to pay for the huge expansion in Medicaid, Obamacare was the precursor of single-payer, where the states were supposed to set up their own exchanges and run the program. But when October 2013 rolled around only 16 states had done so, leaving the federal exchange overwhelmed.
By 2016, 19 states had not implemented Medicaid expansions. From Slate–this is definitely the liberal spin, but it highlights the way the Obamacare system had to fail unless everyone went along perfectly, which they did not.
State governments may have undermined their insurance markets in other, less overtly political ways. The majority have allowed their residents to hold onto so-called grandmothered or transitional plans that they purchased after the Affordable Care Act was passed but before healthcare.gov opened for business. That means people who were healthy enough to obtain affordable insurance back when carriers could discriminate against people with pre-existing conditions have been allowed to stay off the exchanges, leaving insurers with a sicker customer base.
How big a difference did that make? The Kaiser Family Foundation recently looked at this issue by comparing risk scores, which measure how unhealthy the enrollees in health plans are, across different states. They found risk scores were 8 percent lower in states that had expanded Medicaid and banned transitional insurance plans compared with states that had done neither. In states that expanded Medicaid but didn’t ban transitional plans, scores were just 3 percent lower. Now, letting people keep their old insurance isn’t an act of political protest the same way turning down the Medicaid expansion is, since the feds have allowed it. Nonetheless, states that fully implemented Obamacare as it was imagined seem to have more balanced individual insurance markets. (One silver lining here: All Americans will have to relinquish their grandmothered plans after next year, so we can expect some additional healthy customers on the exchanges.)
To be clear, these are not the only reasons why some states are seeing higher prices and less stable markets than others. Some parts of the country, especially the Deep South and Appalachia, are simply older and sicker than others, and would likely face higher insurance costs no matter what in a system like the Affordable Care Act. Unfortunately, those same states have often fought hardest against properly implementing the law, making a troubled situation worse.
The goal of Obamacare wasn’t for insureds to have the lowest possible premium. It was for the maximum number of people to have a certain level of coverage, the key word being coverage. Coverage doesn’t guarantee you’ll get the actual services covered. It’s like having one of those school-issued discount cards sponsored by businesses around town. You can eat at Joe’s sub shop, but Jimmy Johns isn’t on the card. And if Joe’s closes, you pay full price at Jimmy John’s. And the food at Joe’s isn’t all that good, and Joe sold the shop and the new owner decided he didn’t want to give the discount. It’s like that with Medicaid.
Unless every supplier of health care, ever practitioner, was barred from posting a sign “Medicaid not accepted here” and forced to take every form of insurance and accept whatever the carrier decided to pay, there’s absolutely no way to guarantee that people actually receive the health care they’re supposedly covered for.
What the Slate article fails to disclose is that many plan premiums went up by double-digit percentages, and many insurers withdrew from exchanges or states when they realized they had to lose money because of the risk pool and could not limit those losses. Some places in the more rural states only have one choice for insurance.
Any system designed to be anti-competitive will fail because the law of unintended consequences will force people to look for other ways to achieve their personal goals. The goals of families and individuals are low cost health care, not a card declaring “you’re covered.” If that means going to the emergency room for a fever and receiving indigent care, that’s what they’ll do. And they did.
One of the most pernicious problems with Obamacare is the growth of opioid addiction epidemics. Doctors who accepted Medicaid in states that successfully implemented the Medicaid expansion became pill mills as people lined up for their fixes, or to sell the pills on the market. This happened under the noses of regulators and drug manufacturers. Distributors gladly filled the orders. Up and down the line, people should be in jail for this failure of conscience and carpetbaggery.
Within ACA states,too, the counties that decreased the percentage of uninsured the most also had the largest increases in overdose rates.
Across age cohorts, states with full ACA implementation had a jump upward in overdoses, while holdout states stabilized.
This isn’t simply a matter of “blue” ACA expansion states being poorer or being in worse economic shape in 2010: they weren’t.
An exclusive review of Medicaid prescription drug data found oxycodone painkillers flooded into New York from 2012 to 2014, including 8.8 million pills in Westchester, Rockland and Putnam counties alone, enough for six pain pills for every man, woman and child in the Lower Hudson Valley.
The Daily Wire’s Frank Camp has explained how the opioid crisis is directly tied to unnecessary opioid prescriptions. The evidence does suggest that Obamacare’s intentions to get more people insured has had the unfortunate side effect of creating a pipeline for people to obtain such prescriptions that are fueling the crisis.
Burn it all down
By converting Obamacare to a state Medicaid block grant system as Cassidy-Graham will do, every state will line up to expand its Medicaid program. They’ll gladly eat at the trough of Uncle Sugar, and by getting rid of the individual mandate, many who were paying unaffordable rates or simply didn’t want insurance will drop out of the market.
The rest of the people will have to find a way to lower their health care costs, or they’ll be screwed. This is the scenario Daniel Horowitz paints so clearly.
True, and that is the point! If we can’t repeal Obamacare, let’s allow the malignancy of Obamacare to destroy the existing model of insurance, which was never a free market to begin with. When we allow individuals and employers to exit the system, the cartel will no longer have us by the neck. You see, the more they raise their prices, the more people will just give up on insurance. Employers will drop coverage like a hot potato as well. In fact, the coverage regulations forcing insurers to cover people after they get sick for the same price works to our advantage under this scenario, because people will readily leave the system and then stick the system with the tab when they need the coverage.
In the meantime, as we have explored in previous posts (here and here), health-sharing ministries have shown an alternative model to the existing insurance paradigm. Graham and Cassidy are wrong about prices coming down under their bill. The continued higher prices, in conjunction with allowing people to opt out, will create a market for health-sharing association plans in which groups of individuals and associations get together and pool their resources to cover catastrophic needs. The basic needs would be paid for directly by the consumer to the doctor.
This is how any market should work. This will make the consumer, not the government/insurance cartel, the actual consumer. This will spawn a revolution in price transparency and actually bring down costs by circumventing the entire insurance system.
By way of personal disclosure, I have been a member of Medi-Share (a health-sharing ministry that’s exempt from Obamacare) for two years. I pay about half what my friends pay–and their employers contribute to their plans, so I assume I’m paying about 1/3 to 1/4 of their actual premium. However, just about all of my medical expenses are out of pocket. I haven’t met my “annual household portion” (in insurance-speak, my deductible) in two years. I do, however, get the advantage of “in-network” pricing. I also get perks like TeleDoc, a free telemedicine service where a real doctor can diagnose common problems, prescribe medicine, and give advice. We’ve saved hundreds and hundreds of dollars using this service.
I agree that the current system deserves to be burned to the ground, but it won’t happen.
The main sources of unintended consequences are not consumer behavior. Consumers react to the market but they don’t make the market, unless you’re banking on pet rock fads, which are unpredictable by nature. What makes the market are the producers of a product or service. In health care, everyone is a consumer–even doctors.
To get the most consumers, and make money doing it, capitalist insurance companies will find a way to carve themselves a piece of the most lucrative markets. At first, they all supported Obamacare because they smelled money, and many make it hand over fist in the markets where they compete, since they’re allowed to pull out where they don’t make money. Watch them lobby state legislatures and Congress to tweak coverages and products to their liking, and block the growth of medical sharing associations, direct to consumer health care markets, and other innovations. You’ll hear them say it’s “against consumer interest” and slam quality standards.
They’ll paint themselves as the avatars and ombudsmen protecting the little guy from predatory doctors trying to make a buck. Why do you think alternative medicine and chiropractic have so much trouble? Don’t underestimate the power of large corporate hospital administrators, doctors who control licensing boards and wield immense political power at the state level, drug manufacturers and insurance companies who make enormous back room deals with all of them to control the market for health care.
Like Ford finding a way to call a Transit Connect a passenger vehicle, the consigliere of our health market will find a way to package Obamacare-the-state-run-version as something else.
Cronyism wins. But that’s not really a bad thing. In fact, I’m rather counting on it.
The great experiment
The biggest market limiter for health care isn’t insurance coverage, it’s scarcity.
Medical care is scarce: There are only so many doctors and hospital rooms; the pill factories can make only so many pills, and there are real limitations on the raw materials used to make those pills; heart stents don’t grow on trees, but, even if they did, they would be scarce, like apples and oranges and pears and avocados.
We cannot offer the same level of care to everybody with the same condition. They number in the millions, and the doctors who can perform that procedure number about three. (Or, at least they did ten years ago.) Even if they worked 16-hour shifts, seven days a week — even if we pressed them into slavery — they could see only so many patients and perform so many procedures, and those would amount to a tiny fraction of the number of people who might benefit from their attention.
Because of scarcity, medical care eventually reaches the point where one of three things happens: Somebody puts out his hand and says “Pay me,” an officer of the government or an insurance company refuses to approve some treatment, or you die.
Insurance companies say “No” all the time, and we hate them for it. That is because of another fact that we refuse to deal with like mature, responsible adults: Insurance is not a medical product — it is a financial product. Most of us do not need to spend a great deal of money on health care during any given year for most of our lives. I myself pay for most of my medical expenses out-of-pocket, and, in any given year, they rarely add up to what my health-insurance premiums cost. But I do not have health insurance, and pay premiums for that health insurance, in order to have somebody else pay for my annual check-up or routine dental work. I have insurance because I might get hit by a bus or cancer or a heart attack, and, secondarily, because one day I will be old, if I am lucky, and old people have lots of medical expenses.
Do we want the market to say “no” by pricing us out of the particular procedure we can’t afford, or do we want the government to say “no” for us? Insurance companies saying “no” isn’t a hard “no.” It simply means “we won’t pay for that.” Maybe some rich person, or foundation, or charity will decide to pay for it, but the insurance company won’t. When the government becomes the “single-payer” insurance company, generally that turns into a hard “no” because by necessity the government negotiates with all providers to make the health care market (which by nature suffers scarcity).
Hence, you have England, where depending on where you live, the wait for a knee replacement might be a year, or five years. Meanwhile, you suffer. Yes, you can fly to the United States and get it done, if you have the money. But you can’t pay any amount to a U.K. NHS doctor to do it for you at home. A “no” means “no.”
The biggest reason to support Cassidy-Graham is that states act like a great experiment. California doesn’t handle things like Florida. Demographics differ, world views differ, economic status differs and physical climate differs. The greatest opportunity to see how unintended consequences work their way through the system, which states fail and which succeed (or which fail last, depending on your outlook), is to move the money and therefore the cronyism, to the state level.
Compare it to speed limits. In New Jersey, the speed limit on highways is 65. In Hawaii, it’s 60 (why Hawaii has an interstate highway is incomprehensible to me). In South Dakota, Montana and Nevada, it’s 80, and in parts of Texas (God bless’em!) it’s 85. The federal government pays DOT money to all the states, but they all have different laws, fines, and enforcement. This is what Cassidy-Graham will become, albeit a thousand times more complex.
Again, I agree that the current system of health care in America is like buying a car without knowing the sticker price, the features, or the loan value; and in fact the guy buying the exact same car might pay half of what you are about to pay, but you’re not allowed to know it. There’s no transparency, consistency, or even a semblance of consumer-friendliness to it. It was that way before Obamacare sucked the entire diseased mass into Washington, D.C. It cannot get better under political control of the federal government.
Like Mao, we’re just blindly killing sparrows, and that’s going to lead us nowhere good. We need to pass Cassidy-Graham and begin to break the federal stranglehold.
One more reason: Rand Paul
Sen. Rand Paul has offered an amendment that, if adopted, he might swing over to the “Yea” column for Cassidy-Graham. It repeals some of the most egregious trouncing of the Constitution and our personal rights inherent in Obamacare (besides the individual mandate that is).
The amendment would keep the ATF from banning guns for veterans with a PTSD diagnosis. It would also bar insurance companies from inquiring about gun ownership, or using that information to determine coverage eligibility. Finally, Paul’s amendment would roll back the truly Orwellian ACA requirement for doctors to ask patients about gun ownership so that information could be recorded in a federal database. My doctor would get a self-diagnosis of “nunya syndrome.”
The perfect is the enemy of the good. So far, Congress has failed to repeal Obamacare. President Trump has failed to provide vision as to the kind of health care system he really wants–other than it’s not named Obamacare. If we don’t repeal Obamacare with Cassidy-Graham, look for the Democrats to go with single-payer, and Trump very well might support some form of that.
This is really coming down to a binary choice, like the Flight 93 election was in September 2016. Either we break the federal stranglehold on a dying health insurance system that in turn is choking health care providers, shutting down markets, increasing costs across the board, and incentivizing pill mills to spread addiction; or we embrace a national health care system that will bankrupt the treasury and result in stratospheric tax increases along with rationed care. It’s going to be one or the other.
If this year ends with Obamacare intact, we know what will happen, and every Republican in office knows it too.
— Steve Berman (@stevengberman) July 21, 2017
Cassidy-Graham is the last, best hope for a first step away from the cliff. We need to take it.