Lee's Blog

So later in the Facebook discussion:

A: I also don’t think one can reasonably say that Repubs have been staying on the sidelines. In fact, they’re doing all they can to see this fail, pushing back, being recalcitrant, and generally unproductive. I’m not saying that in the context of reasoned debate, either; it’s simply been “party of no” stubbornness.

I think we’d also be hard-pressed to say that this is due to tort reform, or any particular issue they don’t like. Rather, the political calculus kind of dictates it. Republicans have nothing to gain by helping pass real reform; their best bet is to sabotage it, as they have been, and hope that the watered-down version that finally passes doesn’t change much. Politics-wise, they’re doing what’s best for themselves. Unfortunately, it’s Americans who are getting used and abused in the process.

This is a meme that the Democrats have been pushing for a year: the reason the health care “reform” bill has not been enacted is that the evil Republicans have obstructed and sabotaged it. Well, this doesn’t work for anyone who can do second-grade arithmetic.

In order to pass a bill in the House of Representatives, you need a majority of 435 votes. 435/2 = 218 (rounded up). In 2009, the Democrats held no fewer than 254 votes at any time. They could pass anything they wished, and they didn’t need a single Republican to do it.

In order to pass a bill in the Senate, you need a majority of 100 votes. 100/2 = 50. Of course fifty votes would actually be a tie, but the Vice President casts the deciding vote in that case, and the Vice President is a Democrat. The Senate rules allow unlimited debate (filibuster) which can be cut off by a vote of sixty Senators. The Democrats have not had sixty votes at all times during 2009, but they have had sixty votes at various times. At those times, they could tell the Republicans to sit down and shut up while they passed anything they wished.

In order for a bill to become law, the President must sign it or at least not veto it. Obviously The One will sign anything the Democrats want.

So how can “Republican obstructionism” have made the slightest bit of difference? If the Democrats didn’t enact a law that they wanted, it’s because they themselves didn’t agree on what they wanted. The One made it abundantly clear that there would be no negotiation or compromise with the Republicans (”I won; deal with it”), which meant that the Democrats had to agree on every decision. They didn’t; that’s their problem, not the Republicans’. If they had chosen to reach across the aisle — which is what has happened in every Congress prior to this one — they could perhaps have enacted some or even most of what they wanted. They didn’t; that’s their problem, not the Republicans’.

I should point out that it wasn’t the Republicans who demanded the “Louisiana Purchase”; it was a Democrat, Mary Landrieu. It was not the Republicans who demanded the “Cornhusker Kickback”; it was a Democrat, Ben Nelson. It was not the Republicans who demanded that unions be exempted from the tax on “Cadillac health insurance”, a very unpopular exemption demanded by the Democrats’ core constituents, the unions.

If the Democrats contend that losing the power to pass anything they please without input from the other party destroys the Democratic program, what they’re saying is that they can function only in a one-party state*. Think on that.

---

* A comment made to me by someone who may perhaps prefer to remain anonymous.

A couple of days ago I was following a discussion about health care “reform” on Facebook (even contributing once in a while). There were many things that occurred in that discussion that I will probably mention here, but one was the comment by one person that he would favor guaranteed issue (insurer cannot deny coverage due to pre-existing conditions) and community rating (everybody gets charged the same regardless of age, sex, or pre-existing conditions), but not individual mandates.

The difficulty is that you cannot have guaranteed issue and community rating without individual mandates. The sequence of events goes like this:

Government: Insurer, it is unjust and unfair that you deny coverage to people with pre-existing conditions. Cover them or else! [guaranteed issue]

Insurer: Um, okay, we’ll cover them. We’ll just have our actuaries work out the actual cost of their coverage and come up with the appropriate premium, which will be high, of course …

Government: What!? It’s already cosmically unfair that they suffer pre-existing conditions, and you want to increase the injustice by heaping costs on them!? No, you’re going to have to charge everyone exactly the same, so those who are unfairly healthy don’t get a benefit over those who aren’t. [community rating]

Insurer: Let’s just let our actuaries work out the average cost for the whole community, and set the premiums to that …

Young insured: What!? My premiums just went up by a factor of five!? Are you crazy? I didn’t even have any health care costs last year! I’m not paying this! I’ll “go bare”, and if I get sick, well, I’ll just get insurance then.

Insurer: Let’s see now … the only people currently insured are those who already have high medical costs, but we can’t get anyone else to buy insurance, and we can’t raise premiums to cover the actual costs. Hmmm. We need to be in a different line of business.

Government: You can’t quit insuring people.

Insurer: Watch me.

Government: Okay, all you healthy people, you have to buy insurance at the community rate, so that you can subsidize all the sick people and keep the insurers from bailing. [individual mandate]

This whole thing already played out in Massachusetts. The Democrats know how it played out, so they skipped the steps of discovering how the real world works, and just went straight to the inevitable result.

If we’re going to have a debate on health care reform (instead of having the Democratic view of “reform” forcibly imposed on us), then let’s be realistic about it.

I suggested previously that the Democratic party should take a few months to hash out a plan that they would be willing — perhaps even proud — to allow the voters to see.

I was perfectly serious about that; I would make the same recommendation to the Republican party. Don’t want to be the party of NO? Do the same thing. Allow an open (but moderated) forum in which the true problems of health care can be discussed and solutions proposed. Get experts in and get the best evaluation of proposed solutions that you can. Bear in mind that if you come up with a bill, run on it, and enact it, you own it. Better to get bad solutions shot down early by genuine experts than to deceive yourself about the virtues of your ideas, enact them, and let the nation discover the hard way what you did wrong.

I expect that the bills that would come out of genuine public debates like this in the two parties would be quite different. But, again, every Representative and one-third of the Senators are up for re-election in November. If health care reform is so urgent that nothing else matters, then put it front-and-center in every campaign. But not empty platitudes and specious promises; present a genuine bill that you’d be willing to enact.

I entirely understand that the bills that would come out of genuine public debates might well be long (not 2,000 pages, but definitely long). It would therefore behoove the parties to spend some time distilling out the main points. I envision a website which has one page of bullet points; a FAQ section explaining bullet points that might be confusing and honestly responding to objections; a collection of white papers addressing in more detail various points that were considered, including those that sounded appealing but were rejected, so that people can understand why they were rejected; a link to archived discussions (and active discussions); and of course the bill itself.

This would be a lot of work, certainly. But the parties raise hundreds of millions of dollars for each election cycle. The money at stake in health care reform runs into the trillions. The Democratic scheme undertakes to radically transform the relationship between citizen and representative government into … well, something else. Shouldn’t there be a lot of effort put into truly understanding the pros and cons and the desires of those who will be subjected to whatever is enacted?

I have a suggestion for the Democrats, and this is absolutely sincere, as to what to do about health care reform now.

The Democrats have made it absolutely clear that their health care initiative is an exclusively Democratic matter; no Republican input is desired or accepted. That is why losing the power to pass everything on a completely party-line basis is so devastating. That is why they are desperately trying to come up with a way to force this through before the people get the opportunity to vote for anyone else from the Party of NO.

So, Democrats, accept that situation: this is an exclusively Democratic matter. Treat it as such. The Democratic representatives and senators, and other Democratic officials in and out of office, should get together over the next months and draft a model bill to be presented to Congress. Spend several months on it. Make the deliberations open — not CSPAN-open, no need for that — but with websites and on-line participation. Enforce decorum on-line; make your websites an example of how to engage in political debate thoughtfully and without obscenity and abuse.

Do this right! What are the issues with the existing system? Get suggestions from the people; what exactly are they concerned about? Let me help you out a bit. Health insurance isn’t the issue. Nobody really cares whether they have insurance or not. What they care about is whether they can get the health care they need, when they need it, in a way that they can afford. Health insurance is a means to that end, but it is not the end in itself. Bear that in mind. Maybe there’s another means to that same end.

Now, having come up with a comprehensive list of problems that you want to solve, get some input from the people as to how to solve them. Maybe there’s something you haven’t thought of (maybe there isn’t, but it would be useful to spend a little time verifying and demonstrating that there isn’t). Then draft a model bill that addresses those problems with genuine solutions, not just whatever you can throw in to sway an uncertain Senator. Publish your bill on the Web.

Write and publish on the Web white papers explaining precisely how your bill will solve the problems. Do it honestly; now that Jonathan Gruber has been outed as a White House shill, he can come out of the closet and write admittedly partisan pieces on your behalf. Allow feedback, again enforcing courtesy and decorum.

Finally, run on your model bill. The entire House of Representatives is up for re-election in nine months. So is one-third of the Senate. Every last Democrat in both Houses wants to force this through, so every last Democratic candidate or incumbent should run on your model bill. If they win, you have a mandate. Enact your bill — no logrolling, no earmarks, no hanky-panky. Enact the precise bill that the people voted for. Even though two-thirds of the Senate won’t have run on it, I think a mandate obtained through this procedure will be enough that no politician will fight against it or demand concessions to vote for it. And if they do … well, you can rightly condemn them.

As an aside, I note that if a regulatory agency wants to authorize construction of a road, there is a legally mandated period of public comment and debate before any such decision can be made. The Democratic Congress tried to nationalize 1/6 of the economy with less public input than there would be for paving the dirt road outside my house. They almost got away with it, but they’d be a lot more popular if they voluntarily acted like representatives of the people instead of philosopher kings.

I used to work in a doctors’ office. We saw lots of poor people. Sometimes we were paid by Medicare, sometimes by Medicaid. Both programs still exist. Why do people keep condemning the U.S. as leaving poor people to die in the streets?

Imagine that I went to a fancy restaurant and had a nice salad and a glass of water, but when the check came, it showed a six-course meal and a $200 bottle of wine.  I would call the waiter back and point out that I had a salad and a glass of water, and he would be immediately apologetic and find the correct check.  I would not, for a moment, think I needed to call the police and file fraud charges because I would know this was an error.  I would know there is no way the restaurant could have supposed they could get away with such a fraud, and hence it could happen only by accident.

Imagine, on the other hand, that my entire company (over 1,000 people) went out for a celebration in a fancy restaurant, and at the end the check was presented to the CEO showing various expensive meals and bottles of wine.  Although I ordered a salad and water, in fact the CEO was charged for a six-course meal and a $200 bottle of wine on my behalf.  But how would he know?  Would he do a survey of the entire company to find out what every single person ordered, tot them up, and compare with the check?  That incorrect bill might not be an error; it might well really be the result of fraud.

I saw an orthopedic specialist earlier this year.  He examined my shoulder and did both X-Rays and an MRI to determine the extent of the damage.  I paid $20 for the visit.  I have no idea what the actual cost was; the bill didn’t even come to me, because my company offers first dollar health insurance, and I figure, why not get it since it’s subsidized.

Years ago, I saw the same specialist about a “pop” and pain in my calf.  He listened to my story, manually examined my calf, told me what had torn (a tendon, if I recall correctly), and prescribed RICE (rest, ice, compression, elevation).  He charged me for an office visit, and I paid it because I didn’t have first dollar health insurance.  If I have been charged for X-Rays and MRI, I would have immediately pointed out that I had received the wrong bill, and I would not have paid it.  Again, I would have been completely certain that the incorrect bill was an accident and not a fraud, because the doctor’s office would know very well that they could not get away with such a charge to me directly.

So consider — if I had come in this year with the calf injury instead, and he had charged me (i.e., the insurance company) for X-Rays and MRI that were not performed, how would I know?  How would the insurance company know?  They would have to have an investigator, someone whose job it was to be suspicious of doctors.  Like police, such investigators soon come to view doctors as low-life enemies, and doctors soon come to reciprocate the hostility.

Since most actual fraud would go undetected, any incorrect billing that was found would have to be treated as fraud and severely punished so as to deter the (many undetected) other frauds.  Hence, you get travesties like the recent case where the Feds spent a quarter of a million dollars trying a doctor on multiple felony charges for fraud, on the grounds that she had overcharged Medicare by $22, though all evidence was that the overcharge was an accident (indeed, she only pled guilty because she ran out of money).*  I wonder if that doctor will ever treat another Medicare patient.  I guarantee I wouldn’t, in her shoes.

So, first dollar health insurance opens the door to fraud in a way that self-pay doesn’t and can’t.  It’s also more expensive overall than self-pay, of course, even in the absence of fraud, for the obvious reason that the premiums have to cover everything that is paid out, which would be at least equal to the self-pay charges, plus the premiums also have to cover administrative costs and some profit for the investors.

First dollar health insurance (especially as administered by the Feds) produces a hostile environment for doctors, who have to seriously consider whether they even want to practice with the risk that they will make an innocent mistake in billing and be bankrupted and perhaps imprisoned as a result.

What, then, is the best way to improve health care in the United States?  According to our betters in Congress it is, naturally, first dollar health insurance for everybody, and no escape.

*The case started with the Feds trying to nail her for prescribing pain killers for chronic pain patients. I have an opinion about that, too, but since they were unable to convict her on that, they went after her on the trivial overcharge.