There Is No Mystery To Health Care

There are four models of health care financing in the world today. The Bismarck model, used in Germany, Japan, Switzerland, and Belgium, is built on employer-provided private insurance with subsidies and cost controls to make the system universal. The Douglas model, used in Canada, France, and Taiwan, establishes a universal public insurance model that includes all legal residents and is financed by taxation. The Beveridge model, as seen in the UK and Hong Kong, is built on public clinics and hospitals that all legal residents can access without payment at point of service. The fee-for-service model is the tyranny of the market: If you have money, you see a doctor; If not, you stay sick and die needlessly. What ALL of the countries that have fully implemented one of these models have in common is that they cost a lot less per patient than what we spend in the United States. What the first three models have in common is that they cover everybody AND cost a lot less. While they all have problems, those problems pale in comparison to the insane costs and needless suffering of the chaos in the American non-system.

The root of the problem with the US health care system is that we try to implement all four systems.

Veterans use the VA system, which like the UK’s National Health Service, offers state-owned hospitals and clinic staffed with government employees that provide care and medications directly for no or nominal cost. By directly providing services to patients, costs are kept very low, making it the cheapest part of the American non-system, despite the fact that its patient population is a high-risk subset of the population. That’s the Beveridge Model.

Americans with disabilities and those over 65 use the Medicare system. The poorest Americans may qualify for Medicaid, depending on which state they live in. Those systems are government-provided health insurance plans that pay largely private providers according to mandated rates for defined services, like Canada’s Medicare national health insurance. Unlike Canadian patients, American Medicare enrollees usually pay copays at the point of service. That’s the Douglas model.

Americans with white-collar jobs at large companies get their health insurance through work. They enjoy “community rating” and “guaranteed access,” meaning that they and their dependents cannot be denied coverage or charged more because of age or medical history. Employers and younger or healthier colleagues are in effect subsidizing the costs of covering older, sicker employers and family members. While each company is treated as a risk pool for purposes of establishing premiums, the private health insurance companies make a profit through risk arbitrage because of their much larger risk pool. If each policyholder could take advantage of the cost savings of unifying the whole risk pool of all private insurance companies, the result would look a lot like a national Bismarck-style system. In such a system, public plans or subsidies would cover the unemployed or those at small companies, while making prices uniform across the system as a whole to control costs.

Tens of millions of Americans fall through the cracks of these partial systems. Providers must maintain large staffs to navigate multiple billing systems. Networks of providers keep getting larger to provide more negotiating power with insurers, continually driving up prices of medical goods and services. All these interest groups hire armies of lobbyists to make laws and regulations absurdly complex, making services more expensive yet.

The whole premise of conservative political thought on health care reform in the United States today is that there is some combination of policies that will turn a fee-for-service model into a functional system, because markets. One of the major ideas of the conservative movement is that health insurance shouldn’t cover routine care, but should be like homeowner’s insurance or auto insurance, and only cover catastrophic events. The problem with this theory is that 46 percent of Americans couldn’t produce $400 in an emergency, it costs hundreds of dollars for the uninsured to see a doctor in this country and those most at risk from chronic disease would be those most likely to forgo primary and preventive care. This will dramatically increase the risk of illness among those least able to provide for their care and push them onto public health programs at the state level that will be cut or curtailed because the poor have no political power in America.

The Affordable Care Act is the most workable form of pro-market ideology in health care. Despite all the conservative apoplexy it has attracted, the intent of Obamacare was to implement a Bismarck model in the United States using the existing systems of employer-provided care and Medicaid, while filling the gap by creating new state-level risk pools to make the individual market operate like the group market as seen at large companies. The problems with that system are an indictment of the incompleteness of the ACA, not of the Bismarck model itself. The basic ideas in the ACA derive from conservative thought, originating at the Heritage Foundation and first implemented during Mitt Romney’s time as the governor of Massachusetts. It’s an attempt to provide something like universal coverage with minimal state intervention. Of course, conservatives are universally in favor of scrapping it, because reasons.

There isn’t some magical formula issuing forth from the ghost of Milton Friedman. If there was, it would have been found during the forty years in which conservatives have run the economics profession in the United States. The right-wing think tanks have published many thousands of papers in the search for such a model. Obamacare is the direct descendant of those ideas, using private insurance and the individual mandate to move toward universal coverage. Conservatives of both parties successfully defunded the risk corridors, killed the public option, largely scuttled the Medicaid expansion, and weakened the mandate, thus creating the actuarial problems the ACA has today. The purpose of all of that was to prevent the ACA from working, because if it did, it was feared that the resulting ideological dislocation would weaken the conservative movement. The fact that they felt this way about an idea that began life at Heritage highlights how extreme the American right has become.

The ugly truth is that there is no fifth model. There are four, and if you want a functional system, you have to implement one of them. The reason our system costs so much without delivering very much is that we have tried to implement all four simultaneously. There simply is no intellectually honest conservative approach to health care policy. The right claims to want to fix the incomplete Bismarck model we have, but really wants to replace it with a fee-for-service model, which would benefit only the wealthy at the expense of everyone else.


Justin Amash Is In Need Of An Ex-Lax

Nothing puts a smile on my face like killing my supporters!
Nothing puts a smile on my face like killing my supporters!

In an absurdly mendacious Facebook post, far-right ideologue and supposed Michigan Representative Justin Amash said, in effect, `y’all need to chill the fuck out!’:

The AHCA repeals fewer than 10 percent of the provisions in the Affordable Care Act. It is an amendment to the ACA that deliberately maintains Obamacare’s framework. It reformulates but keeps tax credits to subsidize premiums. Instead of an individual mandate to purchase insurance, it mandates a premium surcharge of 30 percent for one year following a lapse of coverage. And the bill continues to preserve coverage for dependents up to age 26 and people with pre-existing conditions.

I want to emphasize that last point. The bill does not change the ACA’s federal requirements on guaranteed issue (prohibition on policy denial), essential health benefits (minimum coverage), or community rating (prohibition on pricing based on health status). In short, Obamacare’s pre-existing conditions provisions are retained.

This is, (how should I put this?), ….

a bald-faced lie.

For all its faults, the Affordable Care Act cut the uninsured rate in half in this country, bent the cost curve down, saved at least 50,000 lives, and shaved at least half a trillion dollars off the 75-year debt projections.

What the new bill does change is significant. It ditches means-based and geographically-based subsidies altogether in favor of an age-based subsidy, so that Bill Gates would get a higher tax credit to purchase a plan on the exchange than I would. At least $600 Billion of the revenue that makes the ACA work is cut in the AHCA. The Medicaid expansions, about half of the ACA reduction in the uninsured, are phased out after 2020, affecting millions who will have little to no access to health insurance if this bill becomes law. That will cost tens of thousands of lives every year.

The changes in subsidies, the uncertainty of the non-statutory cost-sharing subsidies, and the phase-out of the Medicaid expansion will trigger a death spiral on the exchanges and for rural hospitals that will deny millions of Americans life-extending health care and cause immense quantities of needless suffering and death. At least 24 million of those insured on the exchanges and through Medicaid because of the ACA will lose coverage. The coverage losses from the exchanges are probably worth at least another ten thousand deaths a year. These losses will hurt Republican voters the most. Coverage loss maps show that the areas of greatest insured reductions are in some of the reddest places in America, like Nebraska, Kentucky, and Kansas.

Even for those who get health insurance through their employers or those of their family members, about 150 million, the bill has a serious problem. The states can petition this administration for exceptions to the mandated coverage provisions. They will get it. Then, there is a provision in the bill to allow large employers in any state to adopt the exemptions of the most backward state, so that employees of large companies can lose hospitalization coverage, or maternity coverage, or prescriptions, or whatever. I guarantee you will see at least some of this.

The idea that this bill makes no significant changes because somebody did a word count and found 90% commonality in the text is a childishly disingenuous dodge. It doesn’t take much textual change to cause suffering for millions.

And for what? To put some money in the pockets of a tiny handful of wealthy donors and to make a political point. Justin Amash is, how to put this delicately, ……

stunningly full of shit.

Why Obamacare Repeal Failed, or The Dangers of Believing Your Own Sales Pitch.

“… government had always been big for people like us [whites], and we were fine with that. But beginning in the 1960s, as people of color began to gain access to the benefits for which we had always been eligible, suddenly we discovered our inner libertarian and decided that government intervention was bad …”
Tim Wise, Dear White America: Letter to a New Minority

For four decades, the story of American politics has been the story of the triumph of conservative ideology in government. From the rise of Reagan to the impeachment of Clinton and the triumph of Trump, conservative messaging has driven political debate in the United States. Even at their lowest point in 2006-9, the conservative-dominated Republican Party was able to push back against liberals and moderates in both Federal and Sate government. The high point of Democratic legislative power, the Patient Protection And Affordable Care Act of 2010, was based on conservative ideas, took the form of a giveaway to private industry, and was explicitly modeled after Gov. Romney’s popular health care reform in Massachusetts. The “public option” idea for the legislation was removed to get conservative Democratic support in the Senate.

In broader strokes, public higher education, which was once almost free in much of the country, is now increasingly unaffordable for families without substantial savings, placing education and opportunity out of reach for a large and growing share of America’s youth. The top tenth of one percent of income earners, deriving most of their revenue from investments, pay a fraction of the tax rate of those they employ. Financial services represent the largest sector of the economy. Business regulation has been largely dismantled, permitting multi-billion dollar companies to operate with illegal business models. Education and health care are increasingly influenced by politicized Christian radicals.

With all this success, it was natural for GOP leaders to assume that the broader public supported their anti-government, pro-business views for the same ideological reasons they did, thumbing through well-worn copies of Von Mises, Hayek, or Rand. With the ascension of Donald Trump and the collapse of Paul Ryan’s American Health Care Act under the weight of angry town halls across the nation and a 17% approval rate, that assumption has earned some scrutiny. The question remains, however: If middle-aged white voters didn’t share the minarchist ideas of the House GOP caucus, why did they keep returning them to office?

One answer that suggests itself is that the pro-police, pro-military, theocratic, anti-government platform of the Republican Party appeals to people with, ahem, ethnonationalist, views.

You start out in 1954 by saying, “N*gger, n*gger, n*gger.” By 1968 you can’t say “n*gger”—that hurts you, backfires. So you say stuff like, uh, forced busing, states’ rights, and all that stuff, and you’re getting so abstract. Now, you’re talking about cutting taxes, and all these things you’re talking about are totally economic things and a byproduct of them is, blacks get hurt worse than whites.… “We want to cut this,” is much more abstract than even the busing thing, uh, and a hell of a lot more abstract than “N*gger, n*gger.”

  • Lee Atwater, 1981

The roots of the modern War On Drugs are to be found during the Presidency of Richard Nixon, whose chief domestic policy advisor told Harper’s writer Dan Baum:

“You want to know what this was really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”

If the public has been absorbing this ‘dog whistle‘ message for two generations, perhaps we shouldn’t be surprised that they got the message loud and clear, or when the Lieutenant-Governor of South Carolina opposed providing free school lunches to poor children because, as with stray animals, it encourages them to breed. Nor should we be shocked when former Speaker of the House and all-around great guy Newt Gingrich calls Barack Obama the Food Stamp President.

Nor should be be completely blind-sided when, decades into this process of racialized radicalization, some of the those the Party manipulated this way become the Party’s leaders and the dog whistle becomes a megaphone:

Racial Anxiety‘ or ‘Racial Resentment‘ have become the largest drivers of support for Republicans and their policies. For a crucial margin of white voters, feelings of white victimhood are their conservatism. Far from laissez faire, they’re closer to the ideology of Herrenvolk Democracy, in which democratic participation and the benefits of the State should be reserved for members of the majority culture.

Enter Paul Ryan, from youth a believer in Austrian and monetarist economics and in Ayn Rand, the novelist and pop philosopher who viewed the wealthy as the possessors of all moral merit. Ryan probably believes that refraining from taxing the wealthy would produce more wealth overall, but supports it regardless as a moral value. He may be tactically pragmatic, but has demonstrated an unwavering commitment to shrinking the role of the State as a moral and ideological crusade, which is what he has in common with the ideological leadership of the Tea Party and the members of the House Freedom Caucus. Unlike Lee Atwater and John Ehrlichman, they no longer see law-and-order and anti-tax policies as racial code. The grifters fooled their successors.

So, when Caucus members and Republican “mainstream” congresspersons,  who are ideologically identical, ran into a buzzsaw at town halls from red-state crowds dependent on Obamacare, they had a conceptual as well as tactical problem. They had made the mistake of taking the sales pitch for the product because they are the generational inheritors of the modern conservative movement, not its architects. They either will not acknowledge or don’t realize the role of white racial resentment in forming conservative allegiance in the general population.

For a decisive minority of white people in the nation’s interior, the consequences of deindustrialization can naturally be blamed on trade, aid, the rising minority share of the population, and immigration, even if the facts do not support that conclusion. Neither do they see any conflict between that view and the other tenets of modern American conservatism. Unlike the ideologues in the conservative media and on the Hill, they see no conflict between interventionist, protectionist Herrenvolk Democracy and “religious freedom” laws, the Drug War, and “tax reform.” This explains why, despite the protestations of pundits, the vast majority of Republican voters had no trouble touching Trump on their voting screens. Paul Ryan may have forgotten he was talking in code, but the voters didn’t. They wanted the benefits of the State, as manifested in the ACA, at the same time as they wanted the racially-specific “undeserving” excluded from such benefits. That’s why the House GOP’s American Health Care Act, which would have penalized exactly the modest-income middle-aged whites who were Donald Trump’s margin of victory in the Rust Belt, had a 17% approval rate even though it was what the GOP had been promising for years.

Ultimately, American Conservatism is in a crisis because its leaders don’t know what movement they’re leading.