republican 101

Because the Constitution of 1789 (and its imitators) is based neither on socioeconomic classes nor on socioeconomic functions, it takes no position on the relative value of medicine, mining, banking, or farming, or of the individuals and corporations who perform these functions. Much less is our Constitution about arranging and rearranging functions, making some in any given field into winners and others into losers. That is because our Constitution and its imitators presuppose that government exists by the consent of the individuals who live under it, all of whom are “created equal.” By sharp contrast, stakeholders are not equal individuals, but rather unequal collective entities.

From the beginning:

   After a 4-day pause to build suspense (with apologies to our faithful reader), the rest of the list:

    6. More skin in the game: Individuals with a significant financial stake in their health care consumption will be much more likely to maximize the benefit of each dollar spent.  Once again, the point is not to bring about an arbitrary reduction in health care spending because in our Olympian wisdom we have determined Americans spend too much on their health, but to make the dollars that are spent, however many they may be, count.  Making health savings accounts more available, offering a greater variety of health insurance ratings, and similar reforms would allow a real market for health services to emerge.  Competition for customers would be good for doctors, pharmacies, and hospitals – and for health care consumers.  Like most of the reforms on this list, there is no need for the government to create such opportunities – it need only remove the regulations that keep such options from emerging in the present market.

   7. Tort reform: It is easy to complain about the large awards in headline-grabbing civil cases, yet there is not much more benefit to conservative social engineering than liberal social engineering.  Tort reform should not happen just because we don’t like trial lawyers (and sometimes even their clients) getting fabulously rich in “rainmaker” cases.  There is a problem, however, in the area of tort law that has emerged over the last generation from the combined efforts of anti-capitalist ideologues and wealth-seeking trial lawyers: the rise of non-quantifiable damage claims and the use of civil lawsuits in the place of professional discipline and criminal law.  The civil courts are well-designed for adjusting property claims.  Someone who has suffered an economic loss can recoup that loss in a reasonable process that will generally end in a common sense out-of-court settlement.  In such cases, quantifiable monetary losses are compensated with monetary awards.  But in an increasing number of situations, large awards are given for non-economic damages like psychological distress and for non-compensatory purposes like punitive awards.  The latter category is especially problematic.  Narrowing the context to medical malpractice lawsuits, a doctor whose actions truly deserve punishment should either be charged with criminal negligence or brought before a professional panel for review and possible discipline.  Using the civil courts instead unnecessarily increases the cost of liability insurance and therefore medical services while inappropriately awarding plaintiffs money that is essentially equivalent to a fine for criminal activity.  Whatever can be quantified in terms of income lost, new expenses born, and the like is an appropriate item for inclusion in a civil suit settlement or award.  Non-economic damages, however, should be capped at a low number or prohibited altogether.  As long as there are medical boards of review and criminal courts are open, there is no need to use the civil courts inappropriately to police the medical field or any other.

   8. Eliminate mandatory coverage regulations: The more items that are included in mandatory coverage regulations, the more homogenized the health insurance industry becomes.  Such regulations are no doubt responsible in part for the large number of the uninsured in the United States.  For those who are young and healthy, particularly, there is little reason to pay for a policy that has an artificially high price because it covers all sorts of medical care they will never need.  My family is part of a non-insurance health care cooperative (and therefore among the technically uninsured) that does not reimburse expenses generated as a result of certain lifestyle choices.  This makes the monthly fees considerably less than a comparable insurance plan, serving the needs and desires of those involved, but has made the company liable to legal action in a number of states on the grounds that it is a disguised form of insurance.  What public interest is served in the attempts to make such cooperatives more expensive or eliminate them altogether?  Deregulation in this area would allow a much larger number of Americans to find suitable, affordable insurance.

   9. Allow insurance competition across state lines: When each state becomes a health insurance island, the interests of consumers, once again, are compromised.  It is no violation of federalism to make it possible for consumers to purchase insurance policies generated in other states.  In fact, it was one of the very purposes of the Union to create a free market among the several states.  Article I, section 10, of the Constitution specifically prohibits placing tariffs on goods entering one state from another.  The regulatory “tariffs” that limit consumer insurance options violate the spirit, if not the letter, of that principle.

   10. Insurance for citizens, not workers: The present system of employer-based health care, largely the result of special corporate tax benefits associated with providing coverage, causes a number of distortions in the health insurance market.  As argued in previous posts, it obscures a significant portion of the cost of health care decisions.  It also creates many of the oft-noted problems in finding coverage experienced by people with pre-existing conditions.  With the average person changing jobs a half dozen or more times during his work life, each period of transition creates a potential choke point for reinsurance.  Eliminate the tax advantages for the present system and a whole variety of citizen-based, rather than employee-based, plans would emerge that could follow the individual or family from one job to the next over the course of one’s entire working career. 

   As the congress returns next week and President Obama attempts to rekindle the smoldering fires of “comprehensive health care reform,” there will be much pressure from liberal media, academic, and political elites to approve a “compromise” plan with only cosmetic changes to the current House bill on the grounds that something is better than nothing in the midst of our present health care “crisis.”  It has been my desire in this extended series of posts to add my little yelp to the strong voices of many lion who deny this claim.  There are many things worse than our present health care system – including the consequences of almost every significant reform bill that one could imagine coming out of the current congress.  And this should not surprise us – since almost all of the legitimate problems in the present market for health care are the result of previous government reforms. 

   Politics in a hurry is a recipe for bad policy.  Politics in a hurry at the point of a left-wing ideological gun is a recipe for really bad policy.  Politics in a hurry at the point of a left-wing ideological gun under the pressure of an imaginary crisis is a recipe for just about the worst policy of all.

   Politically-speaking, the health care policy alternatives before us at the moment are limited: a strong or weaker version of the President’s plan (any of which would either include or prepare the way for the provisions and approach to health care objected to in my “10 Reasons to Oppose Obamacare” columns) or something not very far removed from nothing.  With a different congress, different options would emerge.  With a different president and a different congress, a whole range of new possibilities would come into being.  For now, then, it is most important that we have clarity on the key question that will be before the congress when it returns from recess: is the status quo preferable to the President’s alternative? 

   There is no guarantee that “reform,” however good may be the intentions of those who advocate it, will make things better.  The history of public policy has many, many chapters that can be summarized: good intentions, bad results.  Unless we currently have the worst possible health care system, there are ways to make it worse.  I believe that there are very good reasons, detailed in numerous previous posts, to believe that the President’s plan will reduce access to health care, increase costs until strict rationing is imposed, create a culture of Darwinian competition for medical resources and pressure on the weak to “get out of the way,” compromise liberty, and vastly expand the reach of the emerging corporatist, bureaucratic state.  Given the choice between the President’s plan and doing nothing, we would be better off doing nothing.  Given a different set of political possibilities, however, a republican approach to health care might look something like this:  

   1. Maintaining a fundamental respect for human dignity – One of the great dangers of nationalized health care is its tendency to compromise human dignity in a whole variety of ways.  From the paternalistic assumption that government boards can better manage my health than I can to the creeping expansion of the number of our fellow men who are defined out of the human family (to justify abortion or the denial of treatment to those whose “quality of life” is substandard), a government-controlled health care system assaults our republican principles at their foundation.      

   2. Keeping the private private – The more health care is conceived of as a service provided by the government rather than a service contracted for between private parties, the more of one’s life is drawn within the public sphere.  There is no national health care “bill,” as the President has put it, as if all Americans, in this regard, comprised one large family – and there won’t be so long as there remains a strong private market for health care services.  It is no small reason to fight for the continued existence and growth of that market that we may forestall the onerous lifestyle taxes and regulations that must surely grow with the government’s role in providing and regulating health care.     

   3. Recognizing the tradeoffs that public spending forces – If I could wish two pieces of wisdom upon every policymaker in the nation, they would be: first, a proper understanding of human nature (consistent with the Biblical account of fallen humanity); second, an appreciation of the economic concept of opportunity cost.  Over and over again, those who craft legislation and regulation fail to appreciate the policy implications of the obvious fact that a dollar spent on item x is consequently unavailable for the purchase of item y.  $1 trillion spent on public health insurance is almost $10,000 that every household in America will not be able to spend on their heating and cooling bill, a healthier diet, more adequate clothing, improved housing, an exercise machine or gym membership, an extra trip to the doctor or dentist, or a safer car.  Any or all of these items might be at least as likely to improve the health or life expectancy of Americans as government-centered health reform, but may be quietly foregone when the money is appropriated for public use.  Spending on a government health care plan, to be justified, must at least be able to show that: a. it will bring about a net improvement in health after factoring in all the opportunities foregone in the collecting of the taxes to pay for it; b. that that net improvement is greater than the improvements available through non-public options, tax credits for health insurance, etc.  To advocate a program that cannot meet these tests is an ideological, rather than a policy, judgment.

   4. Promoting cost transparency – The more that payment for health care is removed from the relationship between patient and provider, the less the health care consumer is able to make his own important judgments about relative spending priorities.  Greater transparency may not lead to less spending – and there is no intrinsic reason to believe that Americans should spend less on their health rather than more – but it will lead to a more informed choice. 

   5. Less “policy,” more responsibility – What portion of our health care system is it necessary for government to control?  Must the government make it its business to reduce health care spending to a certain arbitrary level?  Must the government provide health insurance companies with a list of items they must cover? Must the government ensure that there will be no personal benefit for healthy living in the form of reduced insurance premiums?  Must the government decide what profits pharmaceutical companies may make, what rates doctors may charge, what services hospitals must offer?  There is no necessity that any one group or individual make such decisions.  In these and many similar areas, it is quite possible to have no “policy” at all, but to leave such matters in the hands of the millions of responsible citizens who sensibly go about their own business each day and the thousands of health care providers who respond to their desires and needs. 

   For those seeking a laundry list of “conservative” health care policies and programs to enact, the five points in today’s post must fall rather short of the mark.  There will be time to consider legislative changes (items 6-10) that could mitigate some of the commonly-cited problems of the American health care “system.”  But we will not allow ourselves to be forced into a debate on ground occupied by our opponents, where legislative activity is the measure of a legislator’s excellence, where public policy is expected to solve every private problem, and where individual citizens are collectivized and homogenized into an amorphous mass of government clients and dependents.

American democracy has never been democracy by plebiscite, a process by which a leader is anointed, then the populace steps out of the way, and the anointed one puts his political program in place. In the American tradition, the “mandate of heaven” is gained and lost every day and people talk back to their leaders. They are not held in thrall by them. The leaders are not infallible or a breed apart. That way is the Third World way, the way it plays out in Arab and Latin American politics.

“The politics of charisma is so Third World. Americans were never going to buy into it for long.”

From the beginning: