Things I've Tagged ‘Healthcare’

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Thoughts on

I’m not going to take this on as a design or front‐end‐development critique, because it will add nothing to the conversation. Plus, politics are my style man.

I’m dead serious. The site itself has a nice look to it, but the back end man…yikes.

What I know from the web development community is that there are scaling issues when it comes to front‐end performance, but nothing that cannot be corrected fairly easily. And I for one found it promising that the site was built using responsive design, though I’m not so certain I’d enjoy signing up for healthcare through a mobile phone.

The back end, on the other hand, has been a bit of a disaster for a plethora of reasons, but primarily because the entire system is reliant upon the robustness of antiquated systems; from the descriptions of the issues it appears the entire structure was not adequately tested for the projected user load, but the fact that it failed under strain is not surprising. But I’m done rehashing these points.

“If you like your plan, you can keep it…”

What makes the entire affair an unmitigated disaster is what it ultimately means for consumers and citizens–it means increased costs. This was not an unexpected consequence of the rules that were implemented.

What some were not expecting to see was their existing insurance plans being phased out in an effort to offer plans that meet the requirements of the PPACA. The law required existing plans to essentially remain unchanged in order to maintain a grandfathered status; because this rule included maintaing the cost structure from year to year, this became impossible in practice. The result is a doubling of cost to the consumer as unnecessary coverages are tacked on. You in fact, do not get to keep your plan no matter how much you love it.

If you’re one of the unlucky few to lose your current coverage, and are pushed into the exchange system, you’ll be confronted by much higher coverage costs than you’re used to.

Couple these two points with the exchange system failures and you have the potential for major disruptions in coverage for many consumers. Will that lead to decreases in coverage in complete opposition to the reason the law was touted to begin with? I expect it in the short run.

We should be decreasing costs

If we want health inflation to stay low and health care costs to be less of an anchor on advancement, we should want more Americans making $50,000 or $60,000 or $70,000 to spend less upfront on health insurance, rather than using regulatory pressure to induce them to spend more. And seen in that light, the potential problem with Obamacare’s regulation‐driven “rate shock” isn’t that it doesn’t let everyone keep their pre‐existing plans. It’s that it cancels plans, and raises rates, for people who were doing their part to keep all of our costs low.

Ross Douthat

Precisely right. Aside from the mandate, the fact that every regulation in the new law screamed increased costs for consumers was a giant red flag that proponents of the legislation either ignored completely or denied were even issues.

In spite of the fact that we want as many people as possible to be covered, this was never a good solution. The website is another example of how much of a shit‐show the entire thing was.

How Does a Mandate Become a Tax?

We’ve been instructed to be deliberate in the communication of our ideas; be clear, concise, and say what you mean without newfangled, colorful language. I’d been given this lesson consistently during the course of my education. But words don’t appear to have very much meaning in the legal world–and they probably have very little meaning in the world beyond that. For the legal world, the more you communicate the better you’re able to cover your ass when something inevitably goes wrong, even if that language is designed to confuse the average person.

Since the ruling last week [concerning the PPACA1] I’ve been utterly perplexed by the result as far as the constitutionality of the mandate is concerned. According to my layman’s understanding, the mandate to purchase insurance goes too far in relation to the commerce clause,2 and thus is not constitutional under that reading; however, according to Chief Justice Roberts if it is read a certain way the mandate is a tax rather than a penalty as specified in the text and so can be considered constitutional under the taxing power.

The mandate was never labeled a tax and that language was particularly derided by the original drafters and supporters of the PPACA, so where does this reading come from? How does something neither labeled nor described as a tax suddenly become a tax for purposes of allowing said provision to stand? The opinion discusses the mechanism of enforcement as one that for all intents and purposes is a tax because it isn’t particularly punitive, so I get the reasoning. But I always assumed that the meaning of the words used in the drafting of the law was just as important as intent, in that both typically coincide with one another. And in this case, the mandate was designed as a mandate to pay for insurance or pay the penalty–unless your income was under a certain threshold.

This is not descriptive of a tax,3 but seems more like a parking violation. And reports of Chief Justice Roberts switching his opinion are enough to make me even more skeptical of this whole process. There is no giant conspiracy, but what is the endgame here?

A constitution of enumerated powers is designed to put limits on those powers, not grant broad authority under an exceedingly broad interpretation of a power that was designed to reduce trade barriers amongst the states. I will never understand the academic desire to make this so. If you’re looking to change the operation of our government, and the balance of power the constitution was designed to create, then amend it.

  1. This is the Patient Protection and Affordable Care Act–the constitutionality of some parts of the act were being deliberated by the Supreme Court. I’m really only going to discuss the mandate, as other portions are a little less controversial.
  2. The commerce clause reads: “[The Congress shall have Power] To regulate Commerce with foreign Nations, and among the several States, and with the Indian tribes.” These few words have been used to justify a number of powers that are convenient, but not specified in the constitution, as an effort to regulate interstate commerce. Under the increasingly broad interpretation of the Supreme Court, just about anything can effect interstate commerce, even personally manufactured or grown goods. Go read more about it. This reasoning was thankfully rejected.
  3. “To impose a financial charge or other levy upon a taxpayer (an individual or legal entity) by a state or the functional equivalent of a state such that failure to pay is punishable by law.”>. Accessed 7/3/2012.

Where, exactly, does the U.S. government get the power to require that every one of its citizens must participate in a government‐sponsored health care plan? Ask this of a health care reformer and he, or she, will sniff, think a moment, and (if legally trained) will immediately utter the two most magic words in late 20th century constitutional jurisprudence—Commerce Clause.

If the legality of a health care package featuring federally mandated universal participation is litigated (and we can bet it will be), and the system is upheld, it will mark the final extension of this originally modest grant of federal authority. Thereafter, Congress will be able to regulate you not because of who you are, what you do for a living, or whether you use the interstate highways, but merely because you exist…

David Rivkin Discussing the Individual Mandate from September 29, 1993

This was originally discussed in 1993, the last time the individual mandate was made popular…by Republicans.

The Regulation of Mental Activity is Covered Under ‘The Commerce Clause’

I’m having a rough time wrapping my mind around the implications in a recent court decision upholding the PPACA.1 In it, Judge Kessel writes:

As previous Commerce Clause cases have all involved physical activity, as opposed to mental activity, i.e. decision‐making, there is little judicial guidance on whether the latter falls within Congress’s power…[however], this Court finds the distinction, which Plaintiffs rely on heavily, to be of little significance. It is pure semantics to argue that an individual who makes a choice to forgo health insurance is not “acting,” especially given the serious economic and health‐related consequences to every individual of that choice. Making a choice is an affirmative action, whether one decides to do something or not do something. They are two sides of the same coin. To pretend otherwise is to ignore reality.1

First, how is choosing not to purchase something ‘economic activity?’ I choose not to purchase literally thousands of products annually by simply not purchasing them; under this court’s finding, the most absurd, but seemingly allowable, conclusion I must draw is that these decisions can be regulated by Congress under the commerce clause. One might argue that Congress would never go beyond health care, but what would stop them from writing legislation doing just that in the future? Wouldn’t this set a precedent for future legislation and case law?

Perhaps my logic is unsound, but a little explanation can go a long way here–I certainly need it.

What I can gather, based on some of the commentary I’ve read before and related to this decision, is that the market for health care is deemed a special case in this instance because everyone eventually requires the use of some health services. And now that insurance companies must accept all comers at the same price levels, regardless of risk, the costs would spiral out of control unless everyone purchases a plan to balance things out. Thus, choosing not to purchase health insurance would have a negative economic impact on everyone else, so it must be regulated.

But none of this makes a lick of sense. Government regulation created the conditions, not economic activity/inactivity. What stops them from regulating/mandating everything under this rationale?

  1. Mead v. Holder, Civil Action No. 10–950 (United States District Court for the District of Columbia 2011). Accessed 2/23/2011.

It is difficult to imagine that a nation which began, at least in part, as the result of opposition to a British mandate giving the East India Company a monopoly and imposing a nominal tax on all tea sold in America would have set out to create a government with the power to force people to buy tea in the first place.

Judge Roger Vinson

Rights, Duties, and Obligations in the Modern Era

I recently discovered a brand new and interesting philosophical blog, via Marginal Revolution. If you happen to get an opportunity, please explore–there is quite a bit there worth reading. And so far, I’m enjoying it immensely.

In a recent post discussing rights and duties, James Otteson lays out the interplay between the two very well and the important roles each play:

Whether one has a “right” to something is whether someone else has a duty to provide it. The two—a right and its correlative duty—are logically inseparable; like mountain and valley or ebb and flow, one exists only with the other. Hence if no one has a duty to provide you something, you have no right to it; and you can claim a right to something only if it is someone else’s duty to provide it for you.

He goes on to say that if one really, really wants whatever it is they’re clamoring for, it does not then become a right, nor does it become a duty for another to provide it for them.

The whole post is a pretty interesting discussion concerning positive and and negative liberty, one that I’ll leave to you to read and digest, but it brushes nicely over the current health care debate.

The question we have is, if health care is a right, as claimed, who then has the duty to provide it at their expense? Anyway, read the article and the accompanying discussion for a little balance.

Letter to the Editor: Response to the Moral Argument

In this paper, and among other sources, I have read the claim that the most moral action would be the passage of universal healthcare; and while, from the perspective of some it would indeed seem to be a moral imperative to ensure that the less well off are cared for, it is difficult to claim that the most moral action is a government run program.

From a certain perspective, what is deemed moral is that which is seen as the “greatest good for the greatest number of people.” Though the act of passing universal healthcare is done with great moral intentions, it will ultimately impact the greatest number of individuals more negatively over time, and will serve to help the fewest at inception.

What negative impact would such a program have on a greater portion of society than that which it is designed to serve? Simply, its costs will become increasingly astronomical and undeniably unaffordable over time, and in such a way as to cause catastrophic collapse unless a change is made in expenditures or in tax collection.

And while we are, in sum total, the wealthiest nation on earth, a great deal of this wealth is built on debt, from the car or house many own to the ever increasing debt of the federal government built year after year on deficit spending for various social programs and military expeditions.

This is not to say that those less well off should be left to wallow in misery; it is simply the role of societal institutions, and not government, to ensure individuals are cared for, and seemingly the most moral way. And so from this interpretation of morality it is difficult to say whether the passage of a government program designed to assist such a small percentage of the population is truly the most moral path to take.

But, of course, the issue of morality is complicated. Our tradition of governance is not; it is about negative liberty, or rather what the government will not do in order to maintain an individual’s right to life, liberty, and private property.

Passage of universal health care, or the passage of a similar program, diminishes this tradition by creating a sense of entitlement in a population looking for positive liberty—or what the government will provide—at the expense of an individual’s right to property, by increasing taxes, and the liberty one enjoys when deciding how to provide their own health and wellness, by supplanting that with a system designed to mandate what qualifies as quality care rather than that which is based on an individual’s needs.

Mike Mattner
Benton Harbor, MI

Unsustainable Healthcare Costs

At this point, it seems more plausible that the cost of health insurance will keep rising, just as the costs of health care services have continued to climb. The upshot is that the burdens of mandatory purchase, the subsidy costs and the associated implicit marginal tax rates will all increase, eventually to the point of unsustainability. — Tyler Cowen

We continue to debate healthcare proposals in this country, almost non‐stop, while the economy burns and fails to recover in any meaningful fashion. On the minds of politicians is not the well‐being of the citizenry, or it’s interests, but rather it is the progression of a certain agenda above all else, as the mechanisms are in place to do so; whether or not it can be accomplished within the ranks of the party is mildly debatable, at least.

What the government might consider, rather than this agenda that is, are ideas proven to generate a little momentum in the recovery process: tax breaks, tending to the fiscal health of the federal government, reducing regulatory control on private sector practices, etc. But, health care is just too important.

The quote below is a from Tyler Cowen, How an Insurance Mandate Could Leave Many Worse Off, discussing why the current proposals are eventually doomed to thrive in the pile of unsustainable government ideas.

A further problem is “mandate creep,” which we’ve seen at the state level, as groups lobby for various types of coverage — whether for acupuncture, alcoholism and fertility treatments, for example, or for chiropractor services or marriage counseling.

There are now about 1,500 insurance mandates among the various states, and hundreds of others are under consideration. The dynamic at work here is that the affected groups have a big incentive to push for mandates, while most other people are unaware of the specific issues and don’t become involved.

Because mandates don’t stay modest for long, health insurance would become all the more expensive. The Obama administration’s cost estimates haven’t considered these longer‐run “political economy” issues.

Why politicians will not look to these sorts of predictions as an indicator of why their current plans are foolhardy and dangerous is nerve wracking. This is all via, Tyler Cowen. Be sure to read through the comments as it is usually an interesting discussion.