Crimes Against Liberty (47 page)

The Cato Institute’s Michael D. Tanner noted that the Census Bureau’s latest figures show 45.6 million Americans lack health insurance. But Tanner says we must account for the fact that only some 30 percent of the uninsured lack insurance for more then a year, 16 percent for two years, and less than 2.5 percent for three years or more. About half are uninsured for no more than six months (some have said four months). Much of this, says Tanner, is due to changing jobs and switching coverage through different employers.
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Putting aside the issue of the temporarily uninsured, if we begin with the 45.6 million number, we must first subtract 10 million people who are not U.S. citizens, including an estimated 5.6 million illegal immigrants and 4.4 million legal immigrants who are foreign citizens. Additionally, some 12 million are eligible for Medicaid and the State Children’s Health Insurance Program (S-CHIP) but haven’t enrolled. (For all the handwringing about the millions of uninsured children, this figure includes 64 percent of all uninsured children and 29 percent of parents with children.) Tanner notes if these people went to the hospital for care they’d be instantly enrolled, and thus it’s essentially fraudulent to say they’re uninsured.

There are also millions among the “uninsured” who can afford health insurance but choose not to buy it. These are referred to as the “young invincibles”—those who have decided to gamble on their good health and forego the expense of health insurance. Healthcare expert Sally Pipes wrote that almost 18 million people fall into this category and earn more than $50,000 annually, and almost 10 million of those make more than $75,000 a year.
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Former CBO director June O’Neill prepared a study finding that 43 percent of the uninsured have incomes greater than 250 percent of the poverty level ($55,125 for a family of four), and the income of more than a third of them exceeds $66,000. Another study, produced by Mark Pauly of the University of Pennsylvania and Kate Bundorf of Stanford, found that almost 75 percent of the uninsured could afford insurance but choose not to get it. Moreover, writes Tanner, most of these uninsured are in fact, as noted above, young and healthy: the CBO says some 60 percent are younger than thirty-five, and 86 percent claim to be in good health.

There is overlap among these different categories, making it difficult to determine accurately the number of U.S. citizens who are chronically uninsured and both ineligible for government assistance and unable to afford coverage. Estimates vary, but Sally Pipes estimates the number of these “chronically uninsured working poor” at about 8 million.
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If Obama were truly interested in providing health insurance for these people who fall through the cracks, he could do so with dramatically less cost and without wrecking the quality and access of healthcare for the rest of Americans. Many of these chronically uninsured could be aided by portability reform—by tying insurance to the person rather than the job. One Health Affairs study in 2003 found that only 12 percent of the uninsured were chronically so, with the rest falling in and out of coverage. Many experts maintain if you enacted portability reform—like we do in every other insurance market—the number of uninsured would drop drastically at a reasonable cost to taxpayers. As for any remaining uninsured, we could provide aid at a fraction of the cost of ObamaCare, and without destroying the quality, quantity, and choice of care.

CHOICE AND ACCESS TO CARE

In economic terms it is axiomatic that when you increase demand (which ObamaCare will do by force of law, among other things), and control prices (which ObamaCare will do out of necessity and the sheer force of government inertia), you will end up with rationing. In fact, ObamaCare sets up a board that will make decisions about our choices of care, and the bureaucrats will base their reimbursements on obedience to the prescribed choices. As much as anything else, these realities expose the fraud in ObamaCare. It was promoted on the basis of increasing access, as we’ve detailed. And yet, for all its “fixes,” ObamaCare, after forcing people to procure coverage, will reduce access and quality because it will result in rationing. The choices for care will be made by top-down bureaucrats instead of those who know best: the doctors directly treating the patients. Obama said he wouldn’t interfere with the relationship between doctors and their patients, just as he was pushing through his bill that would empower bureaucrats to direct these very decisions.

But Obama’s own words betray his true intent on controlling healthcare choices. Not only does he favor bureaucratic intervention in intimate decisions between patients and their doctors, he has an embarrassingly unsophisticated perspective concerning it. Recall his statement, “If there’s a blue pill and a red pill and the blue pill is half the price of the red pill and works just as well, why not pay half-price for the thing that’s going to make you well?”
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Or how about this gem from Dr. Barack: “We’re going to start encouraging paying doctors not based on how many tests they take, but based on the quality of the outcome—does somebody end up healthy.... If you go to the doctor you get one test. Then (you are) referred to a specialist, you get another test. Then maybe you go to a third person, the surgeon, you get a third test—it’s all the same test but you’re paying three times. So . . . we’ll pay you for the first test and then e-mail the test to everybody. Right? Or have all three doctors in the room when the test is being taken.”
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Obama appointed Donald Berwick, CEO of the Institute for Healthcare Improvement, to be the administrator for the Centers for Medicare and Medicaid Services (CMS). According to Robert M. Goldberg of the Center for Medicine in the Public Interest, the role of the CMS will be expanded under ObamaCare to define “the quality of health care for every insurance plan, set reimbursement rates for physicians in Medicare and Medicaid, and decide what treatments are more ‘valuable’ than others.” Goldberg surmises, “Berwick will get control of the practice of medicine.”

The CMS will have the sweeping power “to unilaterally write new rules on when medical devices and drugs can be used, and how they should be priced” as part of ObamaCare’s strategy of “retaining costs through controls on specialist physicians. Based on the government’s premise that they often make wasteful treatment decisions,” ObamaCare “will subject doctors to a mix of financial penalties and regulations to constrain their use of the most costly clinical options.”
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It would be disturbing enough for any person to have such broad authority, but Obama’s choice—Donald Berwick—is not just any person. Like Obama, he believes in radical wealth redistribution and that socialized medicine is an ideal vehicle to achieve it. Don’t take my word for it, take Berwick’s: “Any health care funding plan that is just, equitable, civilized and humane must ... redistribute wealth from the richer among us to the poorer and the less fortunate,” he said, adding, “Excellent health care is, by definition, redistributional.” Berwick also idealizes the ineffectual, scandal-plagued British healthcare system, condemning America’s system for running in the “darkness of private enterprise.”
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Writing of Britain’s National Health Service rationing, Berwick said, “You plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.” Goldberg notes that in 2008 Berwick’s pet British system “denied cutting edge cancer drugs to 4,000 people, forcing thousands to remortgage their homes to pay for treatment. Love is blind. With regard to Dr. Berwick’s devotion to the NHS, it’s deaf and dumb as well.”
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ObamaCare’s architects ultimately intended to ration care because that was the only way these command-control types knew to reduce costs. They are philosophically on board with Obama’s idea that a bureaucracy’s payment determination can’t be influenced by a person’s spirit and “that at least we can let doctors know and your mom know that... this isn’t going to help. Maybe you’re better off not having the surgery, but taking the painkiller.”
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They believe in substituting their value judgments for the freedom of choice of American healthcare patients as to whether they need care. Under a free system, a patient can spend as much or as little on healthcare as he wishes. But under a government-run plan—for which ObamaCare lays the groundwork—the government will reduce, deny, and ration care based on a compassionless bureaucratic chart designed by “compassionate” liberals. So while ObamaCare may marginally decrease the numbers of uninsured—though that’s not guaranteed—it will greatly reduce access to quality care.

All government-run healthcare systems ration care, either directly, by denying or limiting certain types of treatment, or indirectly, by imposing cost constraints through budgets, waiting lines, and/or limited technology. One million British people are awaiting admission to government-run hospitals at any given time, and shortages result in the cancellation of some 100,000 operations annually. New Zealanders experience similar troubles. Swedes can wait for heart surgery up to twenty-five weeks, and 800,000 Canadian patients are on waiting lists.
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Moreover, an
Investors Business Daily
poll found ObamaCare will cause up to 45 percent of doctors to retire early. Similarly, the National Center for Policy Analysis reported that ObamaCare “could impact physician supply in such a way that the quality of health care would suffer. The reality is that there may not be enough doctors to provide quality medical care to the millions of newly insured patients.” Why? Because it would make practicing medicine “more trouble than it’s worth.” This reduction in the physician workforce, according to the doctors surveyed, could “result in a significant decline in the overall quality of medical care nationwide.”
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Perhaps the most ominous predictor of rationing in ObamaCare involves so-called end-of-life counseling. Sarah Palin took a lot of flack for arguing that various provisions in the healthcare bill, including end-of-life counseling, could establish “death panels.” Regardless of whether ObamaCare would lead to death panels, one is entitled to ask why such a provision is in the bill at all. What business does the government have insinuating itself into intimate, end-of-life matters? The answer is quite clear: it has no business at all making such decisions, but as the government takes over more and more of the healthcare system, it gains a bigger interest in containing costs in every part of the system.

Furthermore, ObamaCare, as noted above, also expands the role of the CMS over healthcare decisions. These provisions, together with the fact that a number of the bill’s architects, such as Obama’s close advisers on the matter, Tom Daschle and Ezekiel Emanuel, firmly believe in rationing care to the elderly, makes speculation about death panels more than plausible. But there’s more.

Before ObamaCare was passed, Democrats slipped into the stimulus bill a provision to establish a $1.1 billion fund for a Federal Council for Comparative Effectiveness Research, a brainchild of former Democratic senator Tom Daschle. Former New York lieutenant governor Betsy McCaughey warned about this panel when the stimulus bill was being considered. According to McCaughey, the council was based on ideas Daschle had sketched out in his 2008 book
Critical: What Can We Do about the Health Care Crisis
, in which he explained that such a panel is meant to empower an unelected bureaucracy to make hard decisions about healthcare rationing that elected politicians might lack the courage to make. He suggested Americans would be better served if they passively accepted “hopeless diagnoses” like Europeans do. Daschle’s argument, said McCaughey, was that “seniors should be more accepting of the conditions that come with age instead of treating them.” Yet Obama claims conservatives are hyperventilating over this issue.
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Joseph Ashby, in the
American Thinker
, wrote that Rahm Emanuel’s brother, Dr. Ezekiel Emanuel, is on this council. Emanuel’s credo concerning rationing to the elderly is: “Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25 year olds receive priority over 65 year olds, everyone who is 65 years now was previously 25 years.” Some comfort. Some logic. Some values.

It is thus preordained that ObamaCare will ultimately go into cost-cutting mode, saving money by curtailing treatment. As frighteningly long and complex as the ObamaCare legislation is, Ashby warns the regulations promulgated under it could be vastly worse and give regulators enormous power to interpret the law and regulations. This is certainly consistent with our experience in the entire field of administrative law.

Ashby says that if that happens, regulatory czar Cass Sunstein would doubtlessly play a major role in crafting and administering the regulations and thus in controlling medical care. And how does Sunstein view “end of life care?” It should be no surprise, given Obama’s chosen cast of macabre characters, that Sunstein once wrote a paper for the AEI-Brookings Joint Center for Regulatory Studies in which he posited that human life varies in value, which is hardly a principle one would find in the Book of Genesis. It gets worse. Sunstein advocates the government employing “statistical methods that give preference to ‘quality-adjusted life years,’” as determined by the government. In Ashby’s words, “If the government decides the life is not worth living, it is the individual’s duty to die to free up welfare payments for the young and productive.”
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