A Question for Opponents of ACA/Obamacare
Because I need to understand the actual assumptions in play. The question is simple:
Should every American have access to affordable health care?
Now there are a range of answers explicitly or as often explicitly returned by opponents of which the following is just one set:
1) Yes. And every American has access via Emergency Rooms.
2) Yes. And every American willing enough to work can earn enough to pay for/earn health insurance.
3) Yes. But the role for providing that coverage is properly private charity.
4) Yes. But the government, due to its tendency to translate assistance into tyranny,is absolutely the wrong provider.
5) Yes. But the market would provide that if we removed the distortions due to trial lawyers and state bureaucracies via tort reform and cross state border insurance sales.
6) Yes, in theory. But in practice access and affordability are not simultaneously achievable. We simply do not have enough doctors and hospitals to provide access to everyone, nor the ability to expand capacity at an affordable cost, and so the effect of universal access will inevitably be rationing and delays in treatment for everyone.
And we could go on, and please do in comments. But there is another answer floating out there and one that IMHO often accompanies or underlies the above answers but is often hidden by calculation. Or perhaps shame.
7) No. Health care is an economic good that should be delivered entirely according to ability to pay. As for that matter are food, shelter, and education. Maybe we should provide the bare minimum of each needed to sustain life but in the end I am not my Brother’s Keeper. If I choose to freely offer charity then fine. Otherwise not my problem.
Now I have reasoned responses to people who answer with some variant of answers 1 to 6. Once I can get you to “Yes” I flatter myself that I can counter the ‘ands’ ‘buts’ and ‘in theory’. Because those answers are amenable to economic and political arguments about actual health care delivery systems in America today, the cost of that delivery, the limitations on charity to backfill all such needs (and BTW never without backhand assistance via the tax code) etc.
But if truth be told opponents are really starting from “No.” and that there is in fact no shared societal responsibility to provide this particular good then there is only one path left open to me. Because what is left over is no longer a question of economics but of fundamental moral world views.
To put the matter in a different light, if your answer to the question falls somewhere in the range of “Well universal access is an ideal, but one that can’t be achieved because of X, Y, or Z” then we have something to talk about. On the other hand if your answer is in the range of “Well no, that is not in fact a social good to be provided socially” then we are just talking at cross purposes. And supporters of ACA who turn around and ask “What then is YOUR solution?” are asking the totally wrong question. Because if there is no problem there is no needed solution. And operatively (if not always rhetorically) that is where many opponents actually seem to fall. Somewhere between “It is not a problem” and “It’s not my problem”.
Well alrighty then. At least that is an honest answer.
Bruce.
1. No, not in the manner you describe as ER only have to stabilize you and not cure you. Affordable is not through the ER.
2. No, not in the manner you describe it. a family of 4 would have to be in the top quintile to be able to pay for nonsubsidized insurancae.
3. No, not in the manner you propose. Spare us from the Jesus pushers.
4. No, not in the manner you suggest as it is best done at a higher level and the Gov can provide it in a efficient manner unhindered.
5. No, the market has not provided solutions either and two decades later from Hillarycare we finally have the PPACA. Tort reform, crossing state lines, and state managed bureacracies are excuses to do nothing and are minor to the issue of no insurance.
6. No, using doctor availability as an excuse is nonsensical to the main issue of limited healthcare.
7. Not having healthcare is a hidden cost which impacts productivity.
I think it may be an even more emphatic No! These are the same people that believe to provide it would encourage laziness, that charity reinforces bad behavior, that the whip is more powerful than the carrot, and if people aren’t dying at the hospital door, they will lose their motivation to succeed. In their mind, the benevolent, charitable response is to give people the example of dying in the street and letting starvation reduce the surplus population. A mixture of social Darwinism and eugenics at the core.
Bruce
at the risk of convincing Sammy that I really AM a conservative..
if the cost of providing health care for everyone reaches the point where YOU (and I) are paying for “them” more than we think we can “afford”, we will start finding reasons why “we” shouldn’t pay.
This has already shown up in the form of comments from true liberals right here on AB: “i’m not rich, I only make a 100k. Don’t raise MY taxes. Tax the rich.”
And while you may be a saint, or have lived a very protected life, I have known people whose demands on my charity exceeded my (moral) strength.
Now, I don’t think we are at that point yet. And I am pretty sure we could all pay a “fair” insurance (expected cost of medical care over a lifetime… including infancy and old age), IF we (through government) have a chance to control those costs… including, perhaps, a way to weed out the hypochondriacs, and the hypochondriac doctors, and the huge (i am told) costs of paying to prolong the “life” of someone who has no quality of life left a few more weeks. (Death panels anyone?)
I don’t claim to have answers for all of this, but I am not sure any of us can claim the moral high ground.
Run75441
it was probably the “jesus pushers” who created the whole idea of “the good samaritan.”
they may not have been thinking of the same Jesus as Pat Roberts.
Or maybe they only meant it in the way that Jefferson meant “all men are created equal.” But they certainly started something. And pushed it for a couple of thousand years… though maybe not so much since the “Enlightenment.”
Dale you might want to read up on medieval versions of charity as they actually operated before slamming the post Enlightenment. Because the history of even the most charitable of religious orders as founded shows that within a generation the leadership and much of the rank and file and fallen into what we would now call rent extraction in the interest of personal consumption. That is both the Dominicans and Franciscans rapidly became the wealthiest of orders and spent more time extracting deathbed donations from wealthy patrons than actually serving the poor. And of course even more so in the case of the Knights Hospitilars and Knights Templars of a couple centuries before.
Christian charity has a very mixed actual record before say the 19th century and that mainly in service to urban areas. For example it is worth noting that Mother Theresa had to form her Order from scratch because no other Church order or operation were actually serving the population she would.
To take an example closer to home, the official Anglican Church of Ireland extracted huge sums in mandatory tithes from a largely Catholic population and used it to endow rich livings and institutions for absentee Englishmen while doing less than shit for their ostensible parishioners. It was a huge extortion racket. Not that the Irish Catholic Church had a much better record of service delivery as demonstrated by recent revelations.
So I would like to see some examples of the centuries in which the Jeebus people actually delivered anything close to the lessons of the Sermon on the Mount.
Bruce
all “institutions” become corrupt. but the idea of the Good Samaritan is a Christian idea. And many thousand, millions?, of people have spent their lives doing good works in the name of Christianity.
I am quite sure so have Jews and Moslems and Buddhists.
But I have heard there are even mean people in the Democratic Party. At high levels. I even suspect I could find stories about corruption and extortion in governments run by Democrats. or even Atheists.
I have even known people who worship “The Enlightenment” to be less charitable than they imagine themselves.
You do yourself absolutely no credit with “Jeebus.”
Dale I will grant you 1000s and that easily. But to get to millions you would have to stretch the definition of ‘good works’ and ‘devoting their lives’ pretty far. And even some of those 1000s may have been driven by more basic altruism than whatever chatacism they happened to have drilled into them.
A religious do-gooder, even one that attributes his do-goodism to religion, might well have become a do-gooder even if raised in a totally different tradition. Which suggests we do some degree of discount of the particular tradition as motivating the behavior.
We don’t want to fall into the Texas trap where everything good that happens in Texas is naturally because it is Texans doing them. I thinnk in some book or other there is an admonition: “Pride goeth before a Fall”. And the kind of self-pride that comes with congratulating yourself you are from a ‘Judeo-Christian’ tradition and so ipso facto have deserved reason for pride is not at all exempt.
For example most people reject with contempt the idea that ‘Hitler was a Vegetarian’ or ‘Hitler loved dogs’ has anything to do with either his crimes or serve as some sort of mitigation. Evil is as evil does. On the days you aren’t praying. And the same goes for Good in my view.
“Good Christians do good things. Good people do good things. Therefore good things are done because done by Christians.”
Well no, you could drive a Peterbilt through that logical gap. Once again a fatal confusion of correlation with causation.
Bruce
heck, I think I even mentioned that the same could be said for Jews Moslems and Buddhists. I did not mean the list to be exhaustive.
I think I will stand by the “millions.” Just extrapolating from my own experience with a very small sample of the population, it would have to be millions.
I would like to think people would have discovered “altruism” without “religion” ( a nice young man I met once was very anxious that i understand that “Jesus” was not about “religion.” Reading the New Testament, I understood his point.)
But along with “correlation/causation” fallacies, there are other fallacies that people commit in their zeal to defend their own way of organizing Everything. Straw man is the best I can think of in the moment to describe your argument with me.
btw I was only twitting you about “The Enlightenment” because it’s something you repeat from time to time with the same kind of reverence that some people have for their “religion.”
It is not the sort of thing that ought to lead to war.
The problem of relying on the traditional charity model to serve the poor and sick has a side seldom spelled out.
To provide such charity, the charitable person must a) have more resources than they need to survive, and b) be willing to provide from those resources to the person in need.
At present, an increasing percentage of the US population either does not have extra resources, or has a little to spare but are so close to the edge of their own fiscal cliff that providing help merely serves to push their family into the same spot the needy person is in. As the proportion of desperately needy people increases, those who are truly charitable and compassionate are drawn into the same fix. This is one example of “pancaking,” where all the lowest rungs of the social ladder are compacted to the same low level.
Those charitable, compassionate people cannot even devote themselves to helping others on a full time, efficient basis, but still have to work to support themselves, their kin, and the “economy,” I.e. those business owners and financial people who draw their incomes from the layers of people below them in the social structure.
As the pancaked layers of the population become more compressed and needy, with fewer extra resources to aid each other, two things happen — it becomes evident that only a small slice of the population is wealthy enough to provide meaningful help, but also the task becomes so huge that even the ones who want to help may be daunted — or impoverished by the effort and thus become pancaked themselves
Only effective taxation, wage controls and other strategies of distribution can solve this pancaking problem. To pretend otherwise is doomed to fail.
Noni
I think republicans and specially tea partiers have already answered your question,
“Should every American have access to affordable health care?”
With an emphatic NO!
They would rather not spend the money and let you die.
Noni
I would hope that it was clear that you were saying the same thing I was trying to say.
B
But the answer, I think, is not to run around claiming our moral superiority because we are willing to tax someone else to pay for the poor.
Or because we “know” that those who fear government solutions are immoral idiots.
Or because we are enlightened and know that “jeebus pushers” are all con men seducing the poor into voting “against their own interests”.
I believe there are answers, government answers, but we won’t get to them by making enemies out of the people who do in fact have the same interests as we do…
if our interests are not actually “kill the rich” and “destroy religion.”
Not all of the rich are criminal predators. Not all “religious” are con men.
Bruce,
Let me go through these one by one and give a different view:
1. Yes, it is true that anyone who walks into an emergency room is treated whether they can pay or not. And they will send you to some other facility for longer-term care if you need it, again at no cost if you are destitute. Now, the care you receive may be minimal (don’t expect to be treated as if you had a concierge doctor and a private room with flowers) but you will be treated.
2. Yes, it is true that if you work you probably have the resources to pay for some minimal level of care. Of course, what you can afford may not be sufficient to your needs and there are many people who are unable to work and are therefore dependent on others for any care they receive.
3. Yes, private charity has a role, and in this country a large role. Nothing wrong with that. It is helpful but cannot solve the problem of access to health care in America.
4. No, government has a role. There is nothing wrong with the government having a role when people cannot pay out of their own pocket. In these cases they need extra support, and government can and should be helpful to these people
5. Yes and no. The market would certainly work better without these distortions but removing them will not come close to solving the problem of adequate access by all.
6. Yes, true. Health care is a scarce good. There is never enough to satisfy everyone’s wants. But this country is rich enough to provide each and every citizen with some decent level of care. The question is how to do this, not whether it should be done.
7. Yes, health care is an economic good and like every economic good must be rationed, by income and price, by command allocation, or by tradition or custom. The implication above is one must chose one and only one of these alternatives in some extreme and pure sense. That is nonsense. One can design a system that draws on each method.
The tough questions are how much redistribution, to whom should the redistribution be directed, and how do we balance the benefits of redistribution to the recipient against the costs to the payer. Should society strive to give everyone exactly the same level and quality of care, or are differentials in care acceptable? What is the appropriate difference between those that pay for themselves and those that do not?
If society decides to provide greater access by some to what it regards as essential human needs (food, clothing, shelter, health care) who should pay the bill for this effort, why should they pay the bill, what is the acceptable burden they should be asked to carry, and what is the responsibility of those who are able-bodied to contribute to their own support?
Yes, charities are human institutions that fail to perform the way we idealize them to act. But it is a joke to say government can perform the role of transferring resources in a fair and equitable way. The very differential treatment of the political class and other Americans by Obamacare is reflective of this.
I am a member of a Tea Party. The main concerns of Tea Parties are reductions in government spending, the budget deficit, and the national debt. Its main focus is on local issues, especially corruption and cronyism in local government finances. To my knowledge it has not objected to a role for government in the delivery of health care although exactly what that role should be and its impact on fiscal questions is certainly a matter of concern and debate. Given the extensive public sector fiscal imbalances the Tea Party raises questions about how much redistribution in the area of health care the country can support. Nothing wrong with that question.
I close by mentioning that Obamacare was passed in an entirely partisan way with no thought given to the details of how it would work. Because it was poorly designed and imposed on the people bearing its burdens without their consent it is now collapsing and will be either be repealed or substantially revised. Add to this the problem of its support for abortion and one should not be surprised at the degree of turmoil it has engendered in the body politic.
If I may, let me make a comment on this post:
1. Yes, it is true that anyone who walks into an emergency room is treated whether they can pay or not. And they will send you to some other facility for longer-term care if you need it, again at no cost if you are destitute. Now, the care you receive may be minimal (don’t expect to be treated as if you had a concierge doctor and a private room with flowers) but you will be treated.
2. Yes, it is true that if you work you probably have the resources to pay for some minimal level of care. Of course, what you can afford may not be sufficient to your needs, and there are many people who are unable to work and are therefore dependent on others for any care they receive. They may need help to gain access to health care.
3. Yes, private charity has a role, and in this country a large role. Nothing wrong with that. It is helpful but cannot solve the problem of access by everyone to health care.
4. Yes, government has a role. There is nothing wrong with the government having a role when people cannot pay out of their own pocket. In these cases they need extra support, and government can and should be helpful to these people.
5. Yes and no. The market would certainly work better without these distortions but removing them will not come close to solving the problem of adequate access by all.
6. Yes, true. Health care is a scarce good. There is never enough to satisfy everyone’s wants. But this country is rich enough to provide each and every citizen with some decent level of care. The question is how to do this, not whether it should be done.
7. Yes, health care is an economic good and like every economic good must be rationed, by income and price, by command allocation, or by tradition or custom. The implication above is one must chose one and only one of these alternatives in some extreme and pure sense. That is nonsense. One can design a system that draws on each method.
The tough questions avoided here are how much redistribution, to whom should the redistribution be directed, and how do we balance the benefits of redistribution to the recipient against the costs to the provider. Should society strive to give everyone exactly the same level and quality of care, or are differentials in care acceptable? What is the appropriate difference between those that pay for themselves and those that do not?
If society decides to provide greater access by some at the expense of others to what it regards as essential human needs (food, clothing, shelter, health care) who should pay the bill for this effort, why should they pay the bill, what is the acceptable burden they should be asked to carry, and what is the responsibility of those who are able-bodied to contribute to their own support but do not?
Yes, charities are human institutions that fail to perform the way we idealize them to act. But it is a joke to assert government can perform the role of transferring resources in a fair and equitable way. The very differential treatment of the political class and other Americans by Obamacare is reflective of this.
I am a member of a Tea Party. The main concerns of Tea Parties are reductions in government spending, the budget deficit, and the national debt. Its main focus is on local issues, especially corruption and cronyism in local government finances. To my knowledge it has not objected to a role for government in the delivery of health care although exactly what that role should be and its impact on fiscal questions is certainly a matter of concern and debate. Given the extensive public sector fiscal imbalances the Tea Party raises questions about how much redistribution in the area of health care the country can support. Nothing wrong with that question.
I close by mentioning that Obamacare was passed in an entirely partisan way with no thought given to the details of how it would work. Because it was poorly designed and imposed on the people bearing its burdens without their gaining their consent it is now collapsing and will be either be repealed or continued to be substantially revised. Add to this the problem of its support for abortion and one should not be surprised at the degree of turmoil it has engendered in the body politic.
Douglas O Walker
I start out thinking you sound reasonable. More reasonable that the simple minded “not my problem” characterization by… actually… my friend.
But even the devil can sound reasonable. So I have to wonder what all this reason comes down to.
I have already made myself hated by some of my friends because I would not use the government to pay for some “health care” not because it is immoral, but because the expense to the actual person is trivial and really ought to be their private business. And I do hate to see people with their hands out… especially the ones who can afford to pay for their own needs.
On the other hand, it is a trivial moral problem as well… a “not your business” [“what is that to thee? follow thou Me.”] kind of problem. As long as you are paying taxes for bombing people, you have not even the beginning of a “moral right” to worry about “health care” related to someone else’s sexual activity, and the decisions they make about the consequences of that. I guess as a kind of “Jeebus pusher” I figure God can work that out with the persons concerned without help from you and me, who are not concerned. Meanwhile if you go to the hospital with a heart attack or lung cancer or diabetes, do I get to say… I don’t want (my insurance) to pay for your health care when you brought it all on yourself by long known immoral choices?
Nah, to a great extent we are in this together. Our brother’s keepers, whether or not we give a damn about religion, it is the only way humans can hope to survive, whether the danger is from the local lion, famine, enemy nations, or the local thugs. If we are in this together, we are going to have to pay for some of each other’s “needs” whether we agree with them or not. Politics has been the traditional American way of deciding which of them and how much. Maybe that is still what is going on here, but it looks to me like the thugs have got control of politics, and the general human inability to resist them… either mentally in the first place or physically when it comes to the coercive power of governments… or the local big business… well, it makes me unwilling to be fooled by the propaganda, however reasonable, of the tea partiers and the insane republicans and their democratic enablers.
Quick driveby comment — yes, Coberly, we generally do agree, no argument from me.
@Dennis Walker, regarding your point #1, yes, you can get the care you need if you are destitute, and if you aren’t already destitute, the cost of the care will helpfully get you there. /sardonic grin
This will happen even if you are older, on Medicare. In her last three months of life, mom burned through $26,000 in order to be poor enough to qualify for care home support via Extended Care, which she got to enjoy for about five weeks.
And the destitution isn’t selfishly reserved for the actual sick people, oh no. After caring for her for five months, losing my own part time job, and piling up unpaid bills, I have just settled all my own debts by selling off my little house.
I guess I should be happy that I had a house to sell off, and that I was able to find a rental that let me keep my cat and little dog. Lucky duckie.
And most importantly on Walker’s point 1. You cannot get meaningful preventive or continuing care for a not currently critical condition in an Emergency Room. That is you can be chronically ill with diabetes or a heart condition or even early onset cancer and be given at best palliative care or a temporary prescription and a referral to some community free clinic.
That is not health care as most people would define it. And as Noni points out by implication, the hospital has to serve you and in most cases has methods to be reimbursed for non-compensated care and so may not come after you with debt collectors (and if like Catholic order hospitals like Sisters of Providence probably won’t) that is not true for the ambulance that may have delivered you there or often for one or more of the physicians who treated you. That is unless you don’t mind having your credit ruined for years and/or harassing phone calls from debt collectors or debt buyers hoping to collect on that bad debt that care is not free to you. Of course it would be if you were poor enough to be Medicaid eligible, but God forbid you actually have a job that just allows you to scrape up rent and a car payment. Because you will never be able to pass a credit check from that next landlord or car dealer. Because nothing is as free as Tea Party theories assume.
And in fairness Walker concedes on each of points 2-5 and doesn’t really attempt to show that some combination of them with 1 would do the trick.
On the other hand his last paragraph is pure rot as anyone who followed the actual legislative process, which was covered here at AB, in large part by me in great detail in real time would know.
An early and better version of ACA by passed out of the three House Committees with jurisdiction and by Senate HELP in July after a full set of Committee hearings, votes and particularly in House Commerce compromises with at least Blue Dog Democrats. That is all under regular order. This left it to the last Senate Committee with jurisdiction which was Senate Finance. The Conservadem Chairman of that Committee unilaterally decided to bypass Regular Order and go right to negotiations with Republicans in the Gang of Seven Turned Six. That is originally there were actually Four Republicans in the Gang until Hatch dropped out which left three Republicans in Snowe, Enzi, and I think Grassley to balance out Conservadems Baucus, Conrad and back bencher Bingaman. Notably no progressives were allowed a seat including the Chair of Senate Finance’s Sub-Committee on Health Rockefeller.
Though it is true that the Senate Finance version never did pass out of Committee the compromises made to accommodate the Gang of Six between late July and November served to substantially water down the original design of the House Tri-Committee (Dingell) and very similar Senate HELP (Dodd Kennedy) to near unrecognizability as first the Strong and then Weak Public Options were bargained away to gain Republican support. Which in the end never came but still left an PPACA looking a whole lot more like the Heritage designed Romneycare than anything that would have been rammed through by Democrats working in the dark of night-overnight as the Tea Party fantasy would have it.
This law was crafted with substantial Republican input. It is just that after they got a great deal of their wish list attended to they refused to actually put their fingerprints on the final deal. Making every effort Baucus made totally counterproductive, instead we could have had a real Democratic bill on a real Democratic party line with an August signing ceremony on the White House West Lawn with a still alive Kennedy looking on EXCEPT that Baucus with the implicit support of Reid and Obama was allowed to enter into end stage negotiations with Republicans.
In any case the idea that a bill that took ten months to pass and was the subject of daily news coverage was simply passed without meaningful input or notice is just not so. Period.