Apples, oranges, and the mandatory purchase of produce

>> Thursday, September 10, 2009

I have to admit that I didn't actually listen to the President's speech last night--I was too busy playing a videogame with a buddy. (Bad citizen! No cookie for you!) I caught up with Joe Wilson's batshit-crazy outburst on the floor via Twitter, of all things via Kate, and who says the internet isolates people? So I caught up on the speech today when I had time, and there was one point in the speech that MWT highlighted at Blog Of Siram that really bugged the hell out of me (and MWT, though I'm not sure whether or not it was for the same reasons); specifically, this:

And that's why under my plan, individuals will be required to carry basic health insurance--just as most states require you to carry auto insurance. Likewise--likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers. There will be a hardship waiver for those individuals who still can't afford coverage, and 95 percent of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements. But we can't have large businesses and individuals who can afford coverage game the system by avoiding responsibility to themselves or their employees. Improving our health care system only works if everybody does their part. [Emph. added]

No, no, no. Oh good grief, no. That's just awful.

It's clever that the President spins this with a superficially appealing but ultimately inapposite analogy: "most states require you to carry auto insurance." That statement, unlike the President's later statement that Representative Wilson took issue with, is a lie. No state requires you to carry auto insurance. Many or most states do, however, require you to carry auto insurance if you are a licensed driver and/or operate a motor vehicle on public streets or highways.

I have a good friend who doesn't have a license, has never bothered to get one, and doesn't drive (unlike some of my clients, unfortunately, who have been caught driving in similar circumstances--but I digress). There's no law in any state in the country that requires her to get auto insurance, nor is there reason for her to have any. If at some point she decides to go down to the DMV to get a driver's license, then she would have to bring proof of insurance with her, and she would have to maintain insurance while she continued to be a driver. But until that happens?

Furthermore, use of a motor vehicle on the public streets and highways is, unlike living, a privilege and not a right. The state can lawfully decline you the privilege to use the public streets and roads if, for instance, you abuse the privilege by driving drunkenly or recklessly. On the other hand, as a general rule the state can't deny you the right to operate a motor vehicle on your own private property in whatever circumstances you prefer--you are perfectly welcome to build a private track on your own land upon which you drunkenly race around and around in unsafe and emissions-violating wheeled-death-machines sans license and insurance. (I say "as a general rule" because, of course, you might run into other issues--nuisance ordinances, zoning regs, environmental regs, other criminal statutes involving public safety, etc.--but you're not violating traffic laws.)

Health insurance is nothing like auto insurance, in other words. It sounds appealing as an analogy because most Americans drive and even the ones who do so illegally at least generally have a sense that they're supposed to have car insurance. Indeed, there are inevitably a fair number of drivers on any state highway at a given time who have insurance but no valid license. But anyone can elect to turn in their license or to never get one, or to not drive or not own a vehicle. Indeed, in some parts of the country not owning a vehicle and not possessing a license and not bothering with car insurance might well be a prudent, responsible, practical, economical, rational choice. Why spend several hundred dollars a year on insurance, maintenance, gasoline, parking, etc. if one lives in an urban area with reliable public transit? You're not only saving money, you're hugging the planet every day you walk to the bus stop, you big green lug, you.

There's no bar low enough to justify forcing people to buy health insurance, at least not in those raw and blatant terms. It's just morally wrong. The President is right, however, that people who elect to not pay for health insurance inevitably burden the healthcare system. But the solution isn't to try to force these folks to purchase healthcare. (And how, by the way, will you enforce the law if they don't? Send them to jail?) The solution is the other way of forcing people to buy insurance, the politically unpopular one (in this country) that has been embraced by the rest of the industrialized world: provide insurance as a matter of course to all citizens and divide the costs in an equitable manner amongst all taxpayers (preferably in a gradated system that takes into account variations in income)--that's right, nationalized healthcare.

A public option is a political compromise that many liberals are reluctantly advocating or embracing as a better-than-nothing approach, but it's not a solution to this problem. (And, by the way, this is why it's asinine for some to say that liberals will need to compromise and not have their hearts set on a public option--dudes and dudettes, the public option is us meeting you halfway, if that's not good enough, well fuck you, already.) The public option is a solution to turning public healthcare into a massive redistribution of money to the insurance companies--"mandatory" insurance with premiums payable to private companies is an asinine idea, an undeserved windfall to the shareholders of those corporations. The public option also, as the President says, helps keep the insurance companies honest by offering competition, particularly in regions where five or fewer insurance companies compete/collude to control the insurance market. (And how is it that anybody is talking about doing away with a public option and forcing consumers to throw money at companies in these regions, and nobody is talking about Sherman Antitrust Act investigations in these same parts of the country? Hm, yeah, I wonder how that happens to be the case?)

I have to admit a split mind on this: I'm not a supporter of the public option, tho' I'm halfway to taking it over no reform whatsoever. At least, I am until I think about that sentence in the President's speech, whereupon I have to consider that a broken, fatal healthcare system that bankrupts some and kills others is perhaps better than one in which individuals are forced to engage in a public "bailout" of an already insanely-profitable industry on an annual basis for the remainder of their lives. And even with a public option: is it reasonable to force people to buy coverage regardless of whether they're able to pay? My preference is absolutely in favor of treating health like public safety, interstate transportation, public schooling and national defense--areas which are already socialized and paid for through taxes (and in which there are private supplemental options--I have no objection to an individual buying supplemental coverage on top of a national healthcare plan any more than I begrudge a person the right to install a home security system on top of whatever services are provided by local police and fire departments).


Leanright,  Thursday, September 10, 2009 at 2:45:00 PM EDT  

I actually like this post. Operating a motorized vehicle IS a privilege, and abuse of that privilege may cause you to lose your license.

So, there is really no parrallel between the two types of insurance. In California, we are required to carry liability insurance in case we damage the property of ANOTHER driver. To compare health to auto insurance would be like saying I buy insurance in case somebody ELSE gets sick/injured. In a sense, we already do, but if we are to pay for the expenses of someone who continually abuses their OWN health, through smoking/drinking/overeating/STD's, etc...will we be able to revoke their Health Insurance Privilege?

Just curious.

WendyB_09 Thursday, September 10, 2009 at 5:55:00 PM EDT  

Well, in most states if you have a driver's license but do not own a vehicle, you are not required to have insurance. Nor do you have to produce proof of insurance to get your license.

Now, if you have a vehicle, you are required to have both a valid driver's license for your state AND your state's minimum required amount of liability insurance. Most states will not allow you to register/tag a vehicle without them.

Now, how they handle people with no job, no income, and get them the mandatory minimum health coverage, I'll be interested to see. Because at this momoent in time, that includes me and I'd be very grateful for it. What I didn't like was that according to the President, it will take a minimum of 4 years to ramp up that coverage.

Well, I haven't had insurance or a regular primary care provider for well over 8 years now, I suppose I can wait some more. Good thing I won't be able to get refused for pre-existing conditions, at this point anything I could be diagnosed with would be pre-existing.

MWT Sunday, September 13, 2009 at 2:46:00 AM EDT  

Yeah. I have a friend who responded to the implementation of mandatory auto insurance by no longer driving. He was horrified when Hillary Clinton first made that comparison to auto insurance back during the primaries (and I wish I could find the post where he talked about it, but his blog has basically no organization whatsoever T.T) - because, what do people who can't afford it do, stop living?

So as I said, the exemption bar had better be pretty damn high.

I'm in favor of having a nationalized health care system too - and either no longer allowing health insurance companies to be for-profit, or setting things up in such a way that health insurance companies go back to providing health insurance, not health care. However: I also think that the plan as outlined is more realistic about taking into account all sides, and therefore more likely to pass. I'd personally like to see it as a good Step One toward nationalized health care (while everyone on the right no doubt fears same). Thus, I signed the letter (and think everyone else should too).

MWT Sunday, September 13, 2009 at 2:51:00 AM EDT  

Also, Leanright:

How about we just not judge anyone on how they got to their health conditions at all? Because, really, it's none of our business.

Random Michelle K Monday, September 14, 2009 at 11:40:00 AM EDT  

MWT, you forgot that Leanright lives by the addage, "fuck you, I've got mine."


Leanright,  Monday, September 14, 2009 at 11:45:00 AM EDT  

It's none of our business? Really? How about when I buy a home, my credit is "None of their business". If we are paying for it, it BECOMES our business. I need to shed a few pounds, and I don't expect the taxpayers to be responsible for anything that goes along with that. The government wants MY money, and you tell me that it's none of MY business? All due respect, that is the most irresponsible statement ever.

Leanright,  Monday, September 14, 2009 at 11:46:00 AM EDT  

And Michelle, when did I ever say "Fuck you, I've got mine"? And if I had, is that any worse than the liberal addage "Fuck you, I'll get yours"?

Eric Monday, September 14, 2009 at 12:45:00 PM EDT  

Dave, Michelle was summarizing a comment you made in this thread, in which you said, lessee:

I'm quite please [sic] with the health care my family and I have...I really don't want it fucked-up by the government.

...which could certainly be translated as, "I've got mine, screw everyone else." I'm reasonably pleased with my own BC/BS coverage, but that has nothing to do with my concerns about people who aren't covered, my concerns with the ways in which the current system is broken, or (for that matter) my basic sense of social justice and how things like healthcare ought to work in principle.

Quite a few of the regulars here, I think, "have theirs" and are still concerned with what others lack as a matter of course.

The thing is, Dave, you probably are generous in your way and thoughtful of others in your way. The problem is that you probably didn't even think that your statement carried a thoughtless nuance to it. This is the kind of lack of empathy Joe Conason pointed out in Salon last week: there seems to be, let's call it a "frequent" or "recurring" pattern among conservatives of not thinking of others until it's rubbed in their faces that they're not, usually by the universe visiting some unfortunate incident upon themselves or their loved ones.

As for revoking a "Health Insurance Privilege," there are several points.

First, most nationalized healthcare proponents (regardless of whether they prefer an outright socialized system or less-drastic reforms) see basic healthcare as a right. The difference between living as a right and driving as a privilege was indeed the whole point of pointing out the weakness of President Obama's (and before that, then-Senator Hillary Clinton's) comparison. The opt-out for driving is undeniably less-drastic than the opt-out for living.

Secondly, even assuming that healthcare is treated as a privilege and not a right, there are practical problems with revoking the privilege. One, that one of the major reasons for public insurance options is the efficiency and savings that result from things like (a) default participation, (b) economies of scale and (c) no recission; a revocation process basically defeats this by making any public option exactly the same as the private coverage offered now. Two, revocation of a government service potentially implicates Fifth Amendment Due Process rights in a way that private coverage recissions do not; this also impacts efficiency, since it means the creation of a governmental appeals process to handle recission/revocation. Three, part of the point of covering everybody is that preventive care and early care means that health problems are addressed when they're cheaper to cover; under the present system, you (and/or your insurer) already pay increased costs for the underinsured people who wait until they have to go to the emergency room to deal with what ought to be minor routine ailments.


Eric Monday, September 14, 2009 at 12:45:00 PM EDT  


Third, again assuming a privilege and not a right, revocation through alleged abuses potentially creates privacy issues. As one can opt out of auto insurance (and, for that matter, invasions of privacy such as breathalyzer tests and ID checkpoints) by not driving, one can opt out of a credit check when applying for a mortgage by not applying for the mortgage. Government works by different rules, Dave: you have no rights whatsoever in relation to private actors such as banks, only with regard to government (yes, there are certain "rights" that the government has created as an intermediary between you and the bank, operating in a regulatory/licensing capacity--that only confirms the actual point, not rebuts it).

Fourth, assuming privilege, etc., your comments about revocation implicate a common "blame the victim" stance that may or may not be warranted. While there certainly are victims of alcoholism or STDs or whatever who bear the larger share of responsibility for their condition and have made poor choices, there are also those who have stumbled into their plight (or, e.g. in the case of some STD patients, have had it inflicted upon them through no fault of their own--consider, for instance, the devoted and faithful spouse who is infected by a partner who has "stepped out" in the past, or one who has contracted an "STD" through a vector such as blood transfusion), with a wide range of shades between (e.g. one who enters SA addiction as a result of painkillers prescribed for a legitimate condition). Rather than investigating every person to see if their conduct is above reproach, it might be more productive to simply extend coverage to all.

Leanright,  Monday, September 14, 2009 at 1:03:00 PM EDT  

My comment regarding "Revoking Health Insurance Privileges" was a tongue-in-cheek comment. I don't really believe that to be the stance government should take. I was pointing to the fact that if a politician is going to compare the two, then it should be on an equal basis. You know, comparing apples to apples.

What I do NOT believe it the mindset of BLAMING the "have's" by the "have-not's". I believe the goverment can do OTHER things to alleviate the healthcare crisis in America. Fixing COBRA for example...Reducing the out of pocket cost for insurance for those whom have lost their jobs for more than 18 months, etc...Government funded clincis in underprivileged communities throughout the nation, perhaps policies to cover catastrophic illness or injury, etc...These are merely ideas. I am self employed, so I provide my own insurance at $600 per month for me and my family. But, Employer tax breaks for providing insurance are a great option for those who recieve a W2. Issue is, when economic conditions turn, and jobs are lost, insurance goes along with that. If the nation has 30 million uninsured, (and what I've read, 40% of those by CHOICE), then I believe the government would be better suited to provide a solution for those who are not insured by way of job loss, or an uninsurable condition. A plan for the 300+ million of us is too big for our goverment to manage, based upon their "success" (lol) of managing Social Security and Medicare.

MWT Wednesday, September 16, 2009 at 2:59:00 AM EDT  


Do you want firefighters to stop and check that fires in people's houses were not their own fault before they put them out?

Eric Wednesday, September 16, 2009 at 9:10:00 AM EDT  

That's a great idea to cut government expenses, MWT! And police can stop responding to 911 calls that are the result of somebody passing through a bad neighborhood or somebody leaving their doors unlocked!

What'cha think, Dave? Cuts down on that government spending, eh?

Random Michelle K Wednesday, September 16, 2009 at 9:48:00 AM EDT  

$600 a month is half my office mate's monthly salary.

That is not an acceptable option.

Leanright,  Wednesday, September 16, 2009 at 12:53:00 PM EDT  

I often get blasted for not staying on topic, so thanks for the input on my last post. Geez...
The $600 per month covers 4 people...If I heard correctly, the FINE in the Bachus bill is $3800 for not signing on to the goverment plan? Perhaps I'm wrong. That's over $300 per month for one person.

Why is tort reform never part of the discussion? We can't really have an effective discussion about insurance reform if tort reform isn't part of the conversation.

Eric Wednesday, September 16, 2009 at 1:56:00 PM EDT  

Tort reform is a red herring. Texas, if I recall correctly, passed a major tort reform bill a few years back and has seen no diminshment of medical costs (someone please correct me if I'm wrong; I don't have time to fact-check myself right now and may be making an error).

The tort-reform claim is generally that doctors over-treat or under-treat (it varies depending on who's making the claim) because they're afraid of being sued. I'm not sure there's any good hard evidence to support that. More fundamentally, the notion of tort-reform is arguably wrong-headed to start with, since it presumes a fundamental mistrust of the ability of juries to hear evidence in civil cases (a case of "everyone in my neighborhood's an idiot except me") and of judges to rein in juries that do get out-of-control. One also sees a frequent and distressing tendency among some tort-reform advocates (not accusing you of this, Dave, just riffing on the TV talking heads) to show some ignorance (perhaps willful) of how the law works and to cherry-pick cases and/or to misstate the facts of cases to make their point. Among the problems with cherry-picking when discussing tort reform is the fact that while their may be cases of uncontrolled and unwarranted jury awards, there are certainly situations in which gross medical negligence has caused substantial and severe injuries or warrants punitive damages to deter similar misconduct in the future (I always find myself wondering if tort-reformers would be happy with a damages cap if one of their family member lost a limb or suffered irreversible brain damage or underwent some other horror--perhaps lifelong--as a result of an avoidable error or perhaps even a wanton decision by a medical supply company or healthcare provider to cut a corner to save a few bucks on the "off chance" that someone could be hurt).

It's a fair question, and on-topic, but I think it's ultimately a non-starter. If tort reform isn't mentioned by some of us, it's because we don't consider it to be a part of the problem.

As for the Baucus committee's proposed fine, fuck them. It's unbelievable that they're trying to pull that. On a related note, I'm pleased--and maybe Michelle will be pleased--that Jay Rockefeller has said he won't sign onto anything that doesn't include a public option.

Leanright,  Wednesday, September 16, 2009 at 2:30:00 PM EDT  

My Brother in Law is an ER Physician at St. Jude Hospital in Fullerton, CA. He directed me to this article.

Dr. Stuart Weinstein who is with the American Academy of Orthopaedic Surgeons who explained this problem in his article, “The Cost of Defensive Medicine,” Dr. Weinstein writes:

The medical liability crisis has had many unintended consequences, most notably a decrease in access to care in a growing number of states and an increase in healthcare costs.

Access is affected as physicians move their practices to states with lower liability rates and change their practice patterns to reduce or eliminate high-risk services. When one considers that half of all neurosurgeons—as well as one third of all orthopaedic surgeons, one third of all emergency physicians, and one third of all trauma surgeons—are sued each year, is it any wonder that 70 percent of emergency departments are at risk because they lack available on-call specialist coverage?

…Many now adopt an attitude that “views every patient as a potential lawsuit.”

This same attitude is also prevalent among residents. In a recent study of residents across specialties, 81 percent of responding residents said that they view every patient as a potential lawsuit. These protective, fear-of-lawsuit attitudes result in physicians adopting behaviors that increase healthcare costs through the practice of defensive medicine.

…Defensive medicine is defined as providing medical services that are not expected to benefit the patient but that are undertaken to minimize the risk of a subsequent lawsuit. Diagnostic defensive medicine practices have a much greater impact on costs than do therapeutic defensive practices.

…If the Kessler and McClellan estimates were applied to total U.S. healthcare spending in 2005, the defensive medicine costs would total between $100 billion and $178 billion per year. Add to this the cost of defending malpractice cases, paying compensation, and covering additional administrative costs (a total of $29.4 billion). Thus, the average American family pays an additional $1,700 to $2,000 per year in healthcare costs simply to cover the costs of defensive medicine.

Eric Wednesday, September 16, 2009 at 5:34:00 PM EDT  

What appears to be the full article by Dr. Weinstein can actually be read here. Although Dr. Weinstein believes "defensive medicine" occurs (and in all fairness, it might), he actually concedes the point about "hard evidence" in my previous comment:

Defensive medicine is defined as providing medical services that are not expected to benefit the patient but that are undertaken to minimize the risk of a subsequent lawsuit. Diagnostic defensive medicine practices have a much greater impact on costs than do therapeutic defensive practices. The quality of the literature on the true costs of defensive medicine and its impact on healthcare costs is poor; few good studies exist, and cost estimates vary widely. (emphasis added)

I still haven't had the chance to verify my Texas comment, but, again, my understanding is that at least one state has attempted tort reform and failed to control medical costs by doing so. In the abstract, it's not actually clear to me that tort reform would even have an impact--short of barring the courthouse doors to all lawsuits, capping judgements (the remedy most reformers seek) doesn't mean there will be fewer meritless suits, it only means that there will be smaller judgements for all suits in which a jury finds for the plaintiff, regardless of merit.

And assuming that defensive medicine does occur, it may not be a rational reaction: increasing the number of procedures may reduce the chances of "missing" something, but additional unnecessary procedures may create new opportunities for mistakes, which may offset any net safety gain for the physician.

Finally, a more effective solution might well be to nationalize healthcare provision: while state-employed doctors might earn less, they would be entiteled to qualified immunity from suit under the Eleventh Amendment except in cases of gross negligence. Private doctors, like private-sector lawyers, could continue to charge patients whatever was necessary to offset their malpractice insurance premiums. That solution, of course, seems to be even farther off the table than tort reform for some reason.

(And Dave, thank you for a reasonable and sourced response.)

Leanright,  Friday, September 18, 2009 at 1:55:00 AM EDT  

And Michelle, admit it...YOU LOVE ME! That's okay though, I'm rather fond of you!

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