For those on the left side of the political spectrum, single-payer health care — a system in which the government, rather than private insurers, pays for all health care costs — is one of the most popular policy proposals in America. But the recent Hobby Lobby decision is reminding some liberal technocrats that giving the government full control over health care funding also gives the government control over what medical services will be funded.
This is only one powerful and horrific story that highlights the severe problems with Veterans Affairs Medical Centers. Unfortunately, there are easily thousands of stories like the one experienced by this veteran. Kay Daly sums it up well in the article from the American Thinker,
Fighting a bureaucracy the size of the VA leviathan is not only physically exhausting, it is soul crushing as well. My brother was literally losing his will to live. That’s what I saw in the picture he sent to me — a man who was defeated.
The VA is a giant maze of a bureaucratic nightmare. Claims often go missing, unfairly denied, or simply lost. I worked on VA casework for a U.S. Congressman over a decade ago, and the extensive problems with the system predate my experiences.
The VA healthcare system does of course serve as a model for what the future for care looks like most Americans with more government involvement. In 2009, I wrote a commentary on VA healthcare and noted that since government can’t meet the obligation to its veterans, more government control of health care will only “increase the likelihood and scale of injustice.” The VA offers us on a smaller scale a perfect picture of healthcare rationing.
Now, at least five VA treatment centers are being investigated for keeping a secret list of appointment waiting times for patients. Those secretive actions are facilitated so hospital administrators and healthcare providers can secure bonuses for scheduling appointments in 14 days. It would be more shocking if these incidents are only contained to five VA hospitals. Of course the cover up is more widespread.
The American Legion has called for Veterans Affairs Secretary Eric Shinseki to resign. A necessary action perhaps, since one of the main short terms problems is lack of accountability. But the federal government continues to prove that it cannot handle socialized medicine on an even smaller scale. It may be prudent to focus on clearing up the massive backlogs of VA disability and medical claims and offering vouchers for care elsewhere. This is one bureaucracy that is becoming more notable for collecting body counts. That’s never a good image for a healthcare facility.
John Boehner recently stated, in the debt-ceiling talks, that “We’re going to continue and renew our efforts for a smaller, less costly and more accountable government,” which most Americans agree with in principle. However, citizens say that keeping benefits the same for the three big programs, Social Security, Medicare, and Medicaid, is more important than taking steps to reduce the budget deficit by a margin of 60 percent compared to 32 percent for Social Security, 61 compared to 31 percent for Medicare, and 58 compared to 37 percent for Medicaid.
So Americans purportedly want thriftier government, but still want benefits? What gives? Part of the problem, according to James Kwak, is “the idea that there is one thing called ‘government’–and that you can measure it by looking at total spending–makes no sense.”
What Kwak means is that total expenditure is a misleading measure of the “size” of government. He presents this example:
The number of dollars collected and spent by the government doesn’t tell you how big the government is in any meaningful sense. Most government policies can be accomplished at least three different ways: spending, tax credits, and regulation. For example, let’s say we want to help low-income people afford rental housing. We can pay for housing vouchers; we can provide tax credits to developers to build affordable housing; or we can have a regulation saying that some percentage of new units must be affordably priced. The first increases the amount of cash flowing in and out of the government; the second decreases it; and the third leaves it the same. Yet all increase government’s impact on society.”
So increased spending (or decreasing it) does not necessarily mean the “size” of government has grown (or shrunk). Think how regulation is synonymous with big government, but it does not involve a tax or direct spending of any kind.
In fact, “big” government is often viewed through the lens of regulation, rather than cost. For instance, Kwak explains:
When people say government is too big, they often have in mind something like the Consumer Financial Protection Bureau–a regulatory agency that tells businesses what they can and can’t do…the CFPA’s budget is about $300 million, or less than one-hundredth of one percent of federal government spending.”
Again the divergence between cost and “bigness” is seen. The CFPA may be viewed as “big,” intrusive, and unnecessary but it is not large in terms of cost like Social Security and Defense spending.
Kwak states, “popular antipathy toward the regulatory state has been translated into an attack on popular entitlement programs.” Many people dislike certain government regulations and, due to the budget debate, dislike of regulation, the amount of government spending, and specific government programs may have become accidentally intertwined.
As mentioned before, Americans view Social Security, Medicare, and Medicaid as important and worth preserving. Kwak elaborates: “Rationally speaking, your opinion about Social Security or about Medicare should be based on how much you put in and how much you get out–not on the gross size of the program, and not on how big the rest of the federal budget is. Yet instead the total size of the budget has become the driving force behind potential structural changes in Social Security and Medicare.”
Kwak suggests that “we should make decisions on a program-by-program basis, just like a business is supposed to do.” His advice is: “If there’s a program that the American people, through our democratic system, agree will provide benefits greater than its costs, we should do it, independently of the existing spending level. And if there’s a program that isn’t covering its costs, we should kill it.”
Instead of focusing on a generality, “government size”, our elected officials should evaluate programs on a cost-benefit level. Then government agencies that are viewed as too costly or intrusive (the CFPA) could be eliminated and government programs that are viewed as beneficial (SS, Medicare), but need reform, can be focused on in an unbiased way and not be harmed by the “too big” generality.
Jordan Ballor, in a blog post for Acton, wrote: “All government spending, including entitlements, defense, and other programs, must be subjected to rigorous and principled analysis.” Indeed, although the American people think Social Security, Medicare, and Medicaid are beneficial, 52 percent think Social Security needs significant reform, 54 percent think Medicare needs reform, and 54 percent, likewise, for Medicaid. However, without having a clear definition of what “too big” means, successful retooling will be difficult to achieve.
Ballor added: “This means that the fundamental role of government in the provision of various services must likewise be explored. This requires a return to basics, the first principles of good governance, that does justice to the varieties of governmental entities (local, regional, state, federal) and institutions of civil society (including families, churches, charities, and businesses).” True reform requires not simply legal and budgetary change, but a reevaluation of what entities perform certain services, as Ballor suggested.
The Acton Institute is committed to real budget reform, and, to make sure that programs, like Social Security, are evaluated fairly and reformed properly, the United States should make sure it clearly defines the costs and benefits of individual programs before taking drastic action.
Many politicians have talked of repealing the Patient Protection and Affordable Care Act (“Obamacare”). Mitt Romney has said nullifying the healthcare law would be one of his first actions if he was elected president. However, rather than just repealing the law and going back to the status-quo, with minor changes, the American people should demand true reform.
In 2001, Milton Friedman, the famed, Nobel-prize winning economist, published an article titled “How to Cure Health Care.” (Although worthy of serious consideration, Friedman’s analysis does not contain any explicit moral message, and is simply a policy analysis on healthcare. For a more in-depth look at the moral dimension of healthcare reform, visit Acton’s special section on healthcare)
In his essay, Friedman stated that, “The United States spends a mind-boggling percentage of its GDP on a health care system that virtually everyone agrees is a disaster,” and that was in 2001. Spending has only increased over the past decade. In fact, according to the Department of Health and Human Services Center for Medicare and Medicaid Services, the United States spent 17.6 percent of its GDP on healthcare in 2009, and this figure is expected to grow over time.
In addition to out of control spending, studies in the United States and Europe at the time were showing “…public dissatisfaction with the increasingly impersonal character of medical care.” Recently, a 2010 Gallup poll showed a majority of Americans are satisfied with the quality of healthcare they receive (62 percent rated quality as excellent or good), but only 39 percent rated the availability of coverage as excellent or good.
How did this happen? How has massively increased spending led to unsatisfactory coverage?
In four words: the government got over-involved.
Friedman explained, “In other technological revolutions, the initiative, financing, production, and distribution were primarily private, though government sometimes played a supporting or regulatory role.” However, in healthcare, the government decided to intervene and regulate extensively.
It all started at the onset of World War II when, due to wage and price controls enacted during the war, “firms competing to acquire labor at government-controlled wages started to offer medical care as a fringe benefit,” which was not recorded as part of their salary due to the wage-controls. As a result, employees came to expect healthcare from employers as part of their compensation.
The IRS eventually wised up to this and, wanting more revenue, started to tax the contribution. Workers raised an uproar so Congress passed a law, The Revenue Act of 1942 (Section 127 specifically), allowing, in Friedman’s words, “… medical care expenditures to be exempt from the income tax, if, and only if, medical care is provided by the employer.” This system, according to Dr. Donald P. Condit in his Acton Institute commentary “Should Business Be Responsible for Employee Health Care?”, “effectively punishes taxpaying citizens who are paying for health care benefits with after-tax dollars.”
Thus, if an employee paid directly for healthcare, this was added to their taxable income, but, if they went through their employer, it was not, setting up a large incentive to get insurance coverage from one’s employer. Condit states “medical spending has increased with this ‘tragedy of the commons’ scenario, wherein resources [health care dollars] are overconsumed with the perception that someone else [the company, the government] is paying.”
Friedman similarly demonstrated the result of this and other policies dealing with healthcare with a simple example: “In 1946, seven times as much was spent on food, beverages, and tobacco as on medical care; in 1996, more was spent on medical care than on food, beverages, and tobacco.” In 50 years, healthcare went from a minor expenditure to the major expenditure of most people, and, during this period, spending by individuals and government on healthcare approximately quadrupled.
Friedman explained, “On the evidence to date, it is hard to see that we have gotten much for quadrupling the share of the nation’s income spent on medical care other than bureaucratization and widespread dissatisfaction with the economic organization of medical care.”
What can be done?
For starters, Friedman said: “If the tax exemption were removed, employees could bargain with their employers for higher take-home pay in lieu of medical care and provide for their own medical care either by dealing directly with medical care providers or by purchasing medical insurance.” This would make families more responsible for their own healthcare and they could adjust accordingly, either spending less/more on healthcare or taking more/less in wages. (It seems that most would probably spend less on healthcare and take more income in light of this National Journal article).
This kind of reform would help by “reprivatizing medical care by eliminating most third-party payment, and restoring the role of insurance to providing protection against major medical catastrophes,” rather than using insurance to pay “for regular medical examinations and prescriptions.”
This sounds great, in theory, but how would such a drastic change actually be accomplished?
Friedman advocated for medical savings accounts. He stated: “A medical savings account enables individuals to deposit tax-free funds in an account usable only for medical expense, provided they have a high-deductible insurance policy that limits the maximum out-of-pocket expense.” This way, employees, not employers, would be responsible for their own healthcare spending, hopefully eliminating the third-party problem, while allowing the wages contributed to still be tax free.
Several companies, including Forbes, Quaker Oats, and the Golden Rule Insurance Company, tried out medical savings accounts instead of employer provided insurance and found that healthcare costs were lower and both management and employees were more satisfied than under the old employer provided system.
Friedman stated, “Families would once again have an incentive to monitor the providers of medical care and to establish the kind of personal relations with them that were once customary.”
This puts responsibility back on the individual to care for his or her family and brings to mind the words of 2 Thessalonians 3:10: “If a man will not work, he shall not eat.” Modern healthcare is obviously not comparable to biblical food, but the concept of individual responsibility has largely been lost with employer provided healthcare. This reminds all that a family is better served caring for itself rather than relying on someone else to make choices, including healthcare, for them. Condit, in his essay, says as much: “Employer, or any third party, involvement in providing health care can interfere with an employee’s ability to make his or her own decisions and distort individual responsibility.”
Also, allowing families to manage their own healthcare costs would allow for greater efficiency by means of more efficient spending. For instance, instead of using insurance to pay for a doctor visit due to a cold or a small prescription, one could pay out of pocket. If most people paid out-of-pocket, the cost would likely go down because what individual would pay $80 (like my insurance company does) for a 20 minute doctor visit? By putting people in control and not insurance or government bureaucracies, one could expect people to “shop around” for quality doctors. Then, doctors’ offices would likely offer better care to compete for patients, instead of expecting an $80 to $100 payout from the insurance company or the government.
In addition, Friedman advocated for the abolishment of Medicare and Medicaid, which sounds rather radical. However, he said the government should “…replace them by providing every family in the United States with catastrophic insurance (i.e. a major medical policy with a high deductible).”
That way “the family would be relieved of one of its major concerns – the possibility of being impoverished by a major medical catastrophe – and most could readily finance the remaining medical costs.”
This should satisfy the concern that impoverished citizens would not get adequate coverage. Even if a small portion of the population is chronically ill or unable to pay their medical bills, these people would be covered by a government catastrophic care policy.
It is a citizen’s duty to care for those individuals in their communities who simply cannot help themselves. Condit states, “Christians, and others, are expected to fulfill a service obligation, with a preferential consideration for the poor and underserved.” This corresponds to the principles of subsidiarity and sacrifice seen throughout Catholic and Christian teaching.
In Luke 3:11, John the Baptist states: “The man with two tunics should share with him who has none, and the one who has food should do the same.” Jesus himself said, in Luke 14:13, “when you give a banquet, invite the poor, the crippled, the lame, and the blind.” Again, in Jesus’ and John’s teaching, the focus is on “you”, the individual, caring for ones neighbor, rather than an entity such as the government (or a corporation). The government, naturally being more impersonal and disconnected, could provide support in the severest cases, when communities and individuals could not support their own.
Rather than harming the less-fortunate and marginalized, this kind of health reform could free up time and hospital beds (many families would spend much less time and money on care) to help those chronically ill individuals who truly need the best care and doctors available. Friedman’s approach does not solve all the problems of healthcare (how do I know this doctor/hospital is reputable or provides good care since there is no rating service, what about those that refuse to or cannot pay out of pocket, etc.) and this is only a basic analysis, but it does offer a seldom discussed approach to improve care, allow for greater individual independence, and decrease costs.
With health care moving back to center stage in Washington, we’re publishing Dr. Donald Condit’s Acton monograph A Prescription for Health Care Reform as a free eBook readable in a variety of formats. This excellent work continues to be available for $6 (paperback) in the Acton Bookshoppe.
For your free eBook, visit Acton’s Smashwords page. The Condit book will soon be available in the Kindle store (no charge for that, either) and in other eBook retail sites. We’ll keep you updated when they become available.
Via Smashwords, you can download digital versions of the 81-page health care monograph for eBook readers, smart phones and computer screens.
The monograph was released before the passage of the Patient Protection Act in March. Dr. Condit has recently authored an update in the November 2010 issue of the Linacre Quarterly, published by the Catholic Medical Association. The medical association has graciously offered readers of the Acton PowerBlog an open link to Dr. Condit’s new article, “Health-Care Counter-Reform.”
From the Jan. 5 Acton News & Commentary. This is an edited excerpt of “Health-Care Counter-Reform,” a longer piece Dr. Condit wrote for the November 2010 issue of the Linacre Quarterly, published by the Catholic Medical Association. For more on this important issue, see the Acton special report on Christians and Health Care. Dr. Condit is also the author of the 2009 Acton monograph, A Prescription for Health Care Reform, available in the Book Shoppe.
Obamacare and the Threat to Human Dignity
By Dr. Donald P. Condit
Since President Obama signed the Patient Protection Act into law in March 2010, the acrimonious debate on this far-reaching legislation has persisted. For many, the concerns over the Obama administration’s health care reform effort are based on both moral and fiscal grounds. Now, with House Republicans scheduling a vote to repeal “Obamacare” in the days ahead, the debate is once again ratcheting up.
Perceived threats to the sanctity of life have been at the heart of moral objections to the new law. Despite a March 2010 executive order elaborating the Patient Protection Act’s “Consistency with Longstanding Restrictions on the Use of Federal Funds for Abortion,” many pro-life advocates fear a judicial order could reverse long-standing Hyde amendment restrictions on the use of federal tax dollars for abortion. Impending Medicare insolvency and the Patient Protection Act’s establishment of an “independent payment advisory board” to address treatment effectiveness and cost suggest bureaucratic restrictions on the horizon for medical care of the elderly and disabled.
The objections made on fiscal grounds are serious. Prior to the 2008 presidential election, Barack Obama voiced concern for 47 million Americans without health insurance. More recently, supporters of this legislation focused on 32 million Americans, with 15 million immigrants and others left out of the equation, yet still requiring care in United States emergency rooms. The Patient Protection Act increases eligibility for Medicaid recipients, yet state budgets are severely strained with their current underfunded medical obligations. Moreover, doctors struggle to provide health-care access to Medicaid patients when reimbursed below the overhead costs of delivering care.
Who Should Pay?
The perception among consumers of third-party responsibility for health, including payment for health-care resource consumption, is the major factor for unsustainable escalation of medical spending in the United States. Yet the Patient Protection Act augments third-party authority and threatens doctor-patient relationship autonomy, by increasing responsibility of government and employers for health care. Patients and physicians will face increasing involvement of third parties in decision making in exam rooms and at the bedside. (more…)
Dr. Donald Condit joined host Drew Mariani on the Relevant Radio Network to discuss the positives aspects of end-of-life planning as well as the troubling issues surrounding end-of-life care under government health care systems. Dr. Condit is an orthopedic surgeon and the author of Acton’s monograph on health care reform, entitled A Prescription for Health Care Reform and available in the Acton Bookshoppe; he has also authored a number of commentaries on health care for Acton and other organizations; his most recent commentary can be read right here. And don’t forget to check out Acton.org’s special section on Christians and Health Care for a wealth of related information.
To listen to Dr. Condit’s 20 minute interview with Drew Mariani, use the audio player below.
Published today in Acton News & Commentary. Sign up for the free weekly email newsletter from the Acton Institute here.
By Anthony Bradley
The November congressional elections are not so much a referendum on the Obama administration as a check on whether President Barack Obama’s implementation of a Bismarckian vision of government will continue.
Otto von Bismarck, the Prussian prime minister/German chancellor from 1862 to 1890, is the father of the welfare state. He advanced the vision that government should serve as a social services institution by taking earned wealth from the rich and from businesses to deliver services to those who are not as advantaged. Bismarck’s Kulturkampf campaign intended both to keep radical socialists at bay and undermine the church’s role in meeting the needs of local citizens by positioning government to be the primary source of social services. He initiated the ideal of an ever-expanding, beneficent government, which was subsequently imported to the United States in Franklin Roosevelt’s New Deal, expanded further with Lyndon Johnson’s War on Poverty, and currently drives the policies of the Obama administration. Barack Obama is not a 19th-century socialist, but his agenda is unquestionably Bismarckian.In 1891, William Dawson, in Bismarck and State Socialism, explained that Bismarck believed it was the duty of the state to promote the welfare of all its members. On November 22, 1888, in response to Germany’s 1873 economic crisis, Bismarck proclaimed, “I regard it as the duty of the State to endeavor to ameliorate existing economic evils.” In Bismarck-like fashion, commenting on America’s economic crisis, President Obama declared in January 2009 that, “It is true that we cannot depend on government alone to create jobs or long-term growth, but at this particular moment, only government can provide the short-term boost necessary to lift us from a recession this deep and severe. Only government can break the cycle that are crippling our economy—where a lack of spending leads to lost jobs which leads to even less spending; where inability to lend and borrow stops growth and leads to even less credit.” In a Bismarckian world, “only” government can set the national economy right.
Regarding universal health insurance, on March 15th, 1884, Bismarck asked, “Is it the duty of the State, or is it not, to provide for its helpless citizens?” He answered, “I maintain that it is its duty.” It is the duty of the state to “the seek the cheapest form of insurance, and, not aiming at profit for itself, must keep primarily in view the benefit for the poor and needy.” Similarly, under the federal healthcare reform law, Congress forbids health insurance companies from raising insurance premiums until insurers submit to Obamacare officials “a justification for an unreasonable premium increase prior to the implementation of the increase.” In effect, government determines health insurance premiums.
On unemployment, Bismarck believed that government is ultimately responsible for finding jobs for those unemployed through no fault of their own, those lacking opportunity to work and thus prohibited from properly sustaining themselves. On March 15, 1884 Bismarck exclaimed, “If an establishment employing twenty thousand or more workpeople were to be ruined . . . we could not allow these men to hunger”—even if it means creating government jobs for national infrastructure improvements. “In such cases we build railways,” says Bismarck. “We carry out improvements which otherwise would be left to private initiative.” Likewise, in July, President Obama proclaimed, “I believe it’s critical we extend unemployment insurance for several more months, so that Americans who’ve been laid off through no fault of their own get the support they need to provide for their families and can maintain their health insurance until they’re rehired.” Then, in September, President Obama announced a six-year, $50 billion infrastructure proposal “to rebuild 150,000 miles of our roads,” “maintain 4,000 miles of our railways,” and “restore 150 miles of runways.” To keep America working, Obama is channeling Bismarck’s vision of government as creator of jobs.
By the 1890s, for several reasons, Germany was forced to abandon many of Bismarck’s specific reforms. However, Bismarck’s method of using of government as the ultimate provider of social services paid for by the earned wealth of others is the modus operandi of the Obama administration. The outcome of contests for congressional seats will determine whether the nation continues down the path chosen by Barack Obama, but blazed long ago by the visionary of the omnicompetent state, Otto von Bismarck.
Among the warnings sounded as the Democratic health care reform bill was being debated was that the federal insurance mandate included in the bill—even though not national health care per se—would essentially give the federal government control of the insurance industry. The reason: If everyone is forced to buy insurance, then the government must deem what sort of insurance qualifies as adequate to meet the mandate. This piece of Obamacare promises to turn every medical procedure into a major political fight, with special interest lobbying rather than objective medical expertise being more likely to determine what kind of health care gets covered and what kind doesn’t.
The problem goes beyond ugly politics, however, and into the realm of moral repugnance. The contention has already started, as the Catholic bishops have formally protested the pending inclusion of contraception and sterilization among items that must be covered in every American insurance plan.
Whether one agrees with Catholic morality is beside the point. The point is that this is no way to deal with a major economic sector in a free, pluralist society. Some medical doctors think chiropractors are quacks; some chiropractors think medical doctors are quacks. Some people think marijuana is an excellent pain killer; others think it is an immoral drug. The goods and services that the 300 million people in this country consider to be effective—or objectionable—instances of health care vary, sometimes dramatically, according to geography, culture, religion, and ethnicity. Now a single institution, the national government in the form of the Department of Health and Human Services, is charged with arbitrating which goods and services make the cut and which don’t. Those who lack the political clout to get their preferences included will pay coming and going: their insurance premiums will cover things that they don’t want and they’ll have to pay out of pocket for things that they do.
The variety offered by a medical market is a beautiful thing. Monolithic medicine mandated by a law that most Americans opposed is not.
ABC is refusing to air a national ad by The League of American Voters, featuring a neurosurgeon asking the question, “How can Obama’s plan cover over 50 million new patients without any new doctors?”
ABC justified the decision by pointing to a long-standing policy against running partisan commercials. Dick Morris, a onetime advisor to former President Bill Clinton and chief strategist for the League of American Voters, called the ABC decision “the ultimate act of chutzpah.” As he explains:
“ABC is the network that turned itself over completely to Obama for a daylong propaganda fest about health care reform,” he said. “For them to be pious and say they will not accept advertising on health care shuts their viewers out from any possible understanding of both sides of this issue.”
Fox News reports that NBC may also choose not to run the ad.
I suggest we respond to this abuse of the public airwaves by creating a little homegrown balance. Forward the commercial to friends and family, and while you’re at it, steer them to Acton’s health care page, which includes this piece on “The Problem with Socialized Government Healthcare.”