Monday, August 10, 2009

This Libertarian and health care

A long post that will undoubtedly confound my friends and critics alike.

First, some homework assignments.

If you really want to know about end of life issues from a truly non-partisan scholar who has made a career out of studying the issue, you need to start reading Medical Futility Blog, which is published by Dr. Thaddeus Pope of the School of Law at Widener in Wilmington. It is tough reading, no matter where you stand ideologically, because Dr. Pope is so dispassionate, factual, and well-versed in the legal issues, the medical issues, and the research that sometimes he will leaving you breathless. He is not a politician, so he does not mince words.

On the campaign to portray end-of-life counseling as attempt to scare people with the idea that the government is going to kill granny, he lays out exactly why this is a lie, and just when many of my liberal friends would be smiling and saying, I told you [and they did tell people and they are right on this issue], he hits you with this final closing sentence:

Now, there will be rationing. Granny's treatment choices in 2015 will be more limited than they were in 2005. But Section 1233 and ACP have nothing to do with that.

Here is an example of how Dr. Pope clearly and exhaustively takes apart the legal, medical, and moral issues in an end-of-life malpractice case involving Permanent Vegetative State [Luckett v Bodner]

Or presenting the research findings for how placing physicians on salary changes [for better or worse] the way they practice medicine.

But the main thing I want you to do when you read this is to watch the video or read the transcript of an interview with former CIGNA executive William Potter. Sorry, but I have not been able to embed it.

Potter takes no prisoners when talking about his experiences, the tactics used by health insurance companies, and the process of his awakening.

In a particularly moving segment, he juxtaposes his life as a CIGNA Exec:

WENDELL POTTER: And that was my problem. I had been in the industry and I'd risen up in the ranks. And I had a great job. And I had a terrific office in a high-rise building in Philadelphia. I was insulated. I didn't really see what was going on. I saw the data. I knew that 47 million people were uninsured, but I didn't put faces with that number.

Just a few weeks later though, I was back in Philadelphia and I would often fly on a corporate aircraft to go to meetings.

And I just thought that was a great way to travel. It is a great way to travel. You're sitting in a luxurious corporate jet, leather seats, very spacious. And I was served my lunch by a flight attendant who brought my lunch on a gold-rimmed plate. And she handed me gold-plated silverware to eat it with. And then I remembered the people that I had seen in Wise County. Undoubtedly, they had no idea that this went on, at the corporate levels of health insurance companies.

... against a visit back home in Tennessee where he hears about a rural health expedition and decided to go check it out:

WENDELL POTTER: I did. I borrowed my dad's car and drove up 50 miles up the road to Wise, Virginia. It was being held at a Wise County Fairground. I took my camera. I took some pictures. It was a very cloudy, misty day, it was raining that day, and I walked through the fairground gates. And I didn't know what to expect. I just assumed that it would be, you know, like a health-- booths set up and people just getting their blood pressure checked and things like that.

But what I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents, to care for people. I mean, there was no privacy. In some cases-- and I've got some pictures of people being treated on gurneys, on rain-soaked pavement.

And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. People drove from South Carolina and Georgia and Kentucky, Tennessee-- all over the region, because they knew that this was being done. A lot of them heard about it from word of mouth.

There could have been people and probably were people that I had grown up with. They could have been people who grew up at the house down the road, in the house down the road from me. And that made it real to me.

I will come back to this image later, to make a political point. But right now I just want you to read it again and let it sink in.

Potter discusses in detail the techniques used by CIGNA and other companies to influence the political debate--on both sides of the aisle--and at that site you can even get links to some of the talking points documents he carried out of the office with him.

When he talks about the linkages of both Senator Max Baucus [whose two prior chiefs of staff are now insurance company lobbyists who meet with him regularly] and President Barack Obama [who has taken in as an inner-circle advisor AETNA's Ron Williams--the man who brought his company back to profitability by finding legal was to dump 8 million of its 21 million policy holders], Potter is scathing.

The video did not convince me we have a health care crisis in America--I already knew that. But it has had an impact on my thinking, more to solidfy directions I have been taking than to start a completely new line of thought.

Go back to those doctors in animal stalls in rural America. Potter is partly right: they are there providing that care under those conditions because you cannot trust mega-corporations to actually give a shit. In this I differ from a lot of other Libertarians. I am a Braudelian: super-concentrations of capital beyond a certain point become anti-free-market and threaten human freedom in almost as many ways as the State can.

But that does not exonerate the State here either: there are literally thousands of Physicians' Assistants, Nurse Practitioners, and even LPNs or midwives who would be more than willing to make careers in the small towns across America providing low-cost basic care to good people. Yet the licensing laws that the health professionals' lobby have so carefully cultivated over the years prevent that. We can't have non-doctors out there practicing medicine unsupervised [even PAs and Nurse Practitioners with decades of experience] because the occasional errors they might make or diagnoses they might miss are somehow worse consequences for society than denying access to basic care to millions of people. Never have been able to get my head around that one.

So I am going to echo President Obama on this one: sometime recently [I'm not going to bother with a link, you will recognize the statement] he said that if he were designing a system from the ground up he would prefer single-payer, but he's not, so he has to work from where he is.

Likewise: if I were designing a system from the ground up, I would design a system that actually worked on real free-market values, regulated against abuse by force or fraud--but we're not there: we are where we are now.

I will also harken back to something that frequent commenter Tom [my favorite anarcho-capitalist] said about a year ago [paraphrasing, Tom, I cannot find the quote]: If the government would cut back several hundred billion of our tax dollars now being used for military interventions across the globe, since they aren't going to give it back to us it would be better used on health care than on more F-22s.

I guess the last straw for me, however, was truly discovering that Barack Obama does not really believe all the things he's saying: the man cut a deal with Big Pharma and has brought in one of the most cut-throat CEOs in the health insurance industry after taking nearly $15 million in campaign contributions. The idea that he is actually a health care reformer is one of the more widely held fantasies in the American political scene today. What Barack Obama believes in is Barack Obama.

Having said that, I have avoided stating an unequivocal position on health care reform for too long [aside from stating that I am against single-payer, which I remain].

Here are my priorities:

1. Address the issue of millions [I don't care how many the exact number is] of people who do not now have access to medical care. [Do NOT show up and give me the old Emergency Room answer.] Hell, if you want simple, just have the government consider their COBRA premiums to be part of their unemployment benefits for the laid-off [and--by the way--somebody needs to tell the State that it is counter-productive to collect income taxes on unemployment benefits].

2. Separate access to health care/health insurance from employment and provide regulation that says if you are selling health care coverage to people you don't get to cancel it because they get sick. I do have confidence that with real inter-State competition and some rigorous regulation against force or fraud by the insurance companies we could make a variety of options more realistically available to people

3. Pay for all of this rationally without saddling my grandson with an unlivable amount of debt. Cut the goddamn defense budget by about $200 billion for starters. And yes, Medicare and the VA should have the authority both to import drugs from Canada and negotiate with drug companies because to disallow either is ridiculously anti-free market. Of course the largest purchasers will get the best prices: how the hell do you think Wal-Mart stays in business? In other words: end the corporate welfare for the insurance and pharmaceutical companies. While you're at it, allow people to deduct ALL their out-of-pocket medical expenses from their income taxes rather than imposing a 7% floor. If your medical expenses have reached or exceeded 7% of your income you are already close to medical bankruptcy [happened to us last year very nearly].

4. Eliminate State and bureaucratic measures that create artificial barriers to innovative ways of delivering health care. Let PAs and Nurses and other non-doctors actually go out and set up shop in small towns and in shopping centers and do cash and carry business. Adopt a common-sense approach for the FDA that streamlines approvals of medicines already approved in Europe or other countries with similar standards.

I realize that this post will piss off a lot of my libertarian friends because the idea of any State involvement so scares them or angers them that it blinds them to a very important truth: corporate statism is just as harmful to human freedom as nation-statism. Many of the largest corporations around the world have resources that far exceed even some modestly well-off countries. Do they use them better? More ethically?

To misquote Lord Acton: burueacracy tends to abuse people, and absolute bureaucracy tends to abuse people absolutely.

Yes: giving the government sufficient power to rein in mega-corporations scares the hell out of me because history suggests that the government will inevitably abuse that power. But the corporations are already abusing their power, and the truth is that we have, as citizens, far more levers to use against the government than we have to use against the corporations, at least with respect to this one issue.

A final note, which is something of a commercial: Hockessin Walk-in Clinic in Lantana Square is a very special place, as Dr. Vince Schaller [the proprietor] is a very special doctor. He's running this clinic because it is the kind of medicine he wants to practice, and--most importantly--he is constantly challenging the barriers of insurance. If you do not have insurance, Doctor Schaller will see you for $25 up front and allow you to set up a no-interest payment plan for as little as $25/month. This is advertised in the office, although not on the website (for reasons I suspect I understand).

Imagine if Dr. Schaller could employ Nurse Practitioners or PAs as primary care-givers who did not have to bring a physician into the room by law for every single patient, even those with minor problems.

So if you know people who need basic care, don't have insurance, but can afford $25 up front, there is at least one for-profit clinic in Delaware willing to work with you.

[We get all our children's sports physicals done there, partly as a way to help subsidize him in continuing this program.]


Bowly said...

Many of the largest corporations around the world have resources that far exceed even some modestly well-off countries. Do they use them better? More ethically?

What is "better"? What is "more ethically"? If the corporations didn't use force or fraud, then it will be difficult for them beat the government at being unethical (in this an-cap's book). That is not the same thing as impossible, mind you. Pressuring suppliers and/or customers does not count as the same thing as force in my book. If Kellogg's refuses to comply with Wal-Mart's demands, Wal-Mart doesn't throw Kellogg's in jail.

...the truth is that we have, as citizens, far more levers to use against the government than we have to use against the corporations, at least with respect to this one issue.

That's a bold claim. And even if true, the corporations have access to the same levers. That's why I'm not sure that "something" is better than "nothing", on this issue or any other.

Granted, the reason folks like me dislike to cede ground and begin utilitarian arguments about the efficiency of health care systems is that it stipulates to the entire idea of government in the first place (which you address in your post). So maybe I'm biased.

pandora said...

Nicely done, Steve. As usual, on this point, we agree more than we disagree.

tom said...

I too only vaguely remember making that comment. I suspect that the context was either somewhat sarcastic, or along the lines of the incremental steps to get from the status quo to something closer to what I want. Anyone who's read my comments or posts knows that, w/ two notable exceptions, I'm opposed to the government spending even a penny on health care. The exceptions are active military personnel and veterans. And while I'd like to see their numbers decline dramatically in the future, I do believe the government has a genuine responsibility to care for them. I'm curious what I actually said though...

Since your post is already too long, I won't compound it by arguing health care. But I do have a few points about your comments on corporations.

First, how many members of your audience do you think have even heard of Fernand Braudel, let alone know what a Braudelian view might be.

Second, in the U.S. alone, the body of law associated with corporations is so vast and convoluted that no single person, even if they devoted a lifetime of study, could understand it completely. And multinationals have several (or hundreds of) jurisdictions available from which to chose the most favorable set of laws to fit the circumstances. Their opponents, on the other hand, no matter how dedicated are widely distributed and have limited resources. Therefore fighting them seems futile for individuals or ever organized groups.

However, despite the amount of effort that politicians and lobbyists have devoted to very successfully convincing the general population that government needs extraordinary powers to rein in mega-corporations, that impression could not be further from the truth.

Corporations are creatures of government. The largest and most powerful of them have grown to that size precisely because governments make it beneficial and necessary for them to do so, in order to compete more successfully for the benefits & privileges granted to them by government. Their size is well beyond anything that could be supported by economies of scale in a free market.

The only way to rein in the powers of corporations is not to increase the power of government, but to reduce it.

Take away the government's power to give vast amounts of money and special privileges to corporations, and the ones you are most worried about will reorganize into multiple companies of more efficient sizes or collapse under their own weight.

Steve Newton said...

If I recall you were being dismissive rather than sarcastic, because you didn't actually ever think they would cut the defense budget. Unfortunately, I cannot even think of a key word to search for the comment.

Braudel? Probably few, but I have posted at length about Braudel's concept of capitalism on at least three different occasions; I should probably go back and link that sentence to one of them. Good point.

corporations are creatures of the government

Not exactly, at least not in the sense you mean. The large multinationals have effectively grown beyond being creatures of any government into creatures with concentrations of capital (and therefore power) that rival the power of some governments. I will grant you the incestuous relationship between corps and the state (especially as tax farmers), but....

If governments disappeared tomorrow, large bureaucratic business organizations would not. The libertarian/anarcho fantasy is that the market and self-interest would be sufficient to provide any safeguards necessary to human freedom.

My position is different: pretty much any large bureaucratic organization--private or corporate--shares certain specific anti-liberty characteristics, and therefore both represent dangers to human freedom.

Bowly said...

I'm still trying to figure out which levers we will be able to pull if a new health care system turns out to be a disaster. I look at things like Social Security, Medicare, and the U.S. budget in general and assume that the government's response will be to tax, borrow, and kick the can down the road rather than fix any problems (no matter whom we elect, even if I thought my vote mattered).

And since my vote doesn't really matter, I'll just sit back and watch this free society force people to provide health care. Does that make me un-American?

tom said...

"If governments disappeared tomorrow ..."

and you accuse me of fantasy. governments could no more disappear overnight leaving everything else unchanged than any other fantasy scenario could come true. but hypothetically if they did, the corporations would be de facto governments with no restraint and we would be in some cyberpunk scenario.

would you agree that in the equally hypothetical completely free market, corporations could not exist at all? and that under a minarchist government where the sole advantage granted by corporate charter was limitation of liability to loss of your investment, corporations could not grow into the bureaucratic fiefdoms you describe?

if on the other hand, one or more of the major world governments ceased their incestuous relationships and corporate welfare, over time, in those countries corporations would lose their quasi-governmental powers. They would probably just shift their abusive behavior elsewhere, but that is not really our problem.

"My position is different: pretty much any large bureaucratic organization--private or corporate--shares certain specific anti-liberty characteristics, and therefore both represent dangers to human freedom"

no not really. i don't disagree in any way with that statement. i just have different ideas about how to solve the problem.

Delaware Watch said...

First, wow! Second, another wow.

Third this statement "...the truth is that we have, as citizens, far more levers to use against the government than we have to use against the corporations..."--I know you want to confine it to this one issue, but I think this insight applies in far more matters. It's good to have a healthy suspicion of government, but in a democracy it's smarter to be more suspicious about constellations of private power where there is no shred of democratic control (unlike a government).

Great writing, Steve.

Riva said...

This is interesting. My question is, are CATS covered under Obama family health care plan?