That’s inevitably the question that follows: “If you’re not a fan of the current reform proposals, what would you do?”  This is typically a veiled accusation that the dissenter is a proponent of doing nothing, perhaps because he/she doesn’t recognize that there’s a problem.

So let’s address the veiled accusation first: I’m by no stretch of the imagination an apologist for the current system.  I think it’s a deeply flawed system in many ways.  But when trying to get our hands around those flaws, and devise solutions, I think we owe it to ourselves to take a clear-eyed look at what’s actually driving the problems rather than upending the proverbial applecart in service to an ideological agenda that inexplicably regards government as a force for good, and thus almost always exalts the power of the state for the alleged common good, regardless of the cost to the individual.

Take, for example, the problems of insurance continuity and portability.  Some of the biggest complaints about the American healthcare system are that, because most of us get our health insurance through our employers, we run the risk of losing our insurance if we lose our job, and we can’t take our insurance plan with us when we change employers.  That latter complaint sounds petty until you remember the pre-existing condition problem: if John Q. Public develops a medical condition while working for Employer X, his insurance through X is going to cover it — but if he changes jobs and goes to work for Employer Y, he may well be denied coverage for that condition through Employer Y’s plan.  So John will be left to choose between continuing to work in a job he may hate to keep his insurance, or changing to a more satisfying job but having to pay potentially-ruinous medical costs out of pocket.

What’s important to recognize, here, is why most of us get our insurance through our employers.  This didn’t occur organically.  Rather, for reasons that are largely historical and no longer operative, employer-based health insurance receives favorable treatment under the U.S. tax code.  In other words: Surprise!  People respond rationally to incentives.  Alter the incentives, and you will alter the market: eliminate favorable tax treatment for employer-based health insurance and you will get a more robust market for individual insurance, which will in turn significantly ameliorate the continuity and portability issues.  If John can get insurance on his own rather than through his employer, then he can keep his policy despite changing jobs, and even through periods of unemployment.

Another major complaint about the American healthcare system is that insurance premiums are so high.  Again, though — why are they high?  Obviously there are a number of factors, but two important ones are Americans’ price insensitivity to healthcare consumption, and what’s called “community pricing.”

To understand these factors it’s helpful to think about other forms of insurance — for example, car insurance.  Most car insurance policies sold in the United States have fairly high deductibles (often $250 to $500, sometimes more) relative to the value of a typical loss.  Consequently Americans pay out of pocket for routine automobile maintenance and most minor damage; insurance is understood as a hedge against catastrophic (at least, relative to the value of the asset) loss.  Get in a fender-bender and you’ll pay for perhaps one third to one half of the loss out of pocket; but total your car and your insurer pays for nearly the full market value of the vehicle.  As a result, Americans are price-sensitive to routine car maintenance and minor vehicle repair work: we try to minimize our consumption so as to minimize our out-of-pocket expenses.  We’ll baby our cars, attend to the manufacturers’ preventative maintenance schedules, and shop around for the best deals for any work we need done.  Contrast with medical insurance, in the United States: most policies, as the result of regulatory favoritism toward an HMO/PPO insurance model, have absolutely miniscule deductibles in the form of $10 or $15 copays, which leaves the insurer on the hook for virtually every medical expense a patient incurs.  Because the consumer pays next to nothing out of pocket, he has no incentive to minimize his consumption — and so every time he runs to the doctor for the least little sniffle or ache or pain, he costs the insurer a small fortune.  The only way the insurer can recoup its expenditures is to jack up premiums for people who do, or who are likely to, consume more care, or to jack up premiums for everybody across the board.

“Community rating,” though, takes the first option off the table.  Health insurance providers are generally prohibited, in the United States, from charging different consumers different premiums based on actuarial risk.  Again, think of automobile insurance: if you’re a newly-licensed seventeen-year-old driving a $70,000 Beemer that daddy got you as a gift, your premiums are going to be much higher than a suburban housewife with fifteen years of driving experience who putters around town in an ancient minivan.  Different levels of actuarial risk justify the different rates: the suburban housewife is less likely to cost the insurer large sums of money, and so she pays less in premiums.  Health insurers can’t do this.  They are generally required to charge everybody the same rate, regardless of individualized health risks: Lance Armstrong’s premiums are the same as those of an obese alcoholic.  So what happens?  The insurer, to recoup its greater expenditures on behalf of the obese alchoholic, charges everybody more (so that, in a way, Lance ends up subsidizing somebody else’s obesity and alcoholism).

The starting point for American healthcare reform has to be clearing away this underbrush.  Changing the tax laws that incent employer-based health insurance over individual health insurance helps take a bite out of the portability and continuity problems.  Getting rid of the regulatory favoritism toward the low-deductible HMO/PPO model of health insurance, and restoring the understanding that insurance exists to finance extraordinary loss, will generate some consumer price sensitivity to routine medical costs.  Combine that with the elimination of “community pricing” rules that forbid insurers from pricing actuarial risk, and market forces will, all by themselves, guide people towards healthier living.  Take good care of yourself and you’ll pay modest out of pocket costs and low insurance premiums, while still being protected in the event of some catastrophic medical problem.  On the other hand, society will respect your choice to live hard, but not to the extent of subsidizing it.

This healthcare reform debate is like quicksand — every time I think I’ve said all that I have to say about it, something comes along that prompts another blog post.  Today it was a conversation in the comment section of a Facebook post by a friend, which led to my interlocutor saying the following:

Wow… so the people like me just are the margin of error then? Who cares that people would die who couldnt afford coverage or couldnt qualify for it, thats just the cost of keeping as much money in your paycheck as possible and keeping government small.

Maybe we should just get rid of the government and go back to the winner takes all system then too?

And really, if that idea works so well, why do we rank so highly in infant mortality compared to countries like Canada with socialized medicine? Why dod people live longer in European nations, also with socialized medicine, than they do here? Why do the same identical services cost LESS per person overall in nations with socialized medicine than they do here? Why do the wealthy and celebrities go out of the country, especially to Europe, when they get cancer because none of the cutting edge treatments are even available here? Seems like our system is screwing over more than just the small margin of people like me.

And the people like me are sadly not such a small margin. Thousands of people everyday in the country are forced to decide between good medical care for their ailments or keeping their homes and their retirements. Im NOT such a small margin.

Let’s get a few things out of the way, first.  The idea that the wealthy and celebrities in the United States go out of the country, especially to Europe, to obtain medical care is the opposite of true.  The migration is almost entirely in the other direction: the famous and the wealthy who want the best treatment money can buy (and with some regularity just plain folks whose home countries’ systems can’t find space for them) come here, not to Europe.  Similarly, the claim that none of the cutting-edge cancer treatments are available in the United States is largely nonsense: the U.S. is a global leader in cancer research and treatment, with internationally-renowned treatment centers such as the Mayo Clinic, Johns Hopkins, Sloan-Kettering, and Stanford located here.  To the limited extent that truly experimental cancer therapies are unavailable in this country the blame can be laid squarely at the feet of the Food and Drug Administration for its painfully-slow approval processes, and a profoundly broken medical malpractice tort system which incents doctors to avoid prescribing such therapies.

As for infant mortality rates, it’s true that the United States ranks 33rd in the world, behind most other developed nations.  But a country’s infant mortality rate isn’t a particularly useful proxy for the quality of healthcare available in that country: these rates are affected by, for example, infanticide, SIDS, abuse, and neglect, none of which have anything to do with healthcare.  The same is true with life expectancy, which in the United States is impacted enormously by factors having nothing to do with our healthcare system (our high rate of urban violence, for example).  A better proxy would be a metric more closely related to quality of care such as long-term cancer survival rate — and there, the United States compares quite favorably with the rest of the first world.  Similarly, the “other countries achieve better healthcare outcomes for less money” factoid, while a handy talking point, is based on apples-to-oranges comparisons: it turns out that it matters a great deal how you define “better outcomes” and “less money”, and otherwise slice the relevant data.

In terms of margins, and being on them, an uncomfortable truth that I’ve been pointing out on this blog for some time now is that someone, somewhere, is always on the margins, and — this part is important — this is the case regardless of precisely how a society allocates healthcare.  Why is this so?  Because contrary to the claims of people who insist that healthcare is some sort of basic right, healthcare consists of goods and services for which there is virtually unlimited demand but a finite supply.  To put it another way, the laws of scarcity apply to the provision of healthcare: there’s not enough of it to go around, and so somebody is going to get the short end.  This is the case in the United States, in Canada, in Great Britain, in Sweden, in Australia, in Cuba, and in every other country in the world which has yet to discover Star Trek replicator technology and the secret warehouse containing an unlimited number of clones of Dr. Doug Ross.  The question is not whether somebody’s going to go without the care they need, but who and why.  In the United States we ration care on the basis of price.  As such, the marginal cases are the 17 or so million folks who legitimately cannot afford health insurance but don’t qualify for some kind of public assistance, and those who have become uninsurable because of pre-existing medical conditions.  In countries with socialized healthcare systems, care is rationed on the basis of need as determined by politicians and bureaucrats, within the practical budgetary constraint of how much money can be squeezed out of the citizenry without formenting a revolt.  Accordingly, the marginal cases are individuals who have significant but non-emergency healthcare needs and, increasingly, the elderly.

Once we reconcile ourselves to the reality that some people are going to suffer and die for want of medical care whether we like it or not, regardless of how we allocate healthcare, the question then becomes how specifically we should allocate healthcare so as to minimize the suffering and death, consistent with our other values.  The crux of the argument against socialized systems is that their benefits, relative to for-profit sytems, are wildly overstated; that they have enormous collateral consequences to the larger healthcare industry (i.e., you can’t switch over to a socialized system and expect the incentives for medical innovators to remain in place); and they have an intolerable cost in human freedom (of which the basic injustice of being forced to subsidize the healthcare needs of strangers is indeed part, but only part).

“Freedom,” you might scoff.  “That’s just a word.  How can you possibly measure that against somebody’s life?”  Ask these guys.  Every single one of them signed his name on a piece of paper declaring that men had certain inalienable rights, among them life, liberty, and the pursuit of happiness, and knowing that by so doing he was committing treason and would be, if captured, hanged or shot.  For an example of more recent vintage, consider this case out of the state of Kentucky: we value freedom so highly that we’re willing to allow a murderer to escape responsibility for her crimes merely because police didn’t comply with procedural niceties while gathering evidence against her.  And if you prefer the general to the specific, consider that we tolerate around 40,000 deaths each year so that we can enjoy the privilege of driving, and another 2000 or so deaths each year so that we can enjoy the privilege of relaxing in a swimming pool.  Americans, as a people, have long been willing to step over a lot of bodies, and wade through a lot of blood, to be free.

That freedom is messy is, of course, cold comfort to somebody neck-deep in the mess.  But as I have said before: while it may not be fair that people suffer financial ruin merely because they get sick, it’s hardly more fair to force other folks to pick up the tab.  Dispersing injustice is not the same as creating justice.

Senator Robert Byrd (D-WV) wants to name the healthcare bill after his deceased friend Ted Kennedy.

Warning to Democrats: Like many people, I’m very deliberately holding my tongue about Kennedy out of decorum, a sense of respect for the Kennedy family in what is undoubtedly a difficult time.  If, however, you insist on politicizing the man’s death, the gloves come off.

My thoughts about the man are unprintable.  I will thus confine myself to offering condolences to the people who loved him.

Over the weekend, Jonathan Adler at the Volokh Conspiracy critiqued a column by David Rivken and Lee Casey purporting to demonstrate the unconstitutionality of healthcare reform.  Adler finds himself mainly in agreement with liberal critics of Rivken and Casey, albeit not necessarily on each particular.

I think Rivken and Casey are whistling past the graveyard on this.  You can make a straight-faced, not-completely-barking-insane argument that an individual mandate — that is, a federal requirement that individual citizens obtain health insurance — is a necessary and proper element of the overall federal regulatory scheme.  After Gonzalez v. Raich, 545 U.S. 1 (2005) and United States v. Lopez, 514 U.S. 549 (1995), that’s a sufficient “rational basis” to beat back any challenge to such legislation on constitutional grounds.

But what this illuminates is the degree to which the Commerce Clause — which was intended and originally understood as a robust constraint on federal authority insofar as it was one of a finite set of enumerated powers of the federal government — has been folded, spindled, and mutilated by the federal judiciary to the point where it may as well read, “Congress may do anything that it wants, and the states and the people should just lean back and try to enjoy it.”  When Congress can regulate purely intrastate activity on the grounds that it might, maybe, possibly, somehow, when aggregated with other such activity, have an effect on interstate commerce, we are no longer dealing with the Constitution that the people of the United States ratified.  Rather, we are dealing with something out of Plato’s Republic, with black-robed political appointees providing the mythology to justify the rule of our Congressional philosopher-kings.

As the president packed the family aboard Marine One for a summer trip to Martha’s Vineyard, the White House announced that it had revised its 10-year deficit projections upwards from $7.1 trillion to $9 trillion.

Left as an exercise for the reader is to imagine how the media and the political left would have reacted if George W. Bush had done something like this.

GayPatriot, in a terrific post titled “What Obama Calls ‘Cynicism,’ We Call Freedom,” links to a Katherine Mangu-Ward piece at Reason that describes the president’s evidently limitless faith in the munificence of government.  Here’s Ms. Ward:

Back in the misty days of January 2007, [President Obama] warned the Democratic National Committee about us. The “cynics,” he predicted, would fight health care reform. “With such cynicism, government doesn’t become a force of good, a means of giving people the opportunity to lead better lives; it just becomes an obstacle for people to get rid of. Too often, this cynicism makes us afraid to say what we believe. It makes us fearful. We don’t trust the truth.” He blended together his own health care plan, government as a force for good, and truth into a delicious rhetorical smoothie, and they ate it up.

And here’s GayPatriot:

Sorry, Mr. President, it’s not cynicism which prevents me from seeing government as a force of good, but experience, experience with the efficacy of the free market and experience encountering the obstacles of state-run services.   That’s not just my own experience, it’s also that of countless others who have seen the failure of government endeavors to improve out lot, initiatives which succeeded only in impeding the efficient delivery of services and slowing (if not blocking) innovation.  Such experiences have reaffirmed the commitment of many who now oppose Obamacare to a principle, the idea of freedom.

Completely aside from the efficiency argument, though, consider all of the horrors that government has perpetrated just in our own country.  Just to name a few: The Japanese internments.  The Tuskeegee Experiments.  The Kent State massacre.  Waco and Ruby Ridge.  In every one of these cases the people responsible believed they were acting for the commonweal, and yet each incident was a moral atrocity.

Government is not a force for good.  It’s at very best a necessary evil, and with regrettable regularity is just plain evil.  This isn’t cynicism; it’s the uncontestable verdict of history.  The people who founded the country understood this, and at one time liberals did, too.  Even if the thinking is, “Those kinds of things can’t happen because the good guys are running the show, today,” what guarantees do we have that the good guys will remain on the side of righteousness, and will never be replaced by monsters?  So why would anyone with any sense trust an entity that empowers monsters with anything, much less something as critical as healthcare, even if the alternative doesn’t invariably churn out shiny and happy results?

For my money one of the truly remarkable aspects of the healthcare reform debate is how fundamentally dishonest it is.

For example, why is it that anecdotal sob-stories relating the horrors of our by-and-large for-profit healthcare system are probative of the fierce moral urgency of reform, but anecdotal sob-stories relating the horrors of other countries’ socialized healthcare systems are somehow not probative of the possible/probable consequences of moving our system in that direction?  Stop me if you’ve heard this one before: “Yes, the Canadian and British healthcare systems aren’t without their problems, but on the whole those systems produce better outcomes for less money than ours, and we’re not proposing a move to a full-blown single payer system anyway.”

Therein lie two more enormous whoppers.  Better outcomes for less money?  That depends on how you slice the data, and measure “better outcomes” and “less money”.  We’re not proposing a single payer system?  Well, no, not directly — but for many “reform” proponents, likely including the president himself, single payer is demonstrably the goal, and ObamaCare the thin end of the wedge.

But what about the $BIGNUM uninsured people in the country?  The precise talking point varies, but the most common figure, derived from a U.S. census report, is 47 million.  But the disingenuity of the talking point is that only a fraction of those 47 million are involuntarily without insurance due to financial need, and without any recourse to existing public assistance.  A picture is worth a thousand words.

And then there’s the staggeringly dishonest campaign against increasingly-vocal opponents of ObamaCare.  Take yesterday’s video, which has since gone viral.  The woman is being held out as an example of the ignorant right-wing rubes who’ve allegedly been disrupting much-needed reasoned discourse on reform.  In reality she’s a disciple of Lyndon LaRouche (who of course is much more sympatico with the political left than the right) unrepresentative of anything except the other bats in the belfry of American politics.  There’s a far stronger case for hanging the Code Pink crazies around the neck of the political left than a wild-eyed LaRouchie around the neck of the political right.  Barney Frank as some tribune of good-faith debate?  C’mon: he’s one of the most hyperpartisan, ethically-compromised bags of crap in Congress, one of the two people (the other being Chris Dodd) principally to blame for, in an act of brazen political patronage, derailing efforts to reform Fannie Mae and Freddie Mac at a time when the subprime lending implosion could have been prevented or at least significantly mitigated.

Oh, and about that reasoned discourse that’s allegedly being disrupted: let us all recall that if the president had gotten his way, ObamaCare — one of the most consequential pieces of legislation in the last forty years, in terms of scope and long-term effect — would’ve been rammed through Congress in about two weeks, prior to the August recess, without any meaningful debate.  The president’s preference for the way the public “debate” should be structured appears to be a scenario in which skeptics of reform simply shut up and let themselves be hectored, and in which dissenters are reported to the White House.  That last bit was so outrageous that even the White House has had to walk it back.

But the pièce de rèsistance of mendacity thus far has to be this MSNBC report.  Contessa Brewer practically soils herself pushing the “ObamaCare opponents are racists” narrative:

A man at a pro-health care reform rally…wore a semiautomatic assault rifle on his shoulder and a pistol on his hip….there are questions about whether this has racial overtones….white people showing up with guns.

Just one problem: the man Brewer was describing was black.  And the video, you will note, was carefully edited to avoid showing his face or arms, or any part of him that might give an indication of his skin tone.

Appropos of this: there is a great temptation to merely snark that Barney Frank labelling anything “vile” and “contemptible” is a fabulous takes-one-to-know-one moment.  However, this is an apt demonstration of the Stuck Clock Principle: unless someone is proposing herding people into ovens, saying their proposal amounts to “Nazi policy” is profoundly offensive and stupid.  Something can be bad policy without dragging Hitler into it.  Similarly, not everything the Nazis did was uniquely evil — I am certain, for instance, that Hitler brushed his teeth.

This goes, incidentally, for the Code Pink types on the left as well as these Bircher fools on the right.  The Bush-Hitler comparisons have been repulsive and unedifying lo these last eight years (and it would be nice if the left could collectively bring itself to admit that, but I won’t hold my breath); the Obama-Hitler comparisons are equally so now.

CORRECTION: Turns out that the fools aren’t Birchers, but Lyndon LaRouche-ites.

The ululating of the San Jose Mercury News editorial board in support of ObamaCare is as predictable as it is tedious, and today the editors emerge from their creche of Bay Area conformity to exhort the president to keep on keepin’ on with the “public option” despite mounting political opposition:

President Barack Obama is making a huge mistake to cave so easily on a public option as part of comprehensive health care reform, as he appears to be doing this week.

America’s employers and employees have a common interest in driving down health care costs — keeping businesses competitive and workers healthy and productive in today’s global market. That won’t happen if there is no government-run insurance option.

Obama needs to hold firm and better educate the public about why it’s so important…

Obama started out working for a bipartisan consensus, which was the right thing to do. But now it’s clear that Republicans have no interest in bipartisanship. They’re not going to support real reform, no matter how many concessions Obama makes to them or to the talk-radio puppets who disrupt town hall meetings.

Let’s make note of all the nonsense packed into these paragraphs: that it’ll be impossible to control healthcare costs absent some kind of government-run insurance program; that this relentlessly partisan ”I won” administration has now or ever worked earnestly for a bipartisan consensus; that Republicans won’t support “real reform” (as if only liberal policy amounts to “real reform”); that the people attending town hall meetings to voice displeasure with their congresscritters and with ObamaCare are disruptive “talk-radio puppets” rather than, in the main, voters with legitimate concerns.

Also amusing is the subtext that hardening Republican opposition to the plan is going to force the Democrats to go it alone.  Reality check — Democrats enjoy untrammelled power in Washington, right now.  They control the presidency, have a 60-seat majority in the House, and a filibuster-proof majority in the Senate.  Anything they want, they can get right now without a single Republican vote (hence the administration’s aforementioned “I won” attitude).  The sturm und drang over healthcare reform exists not because of anything the minority party is doing, but because the various reform proposals under consideration are deeply unpopular with the electorate, particularly in the swing congressional districts that, in 2006 and 2008, elected moderate and conservative Democrats to break Republicans’ control of Congress.  To put it another way, the problem is that Democrats are being forced to choose between their majority and healthcare reform: to keep the former they probably have to give up on the latter (at least in significant part, anyway).  Moderate and conservative Democrats who help ram ObamaCare through Congress are going to get killed in the 2010 midterms.  That’s the political dynamic, here, and it has nothing whatsoever to do with Republican obstructionism.

But the real “what planet are these people living on?” moment comes at the end of the editorial:

A public option would utilize the government’s immense negotiating and buying power to drive down rates. Medicare operates with just 8 percent overhead and cares for the vast majority of senior citizens of this country. Why isn’t that the theme of town hall meetings?

Uh.  Medicare is currently facing $74 trillion in unfunded liabilities, according to the program’s trustees.  To put that in perspective, total U.S. GDP is approximately $14 trillion.  In other words, to dig Medicare out of the fiscal hole it’s in, we would have to spend every penny of value of everything produced anywhere in the United States for five straight years.  Notwithstanding the government “using its immense negotiating and buying power to drive down rates” — in other words, using political influence and monopoly power to lowball healthcare providers — Medicare is not able to care for the vast majority of senior citizens of this country without burdening future generations with crushing debt.  The idea that the program has in any way, shape, or form controlled healthcare costs is positively delusional.