Ten Questions On Health Care

Nancy Pelosi says that we are on the doorstep of history. Perhaps. History is a an uncertain host. As Mark Steyn said, last week we are on the front porch of history. But, back in December, we were at the garden gate of history. Then Scott Brown was elected, and we backed down the front drive of history, reversing over the neighbor's dog of history.

But as we wait for the passage of ObamaCare, here are a few thoughts. We all know the old saw about legislation and sausage making, but if this reform package is indeed the historic act of compassion and cost control that it is said to be, how do we answer these questions?

1. Why is it necessary to dissemble about its costs? The CBO score is a pastiche of odd inclusions (savings on student loans?), omissions and unlikely assumptions. As the public opinion polls reflect, it is fooling no one but the Democrats, certain elements of the mainstream media and Paul Krugman. (In fairness, the dissembling largely consists of treating the CBO score as something more valuable than it is, see, e.g,. Nancy Pelosi. ("I love the numbers. They're so precise.")

2. Why not pay for it? This question is a subpart of the first. The bill is going to cost quite a bit of money and it is not close to being paid for. If this is such a wonderful thing, then its proponents should not fear an honest assessment of what it will take to fund.

3. Why support it with a series of red herrings and dubious assertions? The post-partisan - no post-political - President Obama has decided to double down on blaming problems with the health care system on the insurance companies. This is silly. Insurance company profit is a tiny sliver of the cost of health care. The inability to get someone else to pay for the cost of treating your pre-existing condition is a problem that requires a solution, but it is not the fault of insurance companies. Covering a pre-existing condition is not insurance.

Most people get insurance through their employers and, by law, most who do have coverage for pre-existing conditions. (Most of those folks, moreover, aren't covered by an "insurance company" at all.)

We could go on. It is highly unlikely that extending coverage to uninsured persons will reduce the cost of their care. It is probable that additional preventive care will increase, rather than decrease, spending on health care, etc.

The bill might still be a good idea. But, if it is, why support it with bad arguments?

4. Why hide the ball on cost controls? It is still unclear to me why the bill is supposed to reduce costs. It certainly does provide a mechanism to aggressively ration care under Medicare and Medicaid by turning them into the Mother of HMOs. But there seems to be a step two that will be required. The President has advocated price controls - an economically illiterate idea - but its apparently out because it couldn't be enacted through reconciliation. Perhaps the idea will be to impose "best practices" (i.e., rationing) on private plans through the manipulation of subsidies and the definition of qualified plans. Whatever the case may be, why not put everything on the table now - as we enact "comprehensive reform." How we are to control costs is not unrelated to - and might rationally affect decisionmaking on - how we provide care.

5. Why enact a bill that is almost certainly unworkable? And not only because it's going to cost a lot more than is claimed and is not paid for. The only way that requirements that preexisting conditions be covered and that not result in higher premiums can possibly work is a coverage mandate. The bill has that, but it seems that the penalty that is to be charged for failing to obtain coverage is substantially less than this coverage would cost. If that's so, then why wouldn't it be rational to wait until you have a significant health issue and buy coverage then? The bill does things - like gutting Medicare Advantage (the Q-Tip vote is going to go ballistic on this, just wait)) and ignoring the doc fix - that no one believes can last. Nancy Pelosi says that after "we kick in this door" there will be more legislation. They'll have to be. If we know that now and we are enacting "comprehensive reform," why not address these matters? The solution might be relevant to how the current bill should be structured.

6. Why deny the bill is what it is? It may not be a "government takeover" of health care in the sense of a single payer system, but it is a massive increase both in government spending on health care and federal management of the health care system. Forever more, the key decisions on health care are going to be made in Washington DC because he who pays the piper calls the tune. The public sees this and that is why it strongly opposes the bill. But if the public is wrong and centralized management of the health care system by politicians and bureaucrats is a good idea, then why not make the case?

7. Why mislead the public about its impact? Many, many people are going to lose the coverage that they have. The distinction between being directly forced to drop it and losing it because of the effects of "reform" is specious and yet the President continues to make this point. The bill is may create a two tiered system of people with relatively robust employer-provided coverage and people on something like Medicaid. You can say that we have that now but it seems likely that one of the prices for expanding coverage may be to weaken coverage for some who already have it. Will 85% of the public still be happy with their health care? By increasing the marginal cost of labor, it may increase unemployment. Is that worth it? We can't decide if we don't acknowledge the trade-offs.

8. Why freeze out the Republicans? There was nothing bipartisan about putting this together. We started with the Obama plan and then tweaked it to get enough Democrat votes to pass it. No Republican amendments or alternatives need apply.

9. Why ignore public sentiment? Here is what the Democrats are telling the public: You don't know what you're talking about it. We know better than you what is good for you. Rather than take his case to the public, the President is taking it to a handful of obscure Congressman and offering Obama knows what. That's fine when your proposal isn't down by double digits in most polls.

10. Why pass a bill with real constitutional problems? It is far from clear that challenges to the mandate or, depending on what they do today, the method of the bill's enactment will succeed, but there are very substantial issues. Both could readily be avoided. If we are going to do more than have a quick look around history's foyer, shouldn't they have been?