Quote of the Day II

The distinctive American version of libertarianism focuses almost solely on the value of freedom, and makes freedom synonymous with non-interference at the hands of government. In more sophisticated variants, libertarianism focuses on the dignified human, makes freedom the most important (but not the only) political precondition for the achievement of dignity, and seeks to ensure that dignity is achievable by all. But the American version dispenses with any complicated talk of the many-sided human personality, or the connections that might tie us together (what we owe to each other), and pursues with single-minded zeal the idol freedom.

-- Steven Kelts, Political Theory professor at GW, guest blogging at The Monkey Cage

5 Freedoms To Be Lost with Health Care Reform

Alright, Michelle sent me this article from CNN Money/Fortune on 5 potential freedoms to be lost with health care reform, at least in its pretty unclear form at this point. I thought I'd post the five here and grapple with them a bit.

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1. Freedom to choose what's in your plan

Today, many states require these "standard benefits packages" -- and they're a major cause for the rise in health-care costs. Every group, from chiropractors to alcohol-abuse counselors, do lobbying to get included. Connecticut, for example, requires reimbursement for hair transplants, hearing aids, and in vitro fertilization.

This I would say is a fair critique, to a point. The good intention: making insurance companies cover people's afflictions in a fair, substantive manner. Obvious big government drawback: special interests will push through their own agendas so that some unnecessary things are included. This is no great insight, and it is an unfortunate cost. But two points.

One, though it be a truism, no plan will be perfect. We will simply have to accept some inefficiencies. Two, some of these higher costs and inefficiencies will hopefully be addressed by the independent committee of experts proposed to be assigned to present an annual report on ways to cut costs, and unlike past committees similar in nature, Congress will be required by law to vote for or against their recommendations, giving the committee some teeth.

What I don't think is that this drawback serves as a significant loss of freedom. The article suggests:

The rub is that the plans can't really compete based on what they offer. The reason: The federal government will impose a minimum list of benefits that each plan is required to offer.

This seems a bit of a non sequitur to me. Because plans are required to provide certain benefits, they will not be able to compete based on the other things that they offer at competing costs? I think there may be some cost increase, considering increasing minimum benefits entails a higher minimum cost, and thus less of an option for more benefits under a cost constraint. But that's in a vacuum. Certainly the presumption could be that the public plan and other reforms will lower costs in other ways sufficiently to offset the possible increase above. Obviously I don't have the economic analysis before me, but I am certain that my analysis is no less formal than the article I'm working with, so I won't worry too much.

I agree the "standard benefits packages" may cause some inefficiencies, but I don't buy them creating any significant loss of freedom. Moving on.

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2. Freedom to be rewarded for healthy living, or pay your real costs

Americans with pre-existing conditions need subsidies under any plan, but community rating is a dubious way to bring fairness to health care. The reason is twofold: First, it forces young people, who typically have lower incomes than older workers, to pay far more than their actual cost, and gives older workers, who can afford to pay more, a big discount. The state laws gouging the young are a major reason so many of them have joined the ranks of uninsured.

This is in some fashions, I suppose, a loss of freedom. But I think the issue is complicated when one takes a long-term and wholistic perspective. People age; the young become old. As such, as per the above argument, the young will then get to the point where their insurance rates become the lower, more subsidized ones. It is far from irrational for a society to decide that the most efficient way to provide health insurance to all its citizens is to place more of the cost on the young than the old, considering that the economic circumstances that the young enter into our the result of the efforts of past generations, that is, the elderly that their higher rates subsidize.

If society tends to force the elderly to retire and lose their income to the young who enter into the ranks of the employed, then there must be a mechanism by which the elderly are compensated by the system and supported, in return for their previous input for society. That is not to say that this system will be perfect, considering we are restricted from considering a single-payer system, which would open up better possibilities for dealing with this issue. But this so-called loss of freedom must be viewed through the perspective that we necessarily give up certain freedoms to secure greater goods and efficiencies within the social contract. This is perhaps one of those instances. So, in strict terms, yes, this would be a loss of freedom, but it is a voluntary loss, decided upon through the mechanisms of democratic republicanism, violating no inviolable rights. Only strict libertarians can object to such a point, and a majority of the American public has not embraced such a political philosophy.

One last thought on that point. It does say:

Under the Senate plan, insurers would be barred from charging any more than twice as much for one patient vs. any other patient with the same coverage.

So then to claim that the reforms "would ban insurers from charging differing premiums based on the health of their customers" isn't exactly accurate. There is some leeway to charge different rates, though of course it will be admitted not full leeway. But we dealt with that point above.

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3. Freedom to choose high-deductible coverage

The bills seriously endanger the trend toward consumer-driven care in general. By requiring minimum packages, they would prevent patients from choosing stripped-down plans that cover only major medical expenses. "The government could set extremely low deductibles that would eliminate HSAs," says John Goodman of the National Center for Policy Analysis, a free-market research group. "And they could do it after the bills are passed."

I don't really have a great answer for that. One thing though is the very cautious phrasing. "Seriously endanger." "Could do it." "After the bills are passed." That makes it sound uncertain, but the author is clearly quite biased enough to not mention the alternative possibility and the chances of and factors involved in each. And it certainly doesn't satisfy the highly inflammatory title of the article, which is not ambiguous or qualifying in its claim. So I will move on from this one, not having read much on this specific aspect of the plan and having undercut its credibility anyway.

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4. Freedom to keep your existing plan

The bill gives ERISA employers a five-year grace period when they can keep offering plans free from the restrictions of the "qualified" policies offered on the exchanges. But after five years, they would have to offer only approved plans, with the myriad rules we've already discussed. So for Americans in large corporations, "keeping your own plan" has a strict deadline. In five years, like it or not, you'll get dumped into the exchange. As we'll see, it could happen a lot earlier.

I don't see how this is a new critique. As the author says, "with the myriad rules we've already discussed." As in, you'll have the same losses of freedom that I've already considered and critiqued. And actually, you get five years to put off this change, or reform, depending on your point of view. It seems to me that the author just wanted to get to five critiques. I don't see how this one has anything new to offer.

But even if it is a new critique, is it accurate and fair? I searched seriously for like an hour to find this article, because I knew that I had read something, somewhere about this. Finally found it at ThinkProgress in a post from July 16th, thus explaining the slight memory loss. Here's how they put it:

In fact, page 16 is the beginning of the section on “Protecting The Choice To Keep Current Coverage.” The section that refers to five years is on page 17, but it’s not about pushing Americans off their current health plans. As the summary on Rep. Pete Stark’s (D-CA) website notes, it simply “provides for a five year grace period for current group health plans to meet specified standards.”

So neither one is exactly untrue. It is at some point a matter of your perspective. I tend to side with the latter, but I am certainly biased. So you can either think of it as, yeah, you get to keep your coverage, crafted under the rules of the former system, but only for at most five years. Or you can say, we're reforming this system, and we want to solve it's problems, but we understand that we're in a recession, and people need time to adjust, so there are five years to do so.

And I also wanted to point this out, as a bit of a side note, from the same post by ThinkProgress:

The House bill actually increases the number of people who receive coverage through their employer by 2 million (in 2019) and shifts most of the uninsured into private coverage. By 2019, 30 million individuals would also purchase coverage from the Exchange, but only 9-10 million Americans (or approximately 1/3) would enroll in the public option, the rest would enroll in private coverage.

This is another critique, not necessarily presented here, but I still thought I'd mention it as long as I was linking to the article. Plus, it does show an increase in freedom I think, at least by the author's standards. Moving on.

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5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges -- and as we've seen, that will soon be most Americans -- must get their care through something called "medical home." Medical home is similar to an HMO. You're assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. It was consumer outrage over despotic gatekeepers that made the HMOs so unpopular, and killed what was billed as the solution to America's health-care cost explosion.

Alright, lots here. To be honest, I had not heard of the medical homes before, so I had to do some searching, and it certainly wasn't something that came up quickly in a google search. And if it's not coming up, my first instinct is not to trust it, because, as Media Matters of America has shown, negative coverage of the bill has outweighed positive coverage by about 100% in the debate on health care in the mainstream media. So if I can't find the critique, then it's probably not really being made, and any critique that can be found is out there, reasonable or not. So that's my first qualm about it.

Here's what J. James Rohock had to say, the President of the American Medical Association:

New models of care like the medical home, where patients have one physician coordinate care across many specialties and settings, benefits patients and rewards doctors for focusing on aspects of care that are vital but less tangible than procedures. This is the type of care physicians want to provide and patients want to get.

So, it's not clear to me that it is a requirement that people now operate through the medical home program, and honestly, I haven't read anything about that, and I read a lot of commentary. So I don't exactly know what to make of it. The context of the NYT times piece from Rohock seems to suggest that it's just one new method that will only be one option or part of the health care reform. Plus, it certainly doesn't suggest that you don't get to choose your own doctor to coordinate care, e.g., your current doctor. And the author of the article doesn't ever cite where this comes from in the legislation. So I really just don't trust it. I don't have any more substantive argument about medical homes themselves. Here's one thing from Knowledge@Wharton, the online business journal for UPenn's prestigious business school, that I found that could lend itself to the article's argument:

The various health reform scenarios being debated on Capitol Hill place some emphasis on bolstering primary and preventive care. The idea -- a familiar theme heard especially in the early days of HMOs -- is that if everyone had a so-called "medical home" with a primary care physician, they would be more likely to get timely and preventive care, thus avoiding more costly trips to specialists and emergency rooms. Uninsured Americans don't necessarily go without surgery or care when they get sick -- but they may put off treatment or be seen by a doctor in the emergency room instead of the doctor's office.

But that isn't very clear either, and certainly doesn't make anything sound certain. I'm going to have to file this claim under another failure to meet the standard set by the article's own title. You will, no wait, maybe lose 5 key freedoms.

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So that's what I got. Certainly my longest blog post ever. What do you think? Where do you disagree with me? I simply don't find much credibility here. Show me more proof, please. It's an online article. The internet has made it so easy to cite sources and show where you get your information. It's not here. So I'm unconvinced. I'd love someone to supplement the argument. But at this point, I reject almost all of it as unsupported or wrong-headed. But I've certainly enjoyed this exercise, and hope for some feedback and improvement.

Spot on:

So here's how this game works: Republican and centrist Dems attack the stimulus and force changes that make it less effective. Then, a few months later, these same parties turn around and attack the stimulus as being ineffective, even though their own requested cuts and critiques made it less effective.

But hey, that’s what the opposition party does. It's what any rational party leader has to expect.

So the lesson for health care is that the attacks will come regardless of whatever accommodations Baucus makes. At the end of the day, it’s better to bite the bullet and get the policy right. Political cover isn’t coming under any circumstances. And more to the point, the pursuit of political cover is itself a dangerous game because it leads people to adopt bad policy for bad reasons.

Health Care Media Matters

And of course Digby is absolutely right to note that this matters very much.

Americans always get nervous when their leaders are perceived to be losers. In fact, they hate it. And when the media skews toward failure unfairly, it has an effect on public opinion.

Negative news will need to negative feelings and associations. It's not difficult to grasp. I'm not sure it's bias so much as the corrupt, commercialized nature of the mainstream media, but it has a terrible effect on our political discourse, and it certainly undercuts the persistent notion of a liberal media bias, a particularly disturbing myth, since it then leads to those actually on the left, mostly in the blogosphere, being decried and dismissed as "Far Left." It's a joke.

A Media Matters for America analysis of transcripts available in the Nexis database has found that broadcast and cable news featured almost twice as many segments mentioning the American Medical Association's (AMA's) reported opposition to a public insurance plan as segments mentioning the AMA's recent announcement that it supported the House Democrats' health care reform bill, which includes a public plan.

The War Being Waged on TARP Watchdog's Independence

From Greenwald. This is a man truly after my own heart.

So seriously does Barofsky take his oversight duties that, as a Washington Post profile noted in March, "he refuses to eat with senior administration officials in the [Treasury] building's executive dining room to maintain his independence."

And the attack:

Most significant of all, and obviously due to Barofsky's truly independent oversight efforts, the Obama administration is now attempting to induce the Justice Department to issue a ruling that Barofsky's office is not independent at all -- but rather, is subject to, and under the supervision of, the authority of Treasury Secretary Tim Geithner. By design, such a ruling would completely gut Barofsky's ability to compel transparency and exercise real oversight over how Treasury is administering TARP, since it would make him subordinate to one of the very officials whose actions Congress wanted him to oversee: the Treasury Secretary's. Barofsky has, quite rightly, protested the administration's efforts to destroy his independence, and has done so with increasing assertiveness as the administration's war on his oversight activities has increased. Why would an administration vowing a New Era of Transparency wage war on a watchdog whose only mission is to ensure transparency and accountability in these massive financial programs?

Personal Values Color Understanding Of Sentences Within Milliseconds

And it seems that fate kindly tossed up a freebie for my first day of blogging. All the more reason why we do not, and cannot, know.

The researchers conclude that existing views and beliefs influence our understanding of language before we even fully process a sentence. This research sheds new light on the way the human brain processes language: instead of reading carefully before forming an opinion, the brain responds intuitively within a mere 200 milliseconds of having more or less grasped what the sentence fragment read so far is suggesting. This response then influences further interpretation. In addition to its significance to language researchers, the study also opens up new avenues for scientific research on how political and ethical beliefs affect our thought processes.

If I'm reading this correctly, one of the chemical responses that occurs in the mind is actually the same as when you hear something that you believe is impossible or at least very unlikely. That's incredible.

The N400 effect is a well-known brain response to an unlikely or impossible meaning (for example, ‘I’m drinking a pizza’). Unlike previous studies, the effect here was determined by the participant’s political and ethical beliefs: statements that were entirely acceptable to one participant proved problematic for others, evoking a strong emotional response. This effect of personal value systems had never been identified before....

The ‘unlikely meaning’ response (N400) could only be clearly identified when participants were given a statement they strongly disagreed with. Further studies will have to be conducted to identify the exact cause of this phenomenon.

Quote of the Day

"Economics textbooks tell us that concentrated markets reduce the competitive behavior that benefits consumers and lead to outsize profits for the dominant firms. Predictably, health-care premiums shot up more than 90 percent between 2000 and 2007, while the profits of the 10 largest insurers increased 428 percent over the same period. Clinton had promised us managed care within managed competition. Instead, the insurers took control of our care and managed to effectively end competition. Neat trick."

-- Ezra Klein, The Ghosts of ClintonCare [via Dish]