Libertarians and health care

I've been having an email discussion with a libertarian friend of mine about the recent passage of the health care reform bill. While the exchange is already too long to post in its entirety, I did want to put up some excerpts. It started when I received an email blast saying that the bill is an inappropriate use of funds to interfere with the functions of private enterprise.

The first thing I mentioned is that I have a personal interest in the bill's provision that patients cannot be denied coverage for pre-existing conditions, as I have already gone through the experience of being denied coverage due to a mild case of high blood pressure that requires me to take some low dosage pills. Luckily, I got a new job later that covered me, and I can now extend the same plan under COBRA if I switch jobs. But it was a tense few months for me.

Later, I wrote:

Me:
Libertarianism has always struck me as a severe case of having only a hammer in your toolbox and perpetually seeking nails. Is the economy doing well? Then it's time to lock in those gains by eliminating regulations. Is the economy doing poorly? There are too many regulations. Is the economy still doing poorly after regulations have been gutted or deliberately unenforced in a particular area? The measures didn't go far enough; the solution is to roll back more of them. When I say that I am results based, what I mean is that you should be willing to actually compare economic conditions during different times or across different countries that have more or less regulation in these areas.

Libertarian "experiments" don't appear to confirm their hypotheses, because countries with varying degrees of regulation don't appear to reflect the claim that an unencumbered economy is a healthy economy. Let me demonstrate with a little on-the-spot research. The United States ranks 38th in a list of countries by life expectancy. Quick spot check. Among the top three countries:

• Japan provides healthcare services, including screening examinations for particular diseases at no direct cost to the patient, prenatal care, and infectious disease control, are provided by national and local governments.
• Hong Kong has a mixed health care system, with public hospitals being managed by their Department of Health.
  
• Iceland has universal health care.

All three of these countries I just looked up have stronger government involvement in health care than the bill that just passed. By contrast, let's take a look at the bottom three.

• In Swaziland, public expenditure on health amounts to 4% of the nation's GDP. This is less than the United States has now (a little over 6%).
  
• In Mozambique, public expenditure on health is about 2.7% of the GDP.
• In Zambia, public expenditure on health is about 3.4% of the GDP.
  

This is the kind of elementary research that I mean when I say that I would prefer evaluation to be driven by outcomes and evidence. Now, granted, health care isn't the only factor in life expectancy. However, there is a clear correlation that seems to belie the assumption that "more public involvement => worse results." Obviously I haven't done an exhaustive survey of all 195 countries on the list. But I'm willing to bet that a completed graph would retain the overall pattern that countries which spend more public dollars on health tend towards higher life expectancies, and vice versa.

Lib:
Of course people are healthier when there is more access to healthcare. The question is, who is better at providing the health care. Governments make the claim to cover everybody. But that's all it is, is a claim. We hear a lot about private insurance companies rejecting individual people's claims. But that's nothing to the number of people rejected by government plans. Just look at Massachusetts.

Me:
I think I've covered this question pretty well by my back-of-the-envelope survey of other countries. But all right -- I took you up on your request and looked. First thing I found was that Massachusetts has the lowest rate of uninsured residents in the country, at 5.5%. It was 8.7% in 2006, before the bill was enacted, so it has dropped significantly. The highest uninsured rate? That would be Texas, illustrious home of no state tax, clocking in at 26.9%.

I also looked for something to corroborate your implication that more claims are denied in Massachusetts than in most other states, but have so far come up empty handed. If you have evidence that Mass's system has enough negatives to offset the very excellent coverage rate, I'm sure you'll let me know. In the meantime, I'll continue my previous theme and take a look at life expectancy by state.

Huh... what do you know? Liberal Massachusetts with their public health program is fifth highest on the list. Texas, with the highest number of uninsured, comes in at 34.

Now, you might fairly regard this as a little bit of sleight of hand, since Mass only enacted their health plan a few years ago, and the results on life expectancy could hardly be expected to be measured thoroughly by now. However, Mass has always been demonized by economic conservatives as being an example of rampant "socialist" liberalism at its worst. So I'm content to have past results of this horror be reflected by the life expectancy now.

In a followup letter, this exchange occurred:

Lib:
The best analysis I've seen of [a nation's economic strength] is the Economic Freedom Index. The way I found out about this web site was a few years back when it made headlines (at least in Europe) that the US was no longer in the top 10...

http://www.heritage.org/index/Ranking.aspx

Me:
That's interesting, but it is begging the question. The Heritage Foundation is a well known conservative economics think tank. Any standard they use for measuring "Economic Freedom" is bound to involve qualities which are in line with the goals of the Heritage Foundation. Such a concept is inherently subjective, and assumes that the things that you want out of a government (i.e., lack of public funding for health care) are for the best. You can probably see why I'm hesitant to accept this as a neutral measure of how good those countries are.

Lib:
[I don't] value life expectancy if it interferes with quality of life. I had the privilege of sitting in on a health panel at Renaissance Weekend last year. There were many doctors and hospital administrators from Massachusetts. They were talking about a patient they refer to as the "Six Million Dollar Man" because there is no limit to what they are obligated to pay to keep this particular patient alive. To continue end of life treatment to this extreme will break the budget if everyone recieved such care.

Me:
You are, again, begging the question. I chose life expectancy because it is a relatively easy to obtain quantification of the overall health of the nation, one which is objective enough that it can't be easily fudged. If all else is equal, I assume you and I would agree that we'd rather live a longer life than a shorter one. (Or as Dave Barry once eloquently put it: "Son, it is better to be rich and healthy than poor and sick.")

But you've introduced a red herring, in saying "if it interferes with quality of life." Without providing any supporting data to show that quality of life suffers a lot from living in Japan, Hong Kong, or Iceland, this has nothing to do with what I said. If you'd like to pick another neutral measurement of quality of life, make a suggestion. But I'm not taking "The Heritage Foundation likes them" as an answer.

Here's an example of another standard you might pick for "quality of life." There is an organization that takes a snapshot of self-reported happiness by country.
http://www.nationmaster.com/graph/lif_hap_net-lifestyle-happiness-net

DEFINITION: This statistic is compiled from responses to the survey question: "Taking all things together, would you say you are: very happy, quite happy, not very happy, or not at all happy?". The "Happiness (net)" statistic was obtained via the following formula: the percentage of people who rated themselves as either "quite happy" or "very happy" minus the percentage of people who rated themselves as either "not very happy" or "not at all happy".

In a similar vein to my previous message, I note that the top three countries -- Iceland, Sweden, and Denmark, all have universal health care.

Breaking news: Democrats suck at politics

Stuff like this makes me repeatedly bonk my head in annoyance.

Under Massachusetts law, it'll probably take 10 days for the election of Scott Brown to be certified and for Brown to be sworn in as a Senator. Nothing nefarious -- that's just how orderly transfers of power work in a democratic system. Consequently, Paul Kirk will continue to serve as Senator up until the point that Brown is properly sworn in.

Barney Frank, God love him, doesn't think Kirk counts:

"I know some of my Democratic colleagues had been thinking about ways to, in effect, get around the results by working in various parliamentary ways, looking at the rules, trying to get a health care bill passed that would have been the same bill that would have passed if [MA AG] Martha Coakley [D] had won, and I think that's a mistake," Frank said. "I will not support an effort to push through a House-Senate compromise bill despite an election. I'm disappointed in how it came out, but I think electoral results have to be respected."

Jim Webb agrees, except ever so more so:

"In many ways the campaign in Massachusetts became a referendum not only on health care reform but also on the openness and integrity of our government process," Mr. Webb said. “It is vital that we restore the respect of the American people in our system of government and in our leaders. To that end, I believe it would only be fair and prudent that we suspend further votes on health care legislation until Senator-elect Brown is seated."

I watched a Daily Show episode this week in which Jon Stewart said something along these lines: "Oh. So apparently what is going to kill Obama's agenda is having only 59 allies in the Senate, which is more than the number that George Bush ever had, back when he did pretty much whatever the [bleeped] he wanted."

But as dumb as the new normal is, where Senate Republicans filibuster every bill every time regardless of content, what is even more stupid is that even leading Senators find it so easy to cut and run.

If Tom Delay had ever commanded a filibuster-proof Republican majority, which was about to end in two weeks, would he have said, "Aw shucks fellas, I guess we'd better put all legislation on hold in order to be fair to the Democrats"? Fuck, NO. What Tom Delay would have done was rush to cram as much legislation as possible into the next two weeks, in order to take maximum advantage of the existing time window.

Look, Democrats. Do I like it that the Senate is now this cutthroat, where both parties need to use every possible political trick in order to gain the upper hand? No. But it is what it is -- if you don't use every opportunity to get what you want, then you get steamrolled by Republicans, who have no such scruples.

Odds and ends 3: Politics

The main podcasts I've been listening to in the car are audio captures Rachel Maddow and Keith Olbermann, since I don't have time to watch them -- or, indeed, the Daily Show -- most days of the week.

So anyway Congress is infuriating me at the moment. I keep starting to write a post, then deciding I don't have enough to cobble together except little one liners. Also, many things I think have already been eloquently expressed elsewhere. But it's odds and ends day, so here are a few things I think.

The health care issue is a bit personal for me. I was not receiving health care when I worked as a consultant for Motive, and there was a brief period when I simply wasn't covered. I tried to replace my old job-based coverage with private coverage from Blue Cross, but I discovered to my dismay that they would not accept me because I have an -- extremely minor! -- history of high blood pressure. No joke, they didn't try to take me on at inflated rates, they just said... sorry, look elsewhere.

I admit that there were other avenues I could have pursued more aggressively, but I got a bit apathetic and didn't follow them up. I got Ben insured and that was the most important thing. Now that my job is covering me again, it's become moot.

But anyway, I think this highlights the fact that the insurance industry does not provide insurance, which is to say, spreading risk around a diverse pool of people. Their response to attempts at "reform" has been to threaten to raise rates, which only highlights the critical need for more competition. Hence the public option, which at this point looks likely to be presented in some form, but very watered down.

Now in the first place, I do not ever want to hear any more press or whiny Congressman saying "Everything we do requires 60 votes!" There is no rule that says they have to get 60 votes. The rule is that you need at least 40 people who will not filibuster, and 50 votes.

Now filibustering is a very different action from voting against something, but you'd never know that from the press. Remember how Congress worked until 2006, when Democrats were actually in the minority? Every time a Dem even dared to breathe the word "filibuster," Republicans would scream and moan about "obstructionists", and wring their hands and talk about the need for a "nuclear option" which would eliminate the barely-Constitutional practice of filibustering once and for all. And Democrats caved. Every time.

I don't know how filibustering suddenly went from "horrible miscarriage of justice" to "this is the way we do things on every vote as a matter of course!" Freaking hypocrites.

Democrats absolutely have enough votes to pass whatever legislation they want, never mind bipartisanship. The problem is that not only are Democrats still scared of their own shadows, as they still insist on eliminating everything useful about health care reform in their haste to capitulate to President Snowe (as Grayson put it). If they had any party unity there could be no filibuster possible. But now Joe Lieberman, of the prestigious Connecticut for Lieberman party, wants to join the filibuster.

Hey, anybody remember why it was important that Lieberman defeat his primary opponent, Ned Lamont? It's because:

"What I’m saying to the people of Connecticut, I can do more for you and your families to get something done to make health care affordable, to get universal health insurance."

Lieberman argued that Lamont was SO liberal that he would hurt the Democrats' credibility enough to be a liability on the important issues. Issues like universal health insurance. Whew! I'm glad we dodged that bullet, so now we have Joe Lieberman fighting for us on that subject!

What's astounding is that Joe Lieberman still holds a key chairmanship position within the Democratic party, even though he is not a Democrat. Reid insisted at the time, and probably continues to say, that we need to do whatever we can to make Lieberman happy so that he will continue to stand with Democrats instead of jumping ship and doing something ridiculous like, say, filibustering against his own former party.

How's that strategy working out, guys?