Thursday, August 20, 2009

Are Sarah Palin and Martin Feldstein closet universal health care supporters?

Why opposing health care "rationing" makes you a socialist

When I took Prof. Marty Feldstein’s intro economics course at Harvard, he was fond of defending inequality with the parable, “If a rich man and a poor man came before me, and I gave one dollar to the rich man but nothing to the poor man, the poor man has nothing to be angry about. He is no worse off for the rich man having the dollar—indeed, he is in the same circumstance as before.” The implication is clear—if one person receives something but another doesn’t, there’s nothing wrong with that, since no one is made worse off.

So Prof. Feldstein’s op-ed in yesterday’s WSJ, in which he ominously warns that “the Obama strategy is to reduce health costs by rationing the services that we and future generations of patients will receive,” is more than a bit disingenuous. Because if he believes that a decision not to fund a treatment constitutes “rationing,” then he’s implicitly acknowledging that health care is a universal, fundamental right that government must provide. In fact, if you think health care “rationing” is a bad thing, you MUST support not only government-funded healthcare, but UNLIMITED government-funded health care—which makes you more of a socialist than President Obama!

I’ll explain.

Start with Prof. Feldstein’s basic argument: if the government funds health care, it will inevitably have to decide which treatments to pay for and which treatments not to, so as not to go bankrupt—thus “rationing” health care. This is no different from the more outlandish assertions by other Republican shysters, who demagogue about bureaucratic “death panels” (Sarah Palin) and “pulling the plug on Grandma” (Sen. Chuck Grassley); it’s just less fiery.

Of course, all these arguments about “rationing” are transparently ridiculous. (And I’m not even talking about the fact that private health insurance companies already make bureaucratic decisions about what to treat and what not to; I’m interested in the logical/philosophical aspects of the debate.) You’d think a Harvard professor would know better.

Think about it this way. If you come to me asking for two dollars and I give you only one, no sensible person would call that “rationing”—I am under no obligation to give you anything, so you should just be happy with the one dollar I did give you. By the same token, if the government decides not to pay for a treatment, that’s not “rationing,” but rather a choice not to provide something it was never obligated to provide; the decision leaves you no worse off than you would have been if no public health care option existed.

Unless, that is, health care is a fundamental right.

The logic is pretty simple. Definitionally, “rationing” is when government PREVENTS you from getting something you could have otherwise obtained, or WITHHOLDS something which it is obligated to provide. Let’s start with the first possibility. If publicly-funded insurance prevented you from obtaining health care, it would mean that all Americans were prohibited both from buying insurance on the private market AND from using their own funds to pay for treatments not covered by the government. Unsurprisingly, Feldstein tries to prove this is President Obama’s goal, claiming:

The White House Council of Economic Advisers issued a report in June explaining the Obama administration's goal of reducing projected health spending by 30% over the next two decades. That reduction would be achieved by eliminating “high cost, low-value treatments,” by “implementing a set of performance measures that all providers would adopt,” and by “directly targeting individual providers . . . (and other) high-end outliers.

Feldstein makes it sound like President Obama would go above and beyond limiting what government pays for, and would actually outlaw the provision of “high cost, low-value treatments.” Sounds pretty scary, right? Except that it’s a complete distortion of the actual report, the result of cobbling together out-of-context quotes from pages 13, 19, and 18 (respectively) to change the meaning of the report.

For example, while the original report’s recommendation is to “facilitate the development of a set of performance measures that all providers would adopt and report,” Prof. Feldstein misquotes the report to say that the state will “implement a set of performance measures.” It’s a subtle change that makes a big difference. The first merely describes a role for government in developing a set of standards for evaluating the quality of treatment patients receive. Sounds reasonable—don’t you wish you had some way of comparing doctors’ quality before choosing one? But Feldstein’s misquote makes it sound a whole lot scarier, like it’s a bureaucratic mandate.

Similarly, “targeting individual providers… and outliers” does not refer to targeting treatments for elimination, as Feldstein implies, but rather targeting exceptionally high-cost geographic regions to reform payment methods, so that providers would be paid for quality of care and not quantity of procedures.

Clearly, fears that President Obama plans to limit what you can freely pay for out of pocket are 100% made up; indeed, no reform proposal on the table would do this. So with the possibility for health care prohibition debunked, accusing President Obama of “rationing” care implies that government is withholding something it has to give you, which would require that you acknowledge health care as an inalienable right.

But wait, it’s not just government’s withholding of treatment that’s bad—it’s the very fact of government (not doctors) making the decision about treatment. Right? Well, that’s not quite accurate. With a public option, the decision is not over which treatments you are legally allowed to receive, but which treatments the government will give you money to pay for. For someone who can’t afford health insurance, “no treatment” is the status quo without the public option. By providing some funding where none would have been otherwise, the public option can only EXPAND choice, and it’s a lie to say otherwise.

To illustrate the point, let’s try to imagine a scenario involving one of Sarah Palin’s “death panels.”

Grandma Betsy is sick. In fact, she’s on her last leg, and is only kept alive by expensive machines—with the government footing the bill. But even the pricey life support can only delay death another two months at most, and after a while, a faceless bureaucrat notices something amiss: a grandma in small-town America is racking up enormous medical bills, despite her no longer being a productive member of Obama’s socialist paradise. A quick calculation that her remaining months’ value to society does not justify the cost of keeping her alive, and the local Death Squad is off to pull the plug on poor Grandma. Payments are ceased, and Grandma can no longer afford treatment, so the treatment stops.

Sounds scary, right? Until you realize, that’s the situation Grandma Betsy would have been in WITHOUT government-supported health care (e.g. Medicare). If she was poor, she wouldn’t have been able to afford expensive end of life treatments in the first place. And if she had private insurance, you better BELIEVE the insurance company would fight tooth and nail to pull the plug (with coma victims, for example, private insurance companies like to get the worst diagnosis—persistent vegetative state—since it allows them to cease paying for care).

So if, as Sarah Palin implies, not paying for Grandma’s treatment makes you a “death panel,” then clearly Palin believes SOMEONE must pay to keep Grandma breathing—and for whatever treatment she wants, regardless of cost. And that someone, it turns out, is the government. Palin’s infamous tirade against universal health care actually begins with the criticism that “government will simply refuse to pay the cost.” In other words, the reason we should not have government pay for health care is… that if we had government pay for health care… government would not pay for health care………. what? We even have Republican leadership accusing President Obama of wanting to reduce Medicare payments. So Republicans now favor greater entitlement spending than Democrats??? What is going on here?

No, seriously. How can government have an obligation to continue funding health care for an old person on death's door, but not for a kid whose parents are too poor to afford doctors visits, or for a construction worker who can’t afford insurance to pay for his heart surgery, or for a 12-year old whose mom couldn’t afford an $80 dental checkup for a tooth abscess and died of a resulting brain infection?

Evidently, influential critics of health care reform aren’t actually concerned over “rationing.” If they were, they would be obliged to support the President in providing choice to those currently rationed out of the health care system by their inability to pay—or to offer a competing plan to provide for the sick. Rather, it’s their ideological opposition to the very idea that there is a right to health care standing in the way. In which case they should just say it—admit that they believe that it’s okay for society to let its sick die in the streets. And eliminate Medicare while they’re at it.

Because while there are better and worse ways to implement universal health care, there is no philosophical middle ground—either you believe that society has an obligation to care for its sick regardless of ability to pay, or you believe that decent society can leave its sick to die in the streets. Take your pick.

There is another possibility. I imagine that few elected officials, Republican or Democrat, actually believe that a decent society can leave its destitute to die in the street. In which case, obstruction by elected officials represents a willingness to sacrifice not only their own moral views, but also the lives of people who will die because they lack health care, for short-term political gain.

I think I know which is more likely the case. I’m just not sure which one is worse.


WSJ inadvertently supports case for health care reform: do you want to trust your health to profit and loss?

There's no money in selling insurance to sick people: more reasons free markets don't work in health care

The Takeover: What opponents of health care reform don't get

The Catch-22 for opponents of health care reform: more health care economics


  1. i enjoyed this. keep it coming.

  2. good stuff. keep it up. unlike me who wrote my blog for two months and then quit