Posted by: theoptimisticconservative | July 18, 2009

Living in Denial

It’s not about “rationing”

Betsey McCaughey did a wonderful service yesterday at the New York Post, highlighting some very objectionable elements of the health care reform bill working its way through the House.

It’s time for us to recognize that the health care reform being proposed by the Democrats is not about “rationing” health care.  It’s about denying people health care.

A point I’ve made before is that when the left says “health care costs too much,” it doesn’t mean you have to pay more for it than you should.  The left relies on you to assume that that’s what is meant – but it’s not.  When the left says health care costs too much, what it means is that you are getting too much health care.  Your ability to pay for health care is enabling you to command too much of it, relative to an absolute idea the left holds about how “society’s resources” should be used.

This is not even just an issue of imposing equality – making sure that you have no more access to health care than the illegal immigrant or the unemployed drug addict across town.

This is an issue of socioeconomic supervision and central planning, with sickness and death as acceptable collateral damage, in the implementation of a collectivist vision.  It’s a worldview that envisions central planning of the societal use of “resources,” typically predicated on a vague popular theory that they are finite or shrinking, or that the use of them is damaging mankind, the natural world, or both – and allocating specified amounts of usage per person in an attempt to control outcomes.

This sense of there being an absolute standard for the use of “limited resources,” one that must be identified and enforced by central government, is wholly antithetical to the philosophy of individual worth and liberty that underlay America’s founding.

We must also be clear on the fact that the concepts of “limits” and the need for “allocation,” as assumptions about the cosmos, are not neutral or empirical.  They are a pessimistic converse of the optimism in the Judeo-Christian understanding that the cosmos, including our solar system and earth, are intended by the Creator to support the life of man, and to offer him the resources for improving that life, and extending the beneficial outreach of man to man.

Empirical science would be the first discipline to acknowledge that it cannot advise us on whether cosmological optimism or pessimism is warranted.  Those who dragoon “science” into pessimistic prognostications are not acting empirically, they are merely selling pessimism as science – very often bolstering their case with pointed comparisons to the supposedly inferior empiricism of belief in a benevolent Creator.

But science cannot, in fact, demonstrate whether Planet Earth is going to “run out of everything” or not, any more than it can demonstrate whether there is a Creator or not.  The actual history of discovery, technology, and various scientific disciplines argues for optimism about the prospects of terrestrial resources, at least as much as it argues for pessimism.  Men have been predicting the earth will run out of what they need for centuries, and yet each new century brings new discoveries and technologies that enable us to use resources differently, improve health, education, and lifespan, and live in whole new ways no one envisioned a hundred years before.

The buried premise in designing health care to deny service is that our finite resources must be managed and allocated by central planning.  There is no other possible interpretation of provisions that would force people to join “qualified” (government-designed) health plans, or else face high tax penalties – and then still be enrolled automatically in a government-“qualified” plan, even if they are willing to keep paying a tax penalty to keep their independent health insurance.

Read the provisions cited by McCaughey.  She is not making them up; they are in the House bill.  It is designed to move everyone as quickly as possible into a “qualified,” government-compliant health plan, regardless of what individuals want to do or are able to do.

Managed-care plans that place “limits on your access to specialists and tests” mean just that.  The purpose of limiting your access to specialists and tests is controlling costs.  Think about that carefully.  If you have a problem that requires the services of an oncologist, but government-managed health care does not consider the potential amelioration for you to be worth the cost, it decrees that you will not see the oncologist.  The ultimate purpose is more than merely keeping you sequestered from the oncological profession.  It is making sure there is government control of “society’s resources” going to oncology, so that you cannot possibly exert a demand for them beyond what government planners have decreed there shall be.

OMB Director Peter Orszag expressed the conceptual approach to this very clearly in his April address to the Association of American Universities:

“Now, many of you have heard me go on about how important it is to reform health care in order to bend the curve on long-term costs and get our nation on firmer fiscal footing – and this data shows how critical that effort is. When we say that health care is consuming too much of our GDP, we are not just citing an abstract statistic. These costs have real implications in sectors across our economy, limit our economic growth, reduce opportunities, and harden inequalities.

“This is why the Administration is making historic investments through the Recovery Act in efforts that will be crucial in bending the curve on the growth of health care costs while improving the health outcomes we can expect from our medical system. We are investing over $19 billion in health information technology to help computerize Americans’ health records, which will reduce medical errors and enhance the array of data that physicians and researchers have at their disposal. We are investing $1.1 billion in comparative effectiveness research, which will yield better understandings of which medical treatments work and which do not. And we are investing $1 billion for prevention and wellness interventions, which will help reduce the impact of chronic diseases and reduce costs.  And in the President’s budget, we make a historic down payment on fundamental health care reform – a commitment also embodied in the budget resolutions passed in Congress.”

When Orszag says “health care is consuming too much of our GDP,” he doesn’t mean your cataract surgery is priced at $5000 instead of $3000.  He means you should not have the power to decide if you are willing to spend $3000 or $5000 on cataract surgery to improve your vision, and command the resources from the economy accordingly.  If you have this power, you and thousands of others may well use it, and use up “society’s resources” on cataract surgery that Orszag sees no need for.  He’d rather have an effectiveness study done, decide what limits will be imposed by government force on the availability of cataract surgery, and spend the resources “saved” on “education.”

Regarding the implications of “comparative effectiveness research, which will yield better understandings of which medical treatments work and which do not” – this has a superficially reasonable tone to it that requires careful analysis.  I imagine the great majority of people reading these words would think of evaluating treatments that work well in comparison to treatments that do not work well.

But seriously:  what treatments that do not work well are in routine use by the medical profession?  Does anyone think research on medical treatments will find that doctors are, for some inexplicable reason, persisting in the administration of treatments that do not work?  In fact, physicians routinely monitor the results of treatment, and change approaches when something that frequently works isn’t working for a particular patient.  There is no such thing as lists of approved, certified, widely-used procedures that, in some generic, tie-breaking sense, “do not work.”

So it is unreasonable to suppose that this – identifying such procedures – is the outcome expected from such research.  Rather, I expect it to be focused on the cost side of treatment, as it relates to how we judge effectiveness.  I developed this theme in “What Liberals Will Get,” in reference to comparative-effectiveness research:

“This sounds reasonable, until we think about what the criteria might be, by which that is to be determined.  Few criteria are quantifiable enough to be seriously considered.  Among them are survival rate, and length of survival, after a procedure.   Quite obviously, results focusing on these criteria would be inherently biased against the elderly, who on average do not live as long after medical procedures as their younger counterparts.

“We could expect some results to be effectively equated to each other, as if they are the same, and a result that would be less satisfying for most people favored by the study criteria if it costs less.  Examples might include amputation and prosthetics, rather than extensive surgery, follow-up treatment, and therapy to save a limb; or radical mastectomy in a single procedure, instead of multiple procedures, with intervals of therapy and monitoring, that might save some of a woman’s breasts, and leave her with a quality of life she much preferred.

“Families who would, if asked in a context-free vacuum, naturally say that they’d like their health care costs to be less, would not necessarily give that answer if situational alternatives were spelled out for them.  Perhaps some families would be just as happy to trade 10 years of Grandpa’s life for a better college for Junior – but there are a whole lot of families that wouldn’t.  Maybe some wives would rather cut health care costs than save a husband’s leg after an industrial accident, and would be satisfied to watch him strap a prosthetic limb to a stump for the rest of his life – but many, many wives wouldn’t.  Perhaps some parents of a 21-year-old daughter with uterine cancer would prefer saving money with a prompt hysterectomy, over trying a more expensive course of treatment that could allow her to go on and bear children – but I venture to guess that the overwhelming majority would not.

“The pretense that under collectivized health care, actual patients and families would still have a choice, in these matters, is beginning to fade.  The very concept of ‘cost-effectiveness studies’ implies a single set of absolute criteria by which to judge effectiveness – criteria that would serve as tiebreakers and decision factors.  A world in which other people get to tell you how much relative value to assign to your mother’s lifespan, your father’s quality of life, your wife’s body parts, and, conversely, everything else ‘society’ uses resources on – that is the world left-liberal advocates are trying to bring about.”

When Mr. Orszag’s priority is to reduce the amount of GDP going to health care, can we really imagine that he will see a heart procedure on an 80-year-old as having the same “effectiveness” as the identical procedure on a 50-year-old?  The 80-year-old, however beloved he is by his family, and regardless of his contributions to the community, is, statistically, only going to live another 6 or 7 years after the procedure, max.  The 50-year-old will live – even with his statistically foreshortened longevity prospects – much longer.  The 50-year-old is still in the work force, “producing” and paying taxes.  He may still have dependent children.  The 80-year-old, on the other hand, may already be using a walker, and costing “society” monster bucks with the resources that go into his support socks and his medications.

In a widely-quoted New York Times interview, President Obama made it clear that he is fully onboard with this cost-accounting, comparative-effectiveness approach being America’s basic health care posture.

“’I don’t know how much that hip replacement cost,’ Mr. Obama said in the interview with David Leonhardt of The Times. ‘I would have paid out of pocket for that hip replacement, just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model is a very difficult question.'”

Well, it’s a difficult question, if you pose it to a collective authority, on behalf of “society.”  But there is nothing compelling us to do that.  Not even the goal of providing quality health care to the indigent, by paying for some public services and encouraging charitable contributions with the tax code, demands that we make the question of each individual hip replacement an issue for “society.”  (So let’s keep those two issues separate and distinct.)

But Obama explicitly and avowedly says we need to:

“’There is going to have to be a conversation that is guided by doctors, scientists, ethicists,’ Mr. Obama said. ‘And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance.’”

The development of Obama’s argument here makes it clear that there is one thing he does not expect:  that the “guidance” from the “independent group,” as it filled its function to rein in that “difficult democratic conversation,” would be to give Granny the hip replacement.


  1. If you had more fact you might argue that hip replacement more skillfully.
    It’s not a choice between hip or no hip.
    The choice is between the titanium 30-year hip and the stainless 15-year model.

  2. Actually, fuster, your point only makes Obama sound like a nitwit.

    If the real “issue” he meant to address is the choice between a titanium hip and a stainless steel one, Obama did an incredibly poor job of articulating that.

    He also suggested a truly idiotic complication of such a decision, in suggesting that it’s a tiebreaker in the societal question of “sustainability” for the use of resources, and that we need to apply to an independent group of experts to provide us guidance on it, even if such guidance is not necessarily determinative, because such a difficult democratic conversation is too much to handle through normal political channels.

    All this for a “titanium” versus “stainless steel” dilemma?

    Either Obama was in fact talking about hip replacement versus no hip replacement — or he’s deranged.

  3. […] Forces Network doesn’t carry commercials.) But some here may actually remember it. Having written about the Disappearing Choice aspect of government-managed health care today — it’s on […]

  4. “A point I’ve made before is that when the left says “health care costs too much,” it doesn’t mean you have to pay more for it than you should. The left relies on you to assume that that’s what is meant – but it’s not. When the left says health care costs too much, what it means is that you are getting too much health care. Your ability to pay for health care is enabling you to command too much of it, relative to an absolute idea the left holds about how “society’s resources” should be used.”

    This is insight, most aptly phrased, JED. It should be exhibited in neon in all public places.

  5. If I have a complaint about your posts, JED, it is that they run too long. The length problem is not that you run out of good things to say, you don’t, but so many of your pithy and insightful comments get buried in the long roll of the paragraphs. You should consider breaking these posts up into shorter segments.

    Anyway, keep up the good work! I do enjoy reading them.

  6. With all due respect to materialist, please do not curtail the length of your posts. One of the reasons I look forward to reading your blog so much is that I can rest assured that I will not be getting a pithy soundbite treatment of a subject. All objections will be treated, all aspects considered, all pitfalls warned against. I really think this is what distinguishes you as a blogger and not coincidentally as a thinker. I can get the quick and dirty from a thousand other people and it leaves one wanting.

  7. materialist and TJMilburn — thanks to both of you for the feedback. It’s very constructive on both sides.

    I do feel materialist’s pain, as I recognize the peculiar strength of the shorter post. It’s definitely easier for readers to graze and move on, with shorter pieces.

    That said, before TJMilburn’s comment even posted, I was thinking of how to put what is pretty much his (?) point, which is that it’s important to me to provide a unique service here — at least some of the time.

    The passage you (materialist) quote, about the true meaning of the left’s mantra about health care costs, does make a nice soundbite, if I do say so myself :-).

    But to my ear, if it is not justified with a documented explanation, it comes off merely as a tendentious talking point. Anyone can say “the left thinks you’re getting too much health care” — but what I want to do is show why that assertion is true. Very few hortatory political writers are doing that, from what I can tell. They tend to assume that their audience agrees with them, and don’t make the effort to argue and justify their points.

    That’s why it seems important to me to fully develop the arguments, cite documentation, quote it, and convey its sense as accurately as possible. In the end, what this should produce is Peter Orszag and Barack Obama making MY point for me.

    Anyone can say “Obama sucks ostrich eggs, and wants to cut your health care.” But I think it’s more informative and persuasive to point out that he really did say hip replacements for old people are inherently ethical issues for government, as it acts in the role of guardian for “society’s resources,” and that it requires a difficult democratic conversation, and the intervention of independent groups of experts, to handle the decisions.

    This is not the way you talk about hip replacements for old people when you are all for them, and figure the market and pricing mechanism will help people decide how much hip replacement is worth to them — or, that public assistance is intended to help people decide TO have hip replacements, as opposed to arranging for GOVERNMENT to decide AGAINST them.

    Anyway. I do try to break up really long posts, either with section titles or by posting them separately as series. One thing I’ve considered doing is adding “pages” (like the Iran Page and Features) where I would collate lists of basic principles or thoughts on the main topics I tend to post on, and organizing links to the relevant pieces, many of which are months old now.

    I don’t see that getting done in the next 6-8 weeks, due to family events (Mom will have a bypass sometime in August, and I’ll be out of my normal routine for that).

    Meanwhile, though, I’ll try to balance brevity, documentation, and thoroughness as well as I can. One thing we did in mililtary intelligence was go to “layered” products, in which you could pursue brief, headline-like links to points made at greater length, but that really isn’t the style I’m going for, in composing a single-subject piece.

    Seeking the “balance” does make for some critical thought, though. I’d like to have more time for editing and layout, and maybe at some point I will. Again, thanks for the feedback, and know that it’s getting serious consideration.

  8. For what it’s worth, I also enjoy the length and development of your arguments. It’s one of the primary reasons I’ve made your site a daily checkpoint. And really, it’s not your responsibility to make yourself easy to read and understand, it’s up to the reader to work that out for themselves. I’m an ‘if A, then B’ kind of guy, probably due to my training in Math and Science, but still, it’s up to me as a reader to pick out the ‘A’ parts to see where or if there are holes. Sure, it would be nice if you pointed all that out for me, but you’re still light years ahead of others in providing the arguments. Just wanted to point out that we as readers also have some expectations that we need to live up to and it’s not all on you.
    Your true value is not in sound bites, unfortunately, that is available everywhere these days, but in the analysis of what are really complex issues.

  9. Write as you will.

    I enjoyed reading the thoughts from your mother when you printed them, and will look forward to reading more from her.

  10. Excellent post. Just one thing to add–behind the statists’ felt need to supervise how society spends “its” resources lies a conviction that those resources are static in kind as well as in quantity. There is no thought that when we progress from the stainless steel replacement hip to the titanium one we increase our effective resources.

    In medicine, this lack of awareness of progress is especially obtuse. The “less effective” procedure of today can become the preferred treatment of tomorrow, if people for whom other treatments fail pay for it now and enable it to be developed.

  11. Thanks, Margo, and welcome. My apologies that it took so long for the comment “approval.” That’s only needed once — any comments you make after this will post automatically.

    I agree wholeheartedly that statists with a view of “resources” as limited are short-sighted and history-challenged. Resources always look limited to us, but the historical truth is that they never really are.

    You make a really good point about the development of less-effective procedures into more effective ones over time. The impact of the “studies” proposed by Orszag would be to interdict the development of experimental procedures, while they were still less effective (and probably comparatively expensive). And yet one of the top benefits of our relatively open, partially market-driven system is that it allows such developments in medicine — which is why we have made such tremendous and rapid advances just in my lifetime.

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