Sunday, May 15, 2011

Newt Officially Worse than Romney on Health Care

There are two categorical objections to a federal individual mandate for health insurance.  The first is that it is unconstitutional for the federal government to force an individual to purchase a product -- any product.  The second is the libertarian objection that it is wrong in any circumstance, whether constitutional or not, to impose such a mandate.  Romney is right on the first question, and wrong on the second.  Newt seems to be wrong on both.

Romney's position that MassCare was just fine, while Obamacare is unconstitutional is a perfectly coherent view.  Just because it is unconstitutional for the federal government to do something does not automatically make it unconstitutional for a state government to do the same.  While I disagree with Romney's defense of the mandate in MassCare as a matter of policy, it does not automatically follow that his legal reasoning is unsound.

Newt Gingrich, on the other hand, seems to defend some variation on the individual mandate at the federal level. 

Newt on Meet the Press today:
(Videotape, October 3, 1993)
REP. GINGRICH:  I am for people, individuals--exactly like automobile insurance--individuals having health insurance and being required to have health insurance.  And I am prepared to vote for a voucher system which will give individuals, on a sliding scale, a government subsidy so we insure that everyone as individuals have health insurance.
(End videotape)
MR. GREGORY:  What you advocate there is precisely what President Obama did with his healthcare legislation, is it not?
REP. GINGRICH:  No, it's not precisely what he did.  In, in the first place, Obama basically is trying to replace the entire insurance system, creating state exchanges, building a Washington-based model, creating a federal system. I believe all of us--and this is going to be a big debate--I believe all of us have a responsibility to help pay for health care.  I think the idea that...
MR. GREGORY:  You agree with Mitt Romney on this point.
REP. GINGRICH:  Well, I agree that all of us have a responsibility to pay--help pay for health care.  And, and I think that there are ways to do it that make most libertarians relatively happy.  I've said consistently we ought to have some requirement that you either have health insurance or you post a bond...
MR. GREGORY:  Mm-hmm.
REP. GINGRICH:  ...or in some way you indicate you're going to be held accountable.
MR. GREGORY:  But that is the individual mandate, is it not?
REP. GINGRICH:  It's a variation on it.
REP. GINGRICH:  But it's a system...
MR. GREGORY:  And so you won't use that issue against Mitt Romney.
REP. GINGRICH:  No.  But it's a system which allows people to have a range of choices which are designed by the economy.  But I think setting the precedent--you know, there are an amazing number of people who think that they ought to be given health care.  And, and so a large number of the uninsured earn $75,000 or more a year, don't buy any health insurance because they want to buy a second house or a better car or go on vacation.  And then you and I and everybody else ends up picking up for them.  I don't think having a free rider system in health is any more appropriate than having a free rider system in any other part of our society.

While there are certainly ways that a system that included a mandate could be significantly less onerous than Obamacare, there is no way to square the circle on the constitutionality of a mandate.  Either a mandate is constitutional, or it is not.  Newt claims that Obamacare is unconstitutional, yet still supports a mandate of sorts.  He cannot have it both ways.


Matt said...

1) Why do I have to have auto insurance?
2) Do you believe hospitals should be obligated to care for patients regardless of their ability to pay? If not --> how do you adress the legitimate ethical concerns this raises about the value of human life? If so then how do you avoid people gaming the system and having insured folks foot the bill?

JoeCollins said...

(1) You aren't forced to buy auto insurance. You can choose not to drive. (Or, at least in some states, you can be rich enough to prove "financial responsibility"/self-insure.)

And unless there's a federal transportation funding issue (which there might be, knowing how these things work), auto insurance is a state mandate and not a federal one.

(2) Obamacare ironically creates an even bigger free-rider issue by creating an incentive to pay the fine instead buying insurance with the knowledge that one will be able to buy insurance after becoming sick due to the pre-existing condition anti-discrimination regulation.

Matt said...

The question of the free-rider risk skirts constitutionality/ethics - that can be simply adjusted by jiggering the incentives (although obviously the downstream impact could be large)

In terms of the individual mandate- would you be agreeable to a system devoid of fines where a person would essentially "opt out" of the system and under these circumstances would not face a fine, but at the same time would not have access to emergency healthcare? Without some accountabuility (a strange word to come from a bleeding heart I know) - it all falls apart. That accountability can be in two forms - either an individual mandate, or a process whereby someone chooses to actively forego coverage.

JoeCollins said...

First (-and I think I'm right about this, but wouldn't bet a kidney on it), the few hospitals not taking federal money aren't mandated to accept emergency uncompensated care.

The pre-Obamacare scheme of uncompensated care, while far from ideal, is better than the alternatives presented.

I'm looking at a 2008 Kaiser study showing $86bn in care for the uninsured, minus $30bn paid out of pocket by the uninsured, leaving $56bn in uncompensated care, which they estimate as 2.2% of health care spending that year.

Various governments subsidized that uncompensated care to the tune of $43bn, leaving about $13bn at the hospital level in uncomp care. The study estimates these losses account for 1.7% of private health insurance premiums.

I'm assuming that the vast majority of this uncomp care is Emergency Dept care. So you've got $56 billion in more or less explicitly socialized losses so people can avoid bleeding to death after being shot in the streets, etc.

I can live with that, especially since I think the policies proposed to deal with this issue make the problem worse by increasing total health care utilization due to more comprehensive coverage and care.

So I guess I'm questioning the premise that "it all falls apart", at least fiscally. I think we have much bigger issues in health care than uncompensated care.

This probably looks like a cop-out, but an important part of conservative political analysis is accepting that there is usually no optimal solution, and you should avoid things that make the problems worse.

Matt said...

I'm not familiar with the Kaiser study, and I suspect that there are many analyses (on both sides of the spectrum) that selectively interpret elements of a highly complex system. Currently the private health insurer system supports more then it's share of the costs - subsidizing the care of Medicaid patients and Medicare patients who tend to pay less then cost (with cost being a moving target - hospitals in large part define their cost and are not paid dollar for dollar) and private insurers having negotiated payments that are > cost (again suggesting that in this case the market didn't add efficiency since healthcare doesn't function like a true commodity). In terms of the unfunded care mandate - it covers "emergency care" - this is not limited to purely ED setting - it could include just about anything. In terms of resourcing appropriately - it's a challenge given the scope of disease. You have high frequency utilizers who are uninsured and for whom debt has no meaning because of the situation they are in. You also have people trying to make it in jobs with inadequate or absent insurance or where it's cost makes it unobtainable. I think the basic divide is that in my mind healthcare is a basic right - it feels unjust to me that folks would die or die younger because of inadequate access to what I view as a communtiy resource. Having said that- I do think we need a containment on costs -I think we need to have rigorous analysis of effectiveness and cost effectiveness and I think that this is necessary in any scenario. I think we need to have advanced directives and end of life planning and I think that should be something that insurers pay for (unfortunately Palin poisoned this with the "death panel" nonesense - before Arizona legistlature actually made itself into a death panel for Medicaid benificiaries). I think we also need to have a culture that emphasizes personal responsibility around things like obestiy and tobacco use. Until we make those cultural shifts, we will continue down this clearly failing path. At this point, I think neither the left nor the right are making meaningful efforts to change things and work together - and until they do we're hosed.