Thursday, March 29, 2012

"The freedom to live like it's 1804"

From a piece by Dahlia Lithwick on the health-care arguments: " we know the [Supreme Court] is worried about freedom: the freedom to live like it's 1804." See also E.J. Dionne here.


hank_F_M said...


It seems that if Ms Lithwick thought about it a bit more she would select a different argument.

In 1804 one was free to choose the doctor of ones choice, not much use for most of the population who only had one doctor in a day or two's travel Today most of the population lives in a convenient distance of several doctors. Traditional health insurance allows one to pick ones doctor and the insurance company pays. Some people choose to join an HMO which would pick a pick a doctor, or give them a limited choice of the doctors in the area, but the person was freely chose to join the HMO. The amount of actual freedom one has in health care has generally been increasing even if in some cases contracts or law limits the theoretical choice more thatn geography in 1804. The extra choice means on has the oppertuity to get the best care available.

The national ACA HMO will have to provide an even more restricted choice of doctors, treatments and options if it is meet cost control goals by artificially limiting the choices one has.

In 1804 there was group that had no freedom in health care. Of course slaves had no freedom at all. If in fact if there owner did not feel it cost effective they would not receive care that was available. Of course they had no option to go any where else.

Not that things will get as bad as then but if you do not like the decision or competence or attitude or cost of your assigned doctor; or the regulations deny the needed care, one has no more freedom to go anywhere else that slave of 1804

I don't think the analogy she makes supports her defense of the ACA, as step back towrds 1804.

Hank’s Eclectic Meanderings

LFC said...

There's nothing in the ACA itself, AFAIK, that limits choice of doctors. (If one chooses a particular sort of plan, perhaps yes, but that's also the case now.)

Thus I don't get the reference to "your assigned doctor". The ACA does not assign doctors. (Ditto with the reference to the "regulations deny the needed care".) The act doesn't affect existing ins. plans or individuals' existing coverage if they have it, AFAIK.

Anyway, her pt is precisely that the health care situation in 1804 was not good for the vast majority of people; hence the conservative Justices are working with an inapt notion of 'freedom' that would result in many people not getting care. Which doesn't bother Scalia...

hank_F_M said...


Yes, the law itself doesn't require it, but is within powers granted to make restrict choices. If fact it provides for committees to do this and does not allow appeal.

The bill despite it's length is very generic on it's day to day operation where it meets real people who are sick. The CBO recently announced that it was going to cost nearly twice the estimate at the time of it's passage which were widely criticized as high at the time. So how are costs going to be brought in line with the income. Do like the HMO's do -- limit the individuals choices of all kinds.

Since the system will effectively be a monopoly HMO one has no choice but to live (or die) with it. You will get the care deemed appropriate by cost control with no choice to go elsewhere. Since CBO is projecting a 200% costs over income it will be ua step back in relult in peole having very little choice in there healt care. as tep back to 1804 not forward.

Hank’s Eclectic Meanderings

LFC said...

I don't understand where you are getting this 'monopoly HMO' stuff from.

The act does not, as I understand it,
affect existing insurance arrangements in any way.

For ex: If you get insurance through an employer, that plan remains exactly the same before and after the ACA.

I'll take myself as an example since I don't think many people are going to be reading this exchange: I pay a certain premium to an insurance company every month. This is not an employment-based arrangement; I do what the ACA will require most (uninsured) people to do by 2014: i.e. I buy my own insurance.

Now the ACA has had and will have, as far as I know, no substantive effect of any importance on my the terms of my coverage. (I'm not saying I have a wonderful plan; I'm saying the ACA does not change it.)

In your first comment you refer to "the national ACA HMO". In your second comment you say the system will "be in effect a monopoly HMO". How does (a) requiring healthy people to buy insurance through exchanges and (b)barring ins. cos. from refusing to cover certain sick people and (c) expanding Medicaid coverage/eligibility
[which are the basic mechanisms, in stripped-down language, at the heart of the Act,as I understand it] create a "monopoly HMO" or any national HMO? The system is still based on private insurance cos., after all.

The whole idea of the individual mandate was originally a conservative idea that, as I understnad it, came out of the conservative Heritage Foundation. Would Heritage have proposed a "natl monopoly HMO"?

Pls quote me the provisions of the Act that you claim wd create a "natl monopoly HMO" or at least explain why the Act in effect does that. I think that is just wrong.

Btw the phrase "national HMO" or "monopoly HMO" was not used once by the lawyers arguing against the Act in the Sup Ct (at least not in the parts of the arguments I heard).

hank_F_M said...

A de facto Monopoly.

   [muh-nop-uh-lee] Show IPA
noun, plural -lies.
exclusive control of a commodity or service in a particular market, or a control that makes possible the manipulation of prices. Compare duopoly, oligopoly.
an exclusive privilege to carry on a business, traffic, or service, granted by a government.
the exclusive possession or control of something.
something that is the subject of such control, as a commodity or service.
a company or group that has such control.
6. the market condition that exists when there is only one seller.
( initial capital letter ) a board game in which a player attempts to gain a monopoly of real estate by advancing around the board and purchasing property, acquiring capital by collecting rent from other players whose pieces land on that property.


All health insurance providers will have to operate on HHS rules. Which will set what is covered, what will be reimbursed. What premium can be charged. etc. There will be very little discretion at the insurance company level. Even though it operates through private providers there will be an exclusive control of the market by HHS. If this was set up by insurance companies on their own, without government blessing, they could be sued for conspiracy to restrain trade.

For any practical purpose a monopoly.

I suspect that this was not brought up before the court because there is plenty of precedent for the government created/operated monopolies. But it s seldom good policy. In effect the economic model will be that of a monopoly not a competitive market. Monopolies private or governmental tend to produce higher prices for poorer services. to ms. Lithwick's point it is easier for a monopoly to reduce choice than increase it.

One of goals attributed to the program is health management not just insurance to cover injuries an illnesses, whish is what HMO's do, the anology should have been clearer.

Whether it is constitutional or not I believe it is BAD policy that will do much more harm that it does good.

Hank’s Eclectic Meanderings

LFC said...

Some aspects of the Act are in effect already, some of course are not. So when does this "exclusive control of the market by HHS" take effect?

I note in passing that one provision of the Act, from what I gather, prevents or will prevent ins. cos. from rejecting people for coverage on the basis of pre-existing conditions. Which seems to me like a good provision.

I'm sure you don't favor single-payer or a UK-style natl health service. So what's your solution to the prob. of 40,000,000 uninsured, people using emergency rooms as basic care providers, etc.? Or don't you think it's a problem?

hank_F_M said...

It is illegal to for a hospital to deny heath care to any one who walks or is carried in.

How is this care paid for. The hospital eats it. That is a problem. A portion of the voluntarily uninsured do pay as they go at least for the less expensive services.. Drug companies sell the hospitals some drugs at reduced price, as due other suppliers.. A small mark up can be added to other patients but the insurance companies and especially the federal government are tightening down on cost control and refusing the reimbursement. A thought, are the lobbyists who supported the ACA interested in their employers bottom line or providing heath care?

The hospital will be reimbursed, the drug companies and other suppliers will now be able to make a profit on selling to hospitals. All good things, but who is going to pay the cost (now full cost) for this treatment. We are going to be spending more money for the same services with out an obvious source of revenue. The hospitals and suppliers are not transferring the money they used to spend . Those who could have afforded insurance but thought it was a bad purchase will be contributing. Premiums can be raised (but isn't his the affordable heath act?) General taxation. Remember the CBO estimates the overall cost of the program to be twice the estimate when it was passed. The level of national deficit has greatly increased even without the ACA

My guess is that those who were uninsured because they could not afford it will have card that allows them to use the emergency room as a primary care giver possibly with less eligibility for care than they get now. There won't be enough money to go around and since they will have the least clout to influence government policy they lose. Basically the health care providers have their bottom line protected the uninsured are where they are now. I have no problem with covering costs and making a reasonable profit which are good things - I do not like marketing the ACA as doing something for people who can't afford health care.

There must be a better way.

Hank’s Eclectic Meanderings