This is Chapter 6 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” This chapter opens Part II of the book. Comments are fervently sought; you can leave them here.
You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.
And here is the up-to-date archive for all the chapters that have been posted so far.
Update – September 1, 2012
Open Wide and Say Moo! is now revised and published!
Now available in the audiobook version!
Apoplexy is a frequent condition among Conservatives today. This is because triggers abound.
And, among these fine Americans, one of the more common and more malignant triggers of apoplectic vocalizations is the assertion that healthcare is a right.
To a Conservative, a right is an attribute that accrues to every person naturally, by virtue of the fact that they are members of the human race. Such natural rights, which invariably are rights to take some action, are are considered to descend from the Creator (as the Declaration of Independence asserts), or at the very least from the inherent nature of the universe, and thus are not subject to addition or subtraction by any human authority – such as by governments. And because natural rights are granted equally to every human, it is an inherent truth that there can be no such thing as a right that imposes obligations or limitations on the natural rights of others. Indeed, the very notion that a right can exist that imposes such obligations on another person is an utter abomination.
Progressives see rights differently. To them, a right is not a right to act, granted by nature, but rather, it is a right to receive something (invariably the product of another’s actions), granted by a man-made Central Authority.
And hence, apoplexy.
Franklin Roosevelt started it. In his 1944 State of the Union message, he said:
“This Republic had its beginning, and grew to its present strength, under the protection of certain inalienable political rights – among them the right of free speech, free press, free worship, trial by jury, freedom from unreasonable searches and seizures. They were our rights to life and liberty.
As our nation has grown in size and stature, however – as our industrial economy expanded – these political rights proved inadequate to assure us equality in the pursuit of happiness.
We have come to a clear realization of the fact that true individual freedom cannot exist without economic security and independence. Necessitous men are not free men. People who are hungry and out of a job are the stuff of which dictatorships are made.
In our day these economic truths have become accepted as self-evident. We have accepted, so to speak, a Second Bill of Rights under which a new basis of security and prosperity can be established for all, regardless of station, race, or creed.”
Roosevelt then proposed, in his Second Bill of Rights, that each American is entitled by rights to:
- A living wage
- Freedom from unfair competition
- Social security
All this, of course, just goes to show how bad an idea the Bill of Rights was from the very beginning. If I had been around in 1789, I would have counseled Mr. Madison thusly: “Jim, don’t do it. You have crafted a perfectly good Constitution already. It carefully enumerates the very few powers which We the People have granted to the Federal government, and it explicitly states that any such power not so granted herein is specifically NOT available to the Feds. If you go amending the thing, before it ever gets going, with a list of specific things the government cannot do to us, you will undermine that overarching prohibition. Your list of restrictions on the government’s power will necessarily be incomplete, and eventually proponents of big government will notice, “It doesn’t say we can’t do this.” And furthermore, even your enumerated prohibitions will be quibbled with, twisted, and reinterpreted over time, in a very lawyerly fashion. And the next thing you know (say, in a quarter millennium or so), you’ll have a huge, powerful Federal government doing all kinds of nasty things to We the People (though no doubt only with the best of intentions), and referencing your fine Constitution as their authority for doing so.”
The Bill of Rights, as President Obama has noted, is a negative list. It enumerated specific items, which were particularly important to Americans at the end of British rule, which the government was not permitted to do to the people.
Franklin Roosevelt turned the whole concept of the Bill of Rights on its head – his was a list of items the government was required to “provide” for the people. His formulation was masterful, and it is a formula that has been carried forward by Progressives to this day. He claimed to derive the authority for his new Bill of Rights from the Declaration of Independence itself, saying that the “pursuit of happiness” requires everyone to have (i.e., to be given) this whole list of stuff, thus neatly eliminating the need to “pursue” the happiness in the first place. He added that failing to provide these rights will lead to dictatorship, ignoring the very reason for the original Bill of Rights – that any government with the power over individuals necessary to provide all these “rights” will itself have to be an extremely authoritarian one.
In any case, Roosevelt’s Second Bill of Rights has been the Progressive’s Shining City on a Hill for nearly 70 years. And it graphically illustrates how differently the Progressives view “rights.” (Conservatives will note that it is entirely possible to address the problem Roosevelt invoked – an unreasonable inequality of opportunity – without creating any new “rights” that will forever increase the power of the government over the people.)
American Progressives generally do not explicitly deny the existence of “natural rights” altogether. (Doing so would cause them embarrassment when they assert their own inalienable “truths,” such as the superiority of Diversity over all other human virtues). But at their core Progressives do not (and cannot) actually subscribe to natural, God-given rights that accrue equally to every person. This is because in the Progressive Program, rights are attributes granted by a Central Authority, aimed at achieving the social justice which is necessary to a perfect society. Therefore, almost by definition, Progressive rights are differential rights. That is, they are rights that, for the sake of social justice, must be at least somewhat different among various defined groups, and accordingly, not only must such rights be actively manufactured, but also they must be appropriately assigned and carefully distributed.
Natural rights granted by some sort of Creator obviously cannot handle such a job. Only a Central Authority can do this.
“Rights” granted under the Progressive Program will necessarily create involuntary obligations upon at least some individuals, at the very least confiscating the products of their efforts, and therefore from the Conservative point of view will always fundamentally violate the essence of what is truly a “right.” A Progressive may or may not be willing to allow that a few natural rights may exist; but they won’t let such rights hinder them. This is because rights granted by the Central Authority, deriving from political power*, take precedence; and any “natural rights” can simply be suspended whenever necessary.
* As Ron Bloom (President Obama’s former Manufacturing Czar) explained, “We kind of agree with Mao that political power comes largely from the barrel of a gun.”
Nothing pleases Progressives more than an opportunity to grant a new right. Every time they do so, the Central Authority gathers yet more power over the actions and the property of individuals, and therefore becomes more capable of moving us all toward societal perfection.
In Part I of this book, I tried to describe the American healthcare landscape as we enter the era of Obamacare. Here in Part II, I hope to show what we should all expect from Obamacare. And the first thing we need to know in this regard is that the passage of Obamacare, for its proponents at least, finally establishes healthcare as an American right, and thus achieves a goal which has been an explicit part – and likely the most critical part – of the Progressive agenda since at least 1944.
This accomplishment – establishing healthcare as a right – carries with it certain implications.
When healthcare is a right, then for the very first time, that which constitutes “healthcare” will have to be explicitly defined. This is because if a medical service is deemed to be “healthcare,” then people have a right to it. Conversely, if a medical service is deemed not to be “healthcare,” then not only don’t people have a right to it, but they also should not have access to it. (If people were allowed access to medical services that the Central Authority deems not to be “healthcare,” people might get the idea that the Central Authority is holding back on them. And that would be a dangerous idea indeed.)
So you can see how important it will be to define, specifically, what healthcare is – and what it is not. Since the Central Authority will be administering the right to healthcare, naturally the experts appointed by the Central Authority will be the ones who will be doing this job.
It will be a job as difficult as it is important. For instance, most people would agree that medical services that aim to prevent disease, restore health, optimize functional capacity in the face of illness, or control symptoms, ought to be included under the umbrella of “healthcare.”
But nitroglycerin and stenting can both relieve angina. One is very cheap and marginally satisfactory; while the other is very expensive and usually much more effective. Should both constitute healthcare, or only one? An expensive new drug prolongs survival with a certain type of cancer by an average of six months. Is that healthcare?
Is a treatment that does not actually cure or ameliorate a disease, but, that, say, slows the normal aging process, to constitute healthcare? If not, we should put a stop at once to the large volume of research currently being done on the aging process.
What about other treatments that enhance the life of individuals in the absence of serious disease or disability, such as face-lift surgery, hair transplantation, Lasik surgery, oral contraceptives when used for the express purpose of preventing pregnancy, or Viagra? Should those be healthcare?
And then there are conditions famously subject to “disease creep” – such as autism spectrum disorder, or ADHD, or even obesity – conditions for which the diagnosis has been increasingly expansive, so as to roll in more and more people who, in earlier times, would have been considered variants of normal. Should treatment of those conditions be considered healthcare?
Since the availability or non-availability of treatment will likely hinge on the answer to this question, there will be a lot of pressure, in both directions, on the Deciders. If it were not for the fact that the people who will be doing this job will be entirely objective and totally non-conflicted government-appointed experts, the process of deciding what is and what is not “healthcare” would be quite worrisome.
Since healthcare is a right, useful healthcare obviously cannot be withheld. Therefore, all the healthcare rationing that is done under Obamacare will have to be covert.
Under Obamacare many of the methods of covert rationing which were traditionally used by health insurance companies (e.g., cherry-picking, driving sick subscribers away, rescission, &c.), will not be available. This means that other covert rationing techniques will have to be developed.
Thankfully, physicians will be a big help here, since their New Ethics makes it OK for them to ration healthcare at the bedside. So it will be important for Obamacare’s administrators to continue establishing incentives for doctors to withhold medical care.
But to really cut down on healthcare expenditures, a lot of creativity will be needed. Fortunately for the Obamacare administrators, while they do not have all the options that were available to the HMOs, they do have the wind of the sovereign authority in their sails. They will be able to try new things that the HMOs could only dream of.
Here is a brief survey of what some of those “new methods” will be. I will be discussing the more remarkable ones in detail in the following chapters.
The big driver of medical expenses, as we have seen, arises from individual doctors making independent spending decisions along with their individual patients. And even though the Central Authority can coerce doctors all day long to withhold expensive medical services, the HMOs graphically demonstrated that you simply can’t coerce doctors enough to make a real dent in skyrocketing healthcare expenditures.
Fortunately for the Central Authority, a right to healthcare naturally leads to a situation in which all those spending decisions must be centralized. After all, a thing so noble as a right to healthcare – with the comprehensive fairness that is demanded by such a right – cannot possibly be achieved by hundreds of thousands of individual doctors acting independently. Comprehensive fairness absolutely requires central direction.
As a bonus, of course, centralized control of the healthcare system also gives you the opportunity to cut costs.
Centralized decision-making is a hallmark of Obamacare. The most notable features of centralization in Obamacare include:
1) The Independent Payment Advisory Board. The innocent-sounding IPAB (for how much damage can any mere “advisory” board do?) actually represents a truly astounding attempt to create a nearly all-powerful, unelected, immutable (in the sense that no governmental body can terminate it) board which will determine the ceiling for all of America’s healthcare expenditures.
2) GOD panels. Numerous expert panels will be created – which observers less sophisticated than myself have referred to as “death panels,” but which I choose to call by the much less insulting and much more justifiable name of GOD panels (“Government Operatives Deliberating”) – for the purpose of publishing the clinical “guidelines” that will tell doctors which specific patients can get which medical services, and when and how they can get them.
3) Stifling preventive medicine. While preventive medical services might actually prevent a disease here or there, the Central Authority has figured out that preventive services of all kinds, without exception, will always cost far more money than they can ever save. So Obamacare has instituted new processes to limit preventive services, and (as you will already have noticed if you are paying attention) to indoctrinate us in the great unwashed that expensive preventive services actually do more harm than good.
4) Herd medicine. A natural by-product of a system in which medicine is practiced strictly according to centrally determined guidelines is that all patients with a particular disease process will be treated the same way. The treatment guidelines generally will reflect clinical studies that report on the average response of patients given treatment A as compared to the average response of those given treatment B. Thus, treatment guidelines will necessarily be directed toward the average patient. If you are interested in improving the average outcome for the entire herd of patients, this might be a good thing to do. But for patients themselves, (who are still stuck on the idea of optimizing therapy for each individual, and 50% of whom will necessarily fall on the wrong side of “average”), this could be very bad news.
5) Slow medical progress. As we have seen, it is runaway medical progress (along with the greedy doctors) that has created this whole mess in the first place. Therefore, making it as difficult as possible for innovators to get their new products to market is a critical feature of the Central Authority’s strategy.
Group medicine, which is analogous to Diversity, is different from herd medicine. Group medicine means that different groups of patients (grouped according to one or more characteristics) need to be treated differently from other groups of patients, even if they have the same medical disorders.
Within each designated group, of course, herd medicine will apply.
An example of group medicine is life-cycle medicine, in which your relative priority to receive medical services is related to your position within the life-cycle. One system that has been suggested by a prominent advisor to President Obama would award persons under the age of 5 and above the age of 65 a relatively low healthcare priority, those between 5 and 14 and between 55 and 65 an intermediate priority, and those between 15 and 54 the hightest priority. Such a system would assure that fewer healthcare expenditures are used to help individuals who are not actively contributing very much to the collective.
Another example would be caring for people who are deemed to be at or near the end of their life. While thoughtful and compassionate end-of-life care can be a great boon, when it is implemented primarily as a cost-saving measure it is open to many abuses.
And then there is the variety of group medicine in which individuals are grouped according to their inherent worthiness, as judged by some feature other than age. Presently, the group known as “the obese” is serving as a test case. If our leaders can set a precedent of implementing medical discrimination against fat people, it will be relatively easy to expand the concept greatly.
Successfully demonizing the obese will set a precedent that goes beyond merely establishing group medicine. Fat people are fat, we are told, because of the choices they make (such as the choice to be slothful and gluttonous), and because of these choices they are consuming far more than their fair share of healthcare. This “fact” is already beginning to lead to regulations that propose to control food choices.
If the Central Authority succeeds in making this case – and they probably will, since who cares about fat people? – they can use the same argument to regulate any other human behavior that they decide might influence a person’s odds of having to consume a bit of healthcare. Some of these behaviors (in addition to what you eat) might conceivably include your hobbies, listening to advertisements for unhealthful products, the number of miles you drive, or owning a firearm.
I have said earlier that the key battle, the one most likely to determine the outcome of whether Americans will retain at least some semblance of individual freedom, or whether the Progressive takeover of our healthcare system – and of our society – will be complete, will be in regard to whether individuals will retain the ability to purchase at least some of their healthcare with their own money (and also, necessarily, whether providers will be able to sell it to them).
The very fact that healthcare is now a right means that it must be provided for you; you should not have to provide it for yourself. And this is how Progressives state their case. But what they really mean is that you should not be permitted to provide it for yourself.
I understand how outlandish this sounds. I also understand that almost nobody seems to be talking about it – so how can it be the case?
Well, I will show you. And since, as I maintain, this question occupies the key position in the battle over healthcare and in the battle over individual freedom, I will get right to it, and show you in the next chapter.
Every new “right” granted to citizens by a Central Authority, while it may or may not succeed in providing the promised thing to the citizens, will always expand the power of the Central Authority over the liberty of individuals. In the case of a right to healthcare, as we have seen, it is simply not possible to provide “the promised thing” in its entirety to everybody. And worse, in the case of healthcare, the very essence of individual liberty is direly threatened.