Saturday, August 08, 2009

Discussing Health Care

Thursday I wrote about the bureaucratic and cumbersome definitions being used in the text of HR 3200. Having thought about that, I think we would do well as a nation to establish clear definitions of our own for the key points on this issue – doing so would not only make it simpler to discuss what we want or oppose, but might also establish some common ground. To that end, I am presenting what I think are the root questions to this issue.

1. What is Health Care, anyway?

Health Care is one of those things that sounds plain to most people, but which can still trip folks up when they get into specifics. For most people, after all, they can take care of their ordinary health needs and in fact they do not like being told what to do on decisions that they consider personal, like nutrition, exercise, and recreational behavior. How many people have you met who agree that smoking is a bad idea but they do it anyway, that they agree they should lose weight but still have high-fat foods in their diet, for instance? People go a doctor for occasional check-ups or mild illness, when experiencing life events like pregnancy or trying to diet, emergencies like a heart attack, stroke, or for a serious condition like Diabetes or Cancer. So, it seems to me that there are these four categories make up Health Care for most people, and some of these categories will be important to only certain types of people.

2. Is this one debate or two? Is Health Care the same thing as Health Insurance, and if not, why are the two being mixed in this debate?

The Obama Administration speaks of “Health Care Reform” on two fronts; changing insurance rules and changing how medicine is practiced. But the Democrats speak of their plan as one action, as if the same measures which – so they say – will reduce costs will at the same time as improving medical care. Such a bold claim needs to be explained in depth, rather than simply asserted.

3. Does Health Care work well in America?

This is a key question in the debate. The plain fact is, medical care in the U.S. is pretty darn good. If you collapse in the street of any major city in the U.S, you can expect to be in an emergency room within 20 minutes in normal conditions. Diagnosis and treatment of Cancer, Heart Attacks, Trauma, Burns, and many other fields is unsurpassed.

4. Does the present Health Insurance system work well in America?

More than two out of three Americans have insurance coverage that they like. It would seem, then, that there are three areas of contention – how to provide satisfactory medical care for people who cannot find suitable private insurance, how to insure the availability of quality medical care going forward, and how to control rising medical costs. A proper discussion needs to cover this ground with consideration of all major perspectives.

5. Are private insurance companies a good thing or a bad thing?

Private insurance companies are routinely demonized for charging higher and higher premiums from customers, but rejecting valid claims in order to make unfair profits. Certainly there are individual companies which do this, but we should remember that every state has an Insurance Board which governs the conduct of insurance agencies, insurance agents must be licensed and the industry is well regulated. In addition, while many Americans are displeased with their automobile and home insurance, most are happy with their health insurance and do not want major changes.

Insurance was not originally meant to be mandatory. For decades the various forms of insurance, whether Life, Health, Vehicle, Home, Liability or Property, were made available as an option to hedge against catastrophic loss or expenses that could not be met under certain conditions. It should be noted that government requirement that all drivers must be covered by at least liability insurance has neither reduced the frequency of motor vehicle accidents nor the cost of such incidents; the requirement that homes bought on mortgage agreements must carry homeowner’s insurance has not reduced the number of claims made on such policies, nor slowed the growth of the cost of that insurance. It is, on the evidence of the history, absurd to imagine that requiring individuals to obtain health insurance or requiring all employers to provide it will in total improve the condition of health of the nation’s citizens, nor reduce cost. There is no evidence whatsoever from past experience to justify such a claim.

6. Would the government do a better job than private insurance companies?

Looking at the history of the VA Hospitals, Medicare and Medicaid, it’s very hard to imagine how replacing any private insurer with a government program would be an improvement. This is an area where proponents of the new plan need to explain how the waste, errors, and sheer corruption of the past would not simply be repeated on a much larger scale.

I would start a discussion with these six questions. It would be a nice change if even these initial starting points could be addressed.

Thursday, August 06, 2009

Why No Congressman Wants to Talk About HR 3200

I have a headache. This is because I have been reading the full text of HR 3200, with the self-described “simple” title of “America’s Affordable Health Choices Act of 2009”.


Remember how some genius created non-alcoholic beer, and in so doing managed to create a beverage with rotten taste, no nutrition, no buzz, and a higher-than-beer price tag, thereby creating something which no sane person would ever wish to purchase, much less imbibe? Well, this bill might be the legislative version of that concoction. It’s frankly very nasty stuff. Want proof? OK, here is the list of definitions of terms from Section 100 of the 1,017-page monster. Read it through and see how well your noggin likes it:

“GENERAL DEFINITIONS.—Except as otherwise provided, in this division:
(1) ACCEPTABLE COVERAGE.—The term ‘‘acceptable coverage’’ has the meaning given such term 5 in section 202(d)(2).
(2) BASIC PLAN.—The term ‘‘basic plan’’ has the meaning given such term in section 203(c).
(3) COMMISSIONER.—The term ‘‘Commissioner’’ means the Health Choices Commissioner established under section 141.
(4) COST-SHARING.—The term ‘‘cost-sharing’’ includes deductibles, coinsurance, copayments, and similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services.
(5) DEPENDENT.—The term ‘‘dependent’’ has the meaning given such term by the Commissioner and includes a spouse.
(6) EMPLOYMENT-BASED HEALTH PLAN.—The term ‘‘employment-based health plan’’—
(A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); and
(B) includes such a plan that is the following:
(i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS.—A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code.
(ii) CHURCH PLANS.—A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974).
(7) ENHANCED PLAN.—The term ‘‘enhanced plan’’ has the meaning given such term in section 203(c).
(8) ESSENTIAL BENEFITS PACKAGE.—The term ‘‘essential benefits package’’ is defined in section 122(a).
(9) FAMILY.—The term ‘‘family’’ means an individual and includes the individual’s dependents.
(10) FEDERAL POVERTY LEVEL; FPL.—The terms ‘‘Federal poverty level’’ and ‘‘FPL’’ have the meaning given the term ‘‘poverty line’’ in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.
(11) HEALTH BENEFITS PLAN.—The terms ‘‘health benefits plan’’ means health insurance coverage and an employment-based health plan and includes the public health insurance option.
(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER.—The terms ‘‘health insurance coverage’’ and ‘‘health insurance issuer’’ have the meanings given such terms in section 2791 of the Public Health Service Act.
(13) HEALTH INSURANCE EXCHANGE.—The term ‘‘Health Insurance Exchange’’ means the Health Insurance Exchange established under section 201.
(14) MEDICAID.—The term ‘‘Medicaid’’ means a State plan under title XIX of the Social Security Act (whether or not the plan is operating under a 6 waiver under section 1115 of such Act).
(15) MEDICARE.—The term ‘‘Medicare’’ means the health insurance programs under title XVIII of the Social Security Act.
(16) PLAN SPONSOR.—The term ‘‘plan sponsor’’ has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974.
(17) PLAN YEAR.—The term ‘‘plan year’’ means—
(A) with respect to an employment-based health plan, a plan year as specified under such plan; or
(B) with respect to a health benefits plan other than an employment-based health plan, a 12-month period as specified by the Commissioner.
(18) PREMIUM PLAN; PREMIUM-PLUS PLAN.— The terms ‘‘premium plan’’ and ‘‘premium-plus plan’’ have the meanings given such terms in section 203(c).
(19) QHBP OFFERING ENTITY.—The terms ‘‘QHBP offering entity’’ means, with respect to a health benefits plan that is—
(A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer;
(B) health insurance coverage, the health insurance issuer offering the coverage;
(C) the public health insurance option, the Secretary of Health and Human Services;
(D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or
(E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official.
(20) QUALIFIED HEALTH BENEFITS PLAN.— The term ‘‘qualified health benefits plan’’ means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.
(21) PUBLIC HEALTH INSURANCE OPTION.— The term ‘‘public health insurance option’’ means the public health insurance option as provided under subtitle B of title II.
(22) SERVICE AREA; PREMIUM RATING AREA.— The terms ‘‘service area’’ and ‘‘premium rating area’’ mean with respect to health insurance coverage—
(A) offered other than through the Health Insurance Exchange, such an area as established by the QHBP offering entity of such coverage in accordance with applicable State law; and
(B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law and applicable rules of the Commissioner for Exchange-participating health benefits plans.
(23) STATE.—The term ‘‘State’’ means the 50 States and the District of Columbia.
(24) STATE MEDICAID AGENCY.— The term ‘‘State Medicaid agency’’ means, with respect to a Medicaid plan, the single State agency responsible for administering such plan under title XIX of the Social Security Act.
(25) Y1, Y2, ETC.—The terms ‘‘Y1’’ , ‘‘Y2’’, ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently numbered terms, mean 2013 and subsequent years, respectively."

If that all makes sense to you and your head is not screaming for relief, see your doctor as soon as the government tells you you are allowed to do so.

Wednesday, August 05, 2009

The Constitution of the United States and Its Usurpation

One of the more over-used claims I have heard in my lifetime, is how this condition or that somehow violates someone’s rights. The U.S. is a great country, in my opinion the very best, but we have waaaaaaaaaaaaay too many lawsuits, not to mention protests against just about everything. We read, see, and hear about ‘Animal Rights’ (not to mention that a certain Obama Administration official once wanted trees to have legal standing to file lawsuits), ‘Right to Life’ vs. “Woman’s Right to Choose’, ‘Right to Die’, and the popular meme of the moment, the ‘Right’ to Healthcare.

There are, it seems, three common sources for the notion of enumerated rights; the Declaration of Independence, the Constitution of the United States, and the popular imagination. The key phrase from the Declaration of Independence is that line about “certain unalienable rights, that among these are life, liberty and the pursuit of happiness”; while some folks try to draw inferences that government should be providing these things to people, I would remind the audience that when this document was written, the theme and tone were to tell the extant government – Britain, King George III and Parliament – where they could go and with what accessories. The Declaration of Independence was in no way an endorsement of government power and influence.

The Constitution of the United States is where most people come to think of rights, yet many beliefs are mistaken. The founding fathers, for instance, have made it abundantly clear not only in the text of the Constitution but in other writings of the time that the Constitution was created not to spell out the rights of the people, but to define the limits of the federal government’s power. The Bill of Rights was noted not to lay out what the citizens were allowed to do, but to emphasize certain boundaries which the government may under no circumstances trample. From that original context, therefore, it is important to understand that “rights” come to mean areas where the government is not allowed to exert power or influence, even with the best of intentions. The legitimate power and authority of government extends only to that degree where the Constitution specifically grants that power and authority – sadly, the actual affairs of government have gone well beyond those limits, and it is doubtful that we shall ever again see the government truly envisioned by the founding fathers. We must make do with the reality in which we live.

The reality of the Constitution, is that it’s really a very simple framework. Let’s have a walk through the structure of the thing and I hope you will see what I mean:


”We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”

That sets out what we’re doing. Union, Justice, Peace, Defense, Welfare, and Liberty are the goals. The rest of the Constitution lays out how these goals are to be accomplished.

Article I

Article I lays out the Congress of the United States, how it is created and how it shall operate. Section 8 is particularly important, setting out taxation, debt, commerce, naturalization of citizens, bankruptcy law, the treasury, post office and rail roads, patents and copyright, the establishment of courts, and the conduct and operation of the military, in that order.

Article II

Article II lays out the Executive Branch, the qualifications for President of the United States and how he/she may be elected. The Constitution clearly shows the President to be Commander-in-Chief of the armed forces, to have the right to make appointments and to recommend actions to Congress, and that he may be removed only by impeachment for “high crimes”, such as Treason or Bribery. The President’s role is clearly set out distinct from the role of Congress; the Congress is expected to deliberate and move slowly and with the deliberation appropriate to its great power, while the President is in a leadership role, so that he may move more quickly but with less effect than the Congress.

Article III

Article III sets out the judicial system, derived from the Supreme Court and – as the Constitution describes them – inferior courts. It is interesting that Section 1 specifically qualifies the right of any judge to sit on the bench to their “good behavior”; I cannot help but wonder how many of our esteemed honors would actually pass a reasonable examination to see whether in fact their behavior as judges could properly be called ‘good’.

Article IV

Article IV gets into greater detail than the previous articles, addressing the rights of states to conduct their public acts with the confidence that other states will consider such acts as legitimate within their own jurisdiction to the degree that relations between those states are affected, the universal applicability of criminal law and civil judgments, the territory and boundaries of states, and the universal protection by the armed forces of each state from invasion or attack.

Article V

Article V sets out how amendments to the Constitution may be created and ratified. This plainly worded section is perhaps the most effective means by which the Constitution remains relevant.

Article VI

Article VI almost reads as an afterthought to the main body of the Constitution, but two points in this article are of paramount importance – the clear affirmation that the Constitution of the United States is the “supreme Law of the Land”, which rather snuffs the notion that interpretation of foreign law should be considered anything close to equal in standing to the Constitution as written and ratified; and the direct admonition that “no religious Test shall ever be required as a Qualification to any Office or public Trust under the United States”, which is in actual fact the strongest clear statement of the separation of Church and State; note that this separation is effected in the conduct of public officials, not in the rights of private citizens.

Article VII

Article VII sets out the ratification of the Constitution.

The Amendments

The twenty-seven Amendments to the Constitution of the United States are, to me anyway, a fascinating historical commentary on the enduring value and stability of the Constitution. It should be remembered, after all, that other nations had Constitutions which failed because they ignored them – the politicians in, for example, the Soviet Union ignored their Constitution whenever they felt like it, or – why does this sound familiar – decided whatever they wanted to do was actually allowed under the Constitution, even where specifically proscribed by the actual document. We see maddening debates over the meaning of the wording in various places, but at least our judges still consider the Constitution as the rule book on our laws.

The first ten amendments, of course, were created at the time of the original Constitution, and are collectively known as the Bill of Rights. It shows something of the concern by Mr. Madison and his colleagues, that even in a document which clearly set out to limit the scope and power of government, they determined it was necessary to enumerate specific rights which may not, under any circumstances, be abrogated. In short summary they are as follows:

1. Freedom of Speech
2. Right to Firearms
3. Quarters for Troops
4. Search and Seizure limits
5. Rights of the Accused
6. Criminal Prosecutions
7. The Right to Juries
8. The Right to Bail, limits on Punishment
9. The Bill of Rights does not list all rights of the people
10. Powers not specifically accorded the federal government by the Constitution belong to the states, or to the people

It gets interesting after that. The eleventh amendment addresses lawsuits against states, the twelfth concerns the election of the President and Vice-President, the thirteenth abolishes slavery, the fourteenth details due process rights, equal protection, and voting rights, the fifteenth prohibits racial discrimination of voting rights, the sixteenth establishes income tax, the seventeenth addresses the election of senators in more detail, the eighteenth banned alcoholic drinks, the nineteenth confirmed the right of women to vote, the twentieth addresses the succession of the President of the United States, the twenty-first repealed the eighteenth amendment, the twenty-second limits the President of the United States to two full terms of office, the twenty-third allows D.C. residents to vote in Presidential elections, the twenty-fourth bans the poll tax, the twenty-fifth details specific conditions for succession of the President, the twenty-sixth sets the voting age at 18 across the nation, and the twenty-seventh prohibits the Congress from voting on their pay more than once in a two-year period. From this, we can see that of the 17 amendments after the Bill of Rights, four address the actions and election of the President of the United States, eight address elections and voting rights, two clarify the operation of the federal government, two ban certain practices, one establishes a new power for the federal government, and one simply cancels a prior amendment.

The sum effect of the Constitution and its amendments, for me anyway, is that this is a simple framework meant to be applied in the spirit of limited government and maximum rights for individuals. From this spirit, it follows that individuals may do as they please, with the common sense restrictions that each of us is responsible for the effect of our actions upon others, and that as a member of our community we have obligations to promote its welfare. There is no right to a certain minimum number of years of life, nor to perfect health, no right to social networking or a secure job, nor to the exclusion of annoying people or discomfort, no right to guarantee that the police can solve every crime or the government solve your every worry.

Which brings us to that problem of imagination. Where did all those government programs come from, if our founding fathers did not had over the authority to create them? In a word, sophistry. Consider the Louisiana Purchase, for example. While I agree that it was a great deal for the United States and a brilliant bit of strategy, it was also clearly unconstitutional. And what about Lincoln suspending the writ of Habeus Corpus during the Civil War? Many historians have argued persuasively that the action was necessary, but again there is no authority in the Constitution for President Lincoln to have done it. The New Deal? As grand as FDR described it and as proud as so many are of their work in those years, nowhere does the Constitution allow the President or the Congress to take over the commerce of the nation in order to try out political theory, as happened in the 1930s. And yes, that in turn makes the Bush and Obama attempts to do the same thing unconstitutional. Frankly, the very notion of borrowing huge amounts of taxpayer money for the benefit of selected companies and industries is so offensive that one imagines Hamilton and Franklin retching at the mere notion, not to mention its repetition in succeeding terms. It will, no doubt, be observed that many courts in the United States, including the Supreme Court, have signed off on these egregious violations of the limits of government, but one might remind such individuals that the courts have made myriad mistakes over the years, from Dred Scott to Plessy v Ferguson to Hepburn v Griswold to Everson to Roe v Wade to Grutter to Kelo v. New London and so on. To this, we must also note that when there is influence or power to be gained by advancing the breadth and grasp of the federal government, the Constitution fares badly throughout history, in courtrooms as much as the halls of Congress.

Many critics of the current proposals argue that we cannot afford them, but at some point it is bound to occur to the citizens of the United States that they never got to vote on these obscene orgies of spending, that the hateful practice of ‘taxation without representation’ is in full effect in the modern world, and that in the end the only hope for the Republic is for its citizens to demand its return. The only right we have, in the end, is the right to take responsibility for our own condition and actions, and their consequence. The only proper role for government is to protect the citizens from enemies and continue the maintenance of infrastructure, but otherwise to shut up and get out of the way of those who do the real work at hand.

Sunday, August 02, 2009

A Clear Sign, But What Does It Say?

I have not written much at all about President Obama’s Approval Ratings in the polls since he was inaugurated in January, but noting the recent trend it seems appropriate to do so now.

I have said many times that for me, the gold standard in opinion polling is the Gallup Organization. This is due not only to Gallup’s long history, but also because Gallup follows a very consistent methodology and set of questions. This allows interested researchers the opportunity to track support within a poll over a period of time, to better gauge the actual cause and effect of his policies and decisions.

The people at Real Clear Politics provide a very useful resource, where general polling support can be easily tracked.

Looking at these polls, the following polls provide a track of Obama’s job approval since January:

Gallup: 68% when sworn in, 56% now, loss of 12 points
Rasmussen: 62% when sworn in, 50% now, loss of 12 points
CBS/NYT: 63% February 22, 58% now, loss of 5 points
NBC/WSJ: 60% March 1, 53% now, loss of 7 points
Pew: 64% February 8, 54% now, loss of 10 points
NPR: 59% March 14, 53% now, loss of 6 points
FOX: 65% when sworn in, 54% now, loss of 11 points

In every case of long-term tracking, President Obama’s levels of job approval are the lowest overall he has seen since taking office, across the board.

But a closer look shows the problem may be more serious, nothing to worry about, or paradoxically, both.

In addition to a high-level overview, the Gallup Organization also publishes support by demographic groups.

An examination of those 28 demographic groups, determined by gender, age, geographic region, race, education, wages, political affiliation and orientation shows that in 22 of 28 demographic categories, support for President Obama is at its lowest or tried for the lowest level since he took office. The six demographic areas where support for President Obama is not at its nadir, are Non-White voters (85% support highest on April 26, 75% lowest on April 5, presently at 79%), Black voters (96% highest on July 5, May 4, and March 8, lowest at 86% on January 25, presently at 95%), Hispanic voters (85% highest on April 26, 70% lowest on April 5 and March 22, presently at 72%), Voters making below $24,000 a year (76% highest on May 4, 66% lowest on June 21, presently at 68%), Republicans (41% highest on January 25, 20% lowest on July 12, presently at 21%), and Liberals (90% highest on June 28, May 31, May 24, and April 26, 83% lowest on January 25, presently at 86%). All of those demographics are relative minorities to the voting population at this time.

Even with the loss of support, however, President Obama still enjoys support levels above 50% across the board, indicating that his personal popularity is strong and the general theme of his administration is well-received. Therefore, it may be reasonable to consider the loss of support nothing more than a shaking out of the fair-weather support, and displaying a strong core of support for the President. That is, of course, assuming his numbers do not continue to fall.

It should, however, be noted that President Obama has lost significant support among major demographic groups. Between February 1 and July 26, President Obama lost twelve points of support from female voters, who were the dominant gender in the 2008 election. White voters made up 74% of the electorate in the 2008 election, and since taking office President Obama’s support among whites has fallen sixteen points according to Gallup. The largest demographic age group in the 2008 election was the 30-49 age group; among this group President Obama has lost twelve points since taking office. Among moderates, the largest political philosophy demographic, President Obama has lost ten points since taking office. The South was the most important geographic region in the 2008 election, and among Southern voters, President Obama has lost twelve points of support since taking office. In the 2008 election, the largest demographic by education was the ‘Some College’ category, and in that category President Obama has lost fifteen points of support since taking office. And among voters earning between sixty thousand and ninety thousand dollars a year, again the largest demographic in their section, President Obama has seen his support fall by twenty points since taking office. The conclusion is unavoidable that, if this loss of support is not rebuilt and assuming the Republicans can present a credible candidate, that at this time President Obama has seriously damaged his re-election chances, since every dominant demographic group from the 2008 election has significantly reduced support for the President since his Inauguration.