Conservative challenges to Obamacare, we are told, are silly, fruitless, and petty. Of course the commerce clause of the Constitution covers the individual mandate. Why wouldn’t it? After all, healthcare is commerce. Doctors, nurses, and pharmaceutical companies are providers; patients are consumers. This model follows the rules of all trade.
Patients Are Not Consumers
By PAUL KRUGMAN
Wait what? Patients are not consumers? But you need consumers for commerce! The foundation of the Obamacare defense is that healthcare is commerce (not only commerce, but interstate commerce), and thereby covered by the Commerce Clause of the Constitution.
During the healthcare debate, Obama assured us that the individual mandate was not a tax. Now, his lawyers assure us that it is a tax. That little reversal is contemptible, but it pales in comparison to Professor Krugman’s assertion that healthcare isn’t a transactionary commodity, and is thereby not commerce. On its face, this is utterly stupid. Healthcare is a marketplace, therefore it must be commercial. Dig a little deeper and you’ll find that it’s also counterproductive. That makes it a two-fer of dumbassery.
Remember, this is the guy that all liberals cite when it comes to the economy.
Earlier this week, The Times reported on Congressional backlash against the Independent Payment Advisory Board, a key part of efforts to rein in health care costs. This backlash was predictable; it is also profoundly irresponsible, as I’ll explain in a minute.
I’m going to hold you to that.
But something else struck me as I looked at Republican arguments against the board,
Enlightenment? Epiphany? The crippling panic that you’re already well along the road to senility?
which hinge on the notion that what we really need to do, as the House budget proposal put it,
Is this really all one sentence? The barrage of commas is making me woozy.
is to “make government health care programs more responsive to consumer choice.”
Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”?
It became both normal and acceptable the moment that patients exchanged money for medical services. Historians place this occurrence somewhere in the range of 50,000BC. (Not really; I’m ballparking to underscore that even cave men know Paul Krugman’s an idiot.) The exchange of goods for medical services is, by even the narrowest definition, commerce. We give this name to business and/or trade that takes place between provider and consumer. There is nothing dirty, sordid, unsavory or uncouth about it. Is this guy really an economist?
The relationship between patient and doctor used to be considered something special, almost sacred.
Liberals look for religion in the strangest places.
Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car —
Here’s my question: Why would something not be commercial if and when money is exchanged?
Sex is often special, sometimes almost sacred. In fact, I've hired a marching band to play lead a parade the next time I get laid. Whereas medicine has the ability to save a life, sex has the ability to create a life. Yet when one pays for sex, it’s undisputably commercial. (And illegal. And probably winds up with you needing to see a doctor for some aloe to rub on the ensuing crotchrot. Sorry, not the point.)
Here’s the difference: while non-prostitutes are willing to give sex away at various points based on emotional involvements, no one is willing to spend four years and hundreds of thousands of dollars at medical school to work long hours at intellectually demanding and stressful jobs for no pay. Even doctors, notorious do-gooders that they are, get tired of things like Doctors Without Borders after a couple years. That’s why they have to constantly guilt each other into patching up bullet wounds in Sierra Leone with butter knives sanitized with a Bic lighter and a handle of cheap rum. It's also why no one is watching ABC’s Off the Map.
Pharmaceutical research is big business. Manufacturers pour time, money, expertise, and uncommon passion into curing diseases that Paul Krugman (and I) can’t even spell. When you take the commerce out of the medical profession, the medical profession dies.
and their only complaint is that it isn’t commercial enough.
You’re an economist. The economy is the product of commerce. This is kind of like hearing a tire salesman publicly berating cars in favor of some mechanical biped. (Yes, it’s that ridiculous.)
What has gone wrong with us?
Speaking only of you, I’d say that the problem here is an economist who doesn’t understand the basic nature of commerce.
About that advisory board:
It’s about time.
We have to do something about health care costs,
No. I have to do something about my own health care costs.
which means that we have to find a way to start saying no.
Let’s follow the train of basic logic for a moment here:
“Saying no” is a euphemism for rationing.
Rationing is the necessary byproduct of the scarcity of a good.
Markets are the most efficient mechanisms for distributing scarce goods.
Paul Krugman advocates against viewing medical patients as consumers
If there are no consumers, there can be no market.
Paul Krugman is advocating medical inefficiency.
QED
In particular, given continuing medical innovation, we can’t maintain a system in which Medicare essentially pays for anything a doctor recommends.
Read: rationing is good.
And that’s especially true when that blank-check approach is combined with a system that gives doctors and hospitals — who aren’t saints —
What happened to the relationship between patient and doctor being sacred?
a strong financial incentive to engage in excessive care.
Define excessive; it sounds suspiciously like you’re saying that it costs too much to keep Grandma alive.
Hence the advisory board, whose creation was mandated by last year’s health reform.
Conservatives euphemized this board as a “death panel.” This is the provision of Obamacare Sarah Palin was talking about. Can we please get a collective “Sarah Palin was right” from the media?
The board, composed of health-care experts,
Read: 15 bureaucrats in a smoke-filled, oak paneled room.
would be given a target rate of growth in Medicare spending.
You’re right. Determining care based on target rates of growth in Medicare spending is much more personal and sacred than the transactional coarseness and commercialistic crudity of a free market for healthcare.
To keep spending at or below this target, the board would submit “fast-track” recommendations for cost control
Read: denials of coverage.
that would go into effect automatically unless overruled by Congress.
Before you start yelling about “rationing” and “death panels,”
Too late.
bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money.
Yet. The prohibition of private healthcare, however, is how every foray into socialized medicine ends.
We’re talking only about what will be paid for with taxpayers’ money.
An excellent distinction. The problem is that expansions in government-sponsored insurance will reduce the number of applicants and threaten the risk-pooling that make the business model for private insurers workable. Employers will stop providing more health care when it is already available through the government. The result is that the only way to get around the rationing imposed by these death panels is to have multiple thousands of dollars to tap into if you need catastrophic care that’s not covered by the government. (I.e. you smoked one cigarette once when you were sixteen and now you need a lung transplant.) Not only does this favor the rich; it makes it so that they're the only one who will be able to survive the holes in government coverage.
And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness.
It’s like the twilight zone. First he demands that the government pay for healthcare, then he’s insulted by the comical notion that we would insist that the government pay for the healthcare they forced down our throats. I should write this quote down somewhere, though. This seems like something to throw in his face later.
And the point is that choices must be made; one way or another, government spending on health care must be limited.
Here’s a more important question: why is government in the business of providing health insurance at all?
Now, what House Republicans propose is that the government
Somewhere in the Chicago
simply push the problem of rising health care costs on to seniors;
Considering that you have literally just gotten done advocating a set of policies that will inarguably result in the deaths of old people, this is particularly brash.
Oh, the idea that vouchers transfer costs is also completely asinine.
that is, that we replace Medicare with vouchers that can be applied to private insurance,
Seriously, this whole comma thing is out of control.
and that we count on seniors and insurance companies to work it out somehow.
One party wants health care. The other party wants to provide health care. Hold on a minute, I’m going to have to go get my abacus.
This, they claim, would be superior to expert review because it would open health care to the wonders of “consumer choice.”
What’s wrong with this idea
Literally nothing.
(aside from the grossly inadequate value of the proposed vouchers)?
Seriously? In a column about the wonders of rationing, you’re going to be insulted by the low value of the proposed vouchers?
One answer is that it wouldn’t work.
That’s like saying “one answer” to 5+5 is 12. Sure it’s an answer. That doesn’t make it right.
“Consumer-based” medicine has been a bust everywhere it has been tried.
As compared to the socialist utopia of the United Kingdom
To take the most directly relevant example, Medicare Advantage, which was originally called Medicare + Choice, was supposed to save money; it ended up costing substantially more than traditional Medicare.
Boy, that sounds like an awfully good argument for reducing the amount of money the government pays private insurers for Medicare Advantage.
In fact, with a voucher system, unlike with Medicare as is, you can literally guarantee costs. If there are 10M people on Medicare and the annual voucher is $1,000, the annual cost is $10B. This doesn’t exactly require a team of actuaries and accountants. There are no hidden fees. The only opportunity for fraud and abuse is for ineligible people to receive a voucher.
With a pure voucher system—unlike virtually every other program that has been proposed—it is completely, utterly impossible for costs to be unexpectedly high.
Fortunately, we still believe in freedom on this side of the pond.
It also has by far the highest costs yet provides a quality of care no better than far cheaper systems in other countries.
Really? Canadians and Brits are waiting in line until they die to see an oncologist. I guess quality is sort of a sliding scale.
But the fact that Republicans are demanding that we literally stake our health, even our lives, on an already failed approach
Keep in mind, he’s saying that letting you decide what healthcare products you pay for is a failed approach, and that it is utterly irresponsible for Republicans to ask you to stake your life on you.
This is the condescension inherent to all statists. They know better than you how to live your life.
is only part of what’s wrong here. As I said earlier, there’s something terribly wrong with the whole notion of patients as “consumers” and health care as simply a financial transaction.
He’s not seeing the stupidity of arguing that healthcare isn’t commerce, is he? Oh well.
Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made.
And so they simply must be made by appointed bureaucrats.
Yet making such decisions intelligently requires a vast amount of specialized knowledge.
Read: you’re too dumb to decide whether to live or die.
Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.
I’m neither a doctor or a lawyer, but I’ve seen enough episodes of House to know that this is what Power of Attorney is for.
That’s why we have medical ethics.
Actually, that’s why we have legal guardians and next of kin. We have medical ethics to prevent bureaucrats and scientists from deciding who lives and who dies.
That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional.
Much like forklift drivers and rodeo clowns, they’re not allowed to drink on the job.
There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.
The Office, Outsourced, (Basically anything on NBC Thursday nights.) The Apprentice, (Arguably) Shark Tank, Mr. Sunshine, Mad Men, Fairly Legal (It’s about mediation, so it doesn’t count as a legal show, although if legal shows count, this would get lopsided pretty quickly) and Undercover Boss.
Of course, one could argue that most of the figures in those shows are not pure heroes; the easier case would be that the doctors on House, Gray’s Anatomy, Off the Map, Royal Pains, Private Practice barely qualify as heroes. Plus, medical dramas are just lazy (For the record, I found more business related shows than medical-related shows.)
The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening.
How is it that an economist thinks that money and commerce are dirty and tawdry?
And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.
Words fail me. This column was every bit as dumb as I hoped it would be.
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