A Positive Aspect of The Affordable Care Act

The Supreme Court begins three days of hearings today on the Patient Protection and Affordable Care Act.  26 states have challenged the constitutionality of numerous aspects of the law, but by far the most controversial piece is the coverage mandate—the requirement that by 2014 every U.S. citizen would have to had purchased (or have had purchased for their benefit) health insurance coverage, or pay a fine.  

I gather that the argument is essentially the Commerce Clause ("To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.") v. The Tenth Amendment (“The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”)  I have no sense of what cases will be cited by either side as precedent.    

One noble pursuit of the Act which doesn't get much attention is the change to the way Medicare reimburses physicians.  Here's Sarah Kliff's recent post on Ezra Klein's blog.  It's not that long, and it seems to me to frame the issues pretty well.  

Pause.  I’d much rather see Medicare become a defined benefit public assistance plan (e.g., “premium support”) than a totally open-ended benefit (i.e., the current “pay for service” model).  Among other things, as currently structured, the open-ended benefit model is bankrupting the U.S.  But, given what we currently have, this provision of the Act seems totally reasonable.

Currently Medicare compensates physicians for volume.  In the Affordable Care Act the federal government says that, at least with respect to Medicare benefits, taxpayers want to compensate doctors for good results, not just attempts.  As a taxpayer, I have to say that I don’t want my Medicare dollars going toward quick turn-arounds.  If I’m required to pay for some guy’s hip replacement in Pocatello, I want the problem fixed correctly and to be done with the expense.

And, yes, I want the guy to enjoy his new hip.

In this provision, Medicare—as a market participant—is acting to exert its preferences (good care, lower taxpayer costs) on the vendors (doctors).  This particular market is warped in many ways, not the least of which is Medicare’s disproportionately large lever.  But, this is a market-based reform.  Doctors have the option to decline Medicare patients.  It may not be as profitable for them to do so, and Medicare administrators may be basing their paternalistic one-size fits all decisions about what constitutes 'good care' on ignorance, but doctors have the choice not to participate in the market if they don't want to.  

That’s important.   

What the Sandra Fluke Affair Reveals

Last week bombastic conservative radio commentator Rush Limbaugh stuck his foot in his mouth—yet again—when he referred to a Georgetown law school student, Sandra Fluke, as a "slut."  The comment was at once base and baseless.  Limbaugh later apologized, sort of.  It was one of those prideful “I didn’t mean to offend you, but my intent is what really matters, and here’s why…” kind of apologies.  Not much contrition there.  You only get away with that sort of thing if the person to whom you’re apologizing isn’t someone you have to see again.   

Previously, Ms. Fluke had testified before the House Democratic Steering and Policy Committee that her cost of birth control, about $3,000 during her time in law school, is prohibitively expensive for a cash-strapped student.  Her testimony was part of Chairwoman Nancy Pelosi’s theatrical attempt to demonstrate why it’s OK for the Patient Protection and Affordable Care Act (a.k.a., 'Obamacare') to force Catholic institutions to cover birth control in their employee and student health insurance plans.  Limbaugh’s slut comment derives from an incorrect inference on the part of another commentator: if condoms cost about $1.00 each, and Ms. Fluke is in school for 3 years, a total cost of $3,000 equates to 2.74 condoms per day.  However, Ms. Fluke was clearly referring to the cost of birth control pills, not condoms, and we simply have no knowledge—thank heavens—about how, um, active she is.  

Rush blew it.  He should never in a million years have called her such a name, but since he did, he should’ve simply said—directly to Sandra Fluke: “I’m sorry.  What I said was awful.  I hope you can forgive me.”  The “yeah, but…” thing makes his epithet that much more offensive.    

  

Predictably, the left has blown a gasket, calling for boycotts of the products of companies that advertise on Limbaugh’s show.  The boycott is working—several major sponsors have pulled out thus far, representing tens of millions of dollars in annual advertising revenue.  It’s the kind of thing that Limbaugh’s show, right now and in its present form, might not survive, if listeners boycott also.  

      

I say predictably not because I think lefties will always react to stuff they dislike with boycotts (although you have to admit, it’s one of their favorite tools), but because Ms. Fluke isn’t really a person, in this situation, but a prop.  That’s how these gross dances go: The Hatfields trot out some faux victim, the McCoys cry: "Baloney, you %@#$!", and the Hatfields scream: "Scandale dans la maison de McCoy!".

I’ll bet you didn’t know that the Hatfields spoke French.

The problem is that this scandale (call it ‘mysogeny’), like so many others, is actually symmetrical.  As Kristen Powers points out, there are plenty of lefty media types who throw around all sorts of horrible, demeaning language but emerge unscathed.  The left retorts, “But wait, Bill Maher is just a comedian.  Surely we can’t hold him to the same standard as a news organization!”  Maybe not, but has Rush Limbaugh, in the lefty mind, now suddenly been promoted from knuckle-dragging entertainer to serious newsman?

What would be helpful right now is not one of Nancy Pelosi’s dramatic productions, not one of Rush Limbaugh’s demeaning rants, and certainly not the left’s hypocritical, self-righteous indignation.  What would help is a little analysis.  

Fortunately, Cathy Cleaver Ruse has done just that for us.  The real issue is this: What limitation are we going to impose on the federal government’s ability to coerce the private sector into facilitating and funding acts which they find to be morally reprehensible?  Ms. Ruse points out that, unlike medicine which alleviates the symptoms of chronic diseases such as asthma, birth control medication facilitates private choice. 

 

I don’t share the Catholic Church’s view that prohibiting pregnancy is wrong.  But this isn’t about my opinion; it’s about what our government gets to force upon our citizens.  There are a whole lot of things with which I disagree (like dressing up as zombie Mohammed), but which I also defend in the name of liberty. 

Sadly, the Patient Protection and Affordable Care Act fundamentally is about forcing a certain view of equality, not facilitating liberty.  We should applaud Georgetown for even making a health insurance plan available, not berate them for declining one type of coverage.  And whenever possible we should flee coercion.