Catastrophe (14 page)

When Barack Obama talks about health care reform, it seems as if all the news is good news. His program, he tells us, will cover 47 million people who now don’t have insurance. It will lower costs for the rest of us by $2,500 annually. It will improve the quality and efficiency of the care we get. It will focus particularly on chronic illnesses to improve the management of our treatment. It will restore American competitiveness by lowering the cost of health care.

And, increasingly, Obama is fond of linking health care reform to the rescue of the economy (never let a good crisis go to waste!).

As CNN reported, in one speech “President Obama pledged…to cure Americans from what he called ‘the crushing cost of health care,’ saying the country could not afford to put health-care reform on hold. ‘This is a cost,’ he noted, ‘that now causes a bankruptcy in America every thirty seconds.’ He said that it would cause 1.5 million Americans to lose their homes.”
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President Obama is right to complain about the high cost of health care, which now consumes 16 percent of our GDP. When Bill Clinton urged reform in 1993, it ate up 12 percent of the GDP—and he warned of disaster if it rose to 14 percent.

But Obama hasn’t explained how he’s going to cover 47 million more people and reduce the cost of health care at the same time.

Let us do the honors.

He won’t tell you this, but the silent centerpiece of Obama’s program is his plan to ration health care, giving it to some and denying it to others.

The bad news is, rationing health care is the only thing that makes his program possible.

You can’t expand medical care just by spending more money. It has to be delivered by a special group of people—doctors and nurses. And there just aren’t enough to go around. We barely have enough to offer health care services as it is. To stretch them even thinner—thin enough to cover 47 million more people—would be impossible.

As the
Wall Street Journal
notes, Obama’s “focus only on extending health-care coverage ignores the serious shortage of primary-care physicians. Physicians are increasingly going into specialties and the ranks of generalists, the essential first line diagnosticians and caregivers, are shrinking. Without more physicians, those receiving the extended insurance will not be able to find health-care providers.”
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Though the number of doctors in the United States rose sharply in the past decades, it has actually been leveling off, with only a slight increase, in recent years. The increase in the doctor population averages about 1 percent per year, not even enough even to keep up with U.S. population growth. And certainly not enough to care for a 20 percent increase in their workload—as projected by Obama’s plan to cover 47 million new people.

The nurse population, meanwhile, has not risen at all. In a March 2008 report, Dr. Peter Buerhaus of the Vanderbilt University School of Nursing predicted that the shortage of registered nurses in the United States could reach as high as 500,000 by 2025.
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If doctors and nurses can barely meet the needs of the 253 million Americans who have insurance or government coverage, how will they deal with the unmet medical needs of the 47 million uninsured Americans whom Obama plans to cover? Where are all those doctors and nurses going to come from?

According to classical economics, when too many people want a service and there are too few professionals to deliver it, the price rises and those who can afford care get it; those who can’t are left out.

That’s what liberals say is happening today. Those who are fortunate enough to have insurance, either through the workplace or through government programs, get the care they need and the others miss out.

Source: Statistical Abstract of the United States.

If you are over sixty-five, you’re eligible for Medicare and most of your health care costs are covered. If you are poor, you are entitled to Medicaid, with similarly extensive coverage. If your employer is enrolled in an insurance plan, you’re covered as well. If you’re a child whose parents earn too much for Medicaid but less than about $50,000 a year, you can get coverage through the State Child Health Insurance Program (SCHIP).

All told, 70 percent of Americans with health coverage get it through their employers.
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But 47 million don’t have coverage.

Who are the uninsured?

• Around one-quarter are eligible for Medicaid but haven’t applied. They generally aren’t sick. When they need care, they enroll in Medicaid and get it.
  

• Another sixth are illegal immigrants. Although Obama says he won’t cover them, he will speed their path to legal status and thus to coverage.
  

Who are the rest? They are mainly working-age adults who are not impoverished but don’t have coverage through their jobs.

Obama has already extended coverage to more children under the SCHIP program and to unemployed adults under the COBRA program. The feds pay two-thirds of the cost of insurance for anyone who is unemployed for nine months.

But how will Obama extend coverage beyond its current limits? Though he hasn’t specified the details of his program, its broad outlines are visible. To cover those without insurance, Obama will require all employers either to pay for insurance or to give money to a federal program to buy it for them. He will also launch a new federal government insurance program offering benefits comparable to those given members of Congress. Consumers or employers could switch from their current plans, if they wished, to enroll in the new federal program.

That’s the good news.

The bad news is that adequate medical care for the additional 47 million people is going to mean worse care for the rest of us.

The issue isn’t money. Obama estimates the cost of his health care program at about $600 billion over ten years. That’s surely a lowball estimate; cost calculations on medical care always are. But he can and will raise the extra money.

How? Despite pledging not to tax employer-paid health benefits during the campaign—and attacking McCain for proposing it—he might reverse field and institute such a tax. As of this writing, he is promising to fund at least half of his program by curtailing tax deductions for state and local taxes, charitable donations, or mortgages for those making more than $200,000 per year. But the charities are kicking up a fuss, and he may have to backtrack.

One way or another, he’ll probably come up with the money. Democrats are good at that.

But it isn’t money that is the problem—it’s the supply of doctors and nurses. You can’t just
buy
good medical care. It takes years to train doctors and nurses to deliver it. Even if Obama were to start now, massively recruiting future doctors and nurses, it would take at least five to ten years to build the workforce he needs.

The
New York Times
reports that Massachusetts has adopted a variant
of the plan Obama is likely to propose—and impose—is facing just such a shortage of medical personnel:

You can spend more money on health care, but that won’t buy you an instant enlargement in the number of doctors to provide it.
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And Obama’s cuts in the cost of health care will inevitably involve limiting compensation, at least for doctors and perhaps for nurses too. The tighter the limits, the lower the cost—but the fewer people who will enter the professions. So cost limitations are likely to worsen the supply shortage.

The answer, then, has to be rationing—government control over who gets what service. Since the problem isn’t how to pay for the service but how to find the medical personnel to deliver it, Americans won’t be able to opt out and pay for the services themselves. Rationing means being told what tests, procedures, operations, treatments, medicines, therapy, and so forth you’re able to get and which ones you’re not. These decisions, of course, will be made not by your doctor or nurse but by bureaucrats—people who’ve never met you but who will literally determine whether you live or die.

If you read between the lines of Obama’s happy pronouncements on health care, you can see that he is leading toward rationing.

Mindful of the mistakes Bill and Hillary Clinton made in 1993, Obama always goes out of his way to say that if you’re happy with your insurance, you can keep it and not be affected by his changes. But then he goes on to say that he’ll cut the cost of your premiums by $2,500, presumably by implementing the standardization and management procedures described above.

Obama won’t control your insurance company. He’ll just control the
money. And it will be his bureaucrats, not your insurance company, who will make the key decisions and lay out the guidelines. Of course, Obama will leave it to your insurance company and its managed care people to break the bad news to you. Government won’t do that. It’ll be too busy pulling the strings behind the scenes—setting the standards, designing the protocols, making up the requirements, and deciding how the money will be spent.

HOW WILL RATIONING WORK?

Rationally.

If you’re old and near death, the system will not allow you a full spectrum of medical services, tests, medications, or options. If you die somewhat prematurely as a result, that’s an unfortunate by-product of the needs of the system. After all, there are younger people who need the care more than you do, and there’s not enough to go around.

You won’t always get to see a doctor. Often you’ll have to make do with a nurse-practitioner. A particularly brutal form of triage will be used to decide who can most benefit from what sort of care.

The victims will be the elderly, the sickest, and those who smoke or otherwise inflict harm upon themselves.

The beneficiaries will be the young, the poor, the newly legalized illegal immigrants, and others of Obama’s constituency.

How do we know? That’s how it works in Canada.

THE CANADIAN EXPERIENCE

Canada has the same kind of government-provided health care that Obama is suggesting for the United States. It looks like a different system, but it’s not really. In Canada, the government pays for all medical care. Under
Obama, the government will work through private insurance companies, as well as its own insurance plan, to deliver health care. But there’s not much difference.

Obama would offer insurance to everyone, making employers write policies for their workers or pay an equivalent amount into a fund to give them insurance. The federal government would subsidize anyone who couldn’t afford insurance.

But under Obama’s plan, as in Canada, the central government will decide what the insurance can and cannot cover. The all-important utilization controls will reside in Washington or, as in Canada, in the various state capitals.

The reason the systems are parallel is that the problems are the same. Each country’s government is trying to cover everybody without enough medical personnel to go around. So the resulting rationing (aka “efficiency”) puts patients at the mercy of their local bureaucrats.

And here’s the key point: in Canada, you can’t spend your own money to get good health care. It’s illegal. In a recent article, Brett Skinner, the director of health and pharmaceutical policy research at the Fraser Institute, notes that “Canadian patients…are worse off than uninsured Americans, the latter of whom are at least legally allowed to use their own money or credit to buy health care. Canadian patients who want to escape the delays in the public system are also barred from paying privately for health care services. In practical terms, Canadian patients are unable to buy quicker access or better care than the government health program provides.”
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