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Monday, March 20, 2017

Reforming Obamacare, Part 2

A reader suggested that Wyoming may already have its own death panel, namely the palliative-care council created by SF88, Senator Scott's bill that passed the state legislature this session and became State Enrolled Act 81. Technically, this council is not a death panel in the traditional sense. Its work is not tied to cost containment, and it is explicitly banned from discussing euthanasia. However, it is worth noting that once the palliative-care council exists, it can be reformed to become a formal death panel. 
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On Thursday I explained the difficulties of reforming Obamacare. These difficulties should in no way prohibit Congress from carrying out necessary reforms, nor should they constitute an excuse for Republicans in Congress to settle for token reforms. This is not the time to rewrite the cocktail menu in the bar on the Titanic. What we need is nothing short of a complete repeal and a solid free-market replacement. 

In an article later this week I will address the economic reasons for free-market health insurance; before we get there, though, I would like to point to one side of this issue that is often overlooked in the public debate: the demotion of life itself to a fiscal instrument in the hands of government.

Government gets involved in health care for two stated reasons: the egalitarian ambition to redistribute health care resources, and the ambition to make health care "affordable". These two reasons overlap to some degree, but usually the first reason constitutes the opening salvo from health care statists. The "affordability" argument is usually added on as a back-up in case the egalitarian charge to create a single-payer health care system fails. 

Obamacare is the brainchild of the secondary strategy. Health care statists learned the lesson from the complete failure of the Health Security Act of 1993. That bill, better known as Hillarycare, would have created a single-payer system in the United States, and with it the largest government bureaucracy in the world. The Obama administration knew that their ambitions to have government take over health care would also fall flat to the ground if they went straight for single-payer. Therefore, they resorted to the secondary argument, namely that government must make health insurance "affordable". Once government had become universally accepted as the arbiter of the health insurance market, people would be much more willing to accept a single-payer system. 

The Obama administration and its Democrat supporters in Congress never got around to eradicating private insurance; it is entirely possible, even likely, that Secretary Clinton had her eyes set on the single-payer trophy. Her loss to Donald Trump likely saved us from the final leg of health care socialization. However, that does not mean that the threat of single-payer health care has been eliminated. Quite the contrary: so long as the bulk of Obamacare remains in place it is easy for the federal government to take the final step and socialize the entire health care system. 

For this reason alone, the Republican Congressional majority must work with President Trump to roll back Obamacare in its entirety. Anything short of that will leave us vulnerable to another bold attempt by health care statists. The rollback does not have to happen in one step - although that would be preferable - but so long as they have a plan, and they stick to it, they deserve our support and encouragement. 

I sometimes get the impression that the efforts that Republicans put into health-care reform are not always principled in nature. On the contrary, with a few rare exceptions (can you say Rand Paul?) the GOP seems to be more interested in that cocktail menu on the Titanic than in getting us all off the boat. Let me therefore offer an argument that is practically never brought up in the health-reform debate, but should be right at its forefront.

As I mentioned earlier, government-provided health care sooner or later becomes an issue of demoting life to instrumental status. To egalitarians, this is perfectly normal and rational,* but anyone whose principles stand on the value system that forms the foundation of this constitutional republic, should immediately dismiss the idea of government superseding life itself. 

This is not a hypothetical problem; it is not the topic for eclectic 2AM conversations. It is a very real issue that is right around the corner in all our lives. 

The most immediate example of the clear and present danger of a government takeover of all our lives is the Independent Payment Advisory Board (IPAB). Also known as the Obamacare Death Panel, this board still exists. It has never gone into effect, probably because President Obama realized that he would never be able to fill the board so long as Republicans controlled the House. However, all that stands between us and an active, government-run death care panel is a thin line of voter-conscious Republican members of the House of Representatives. 

A year ago, James Carpetta at the American Enterprise Institute cautioned that so long as IPAB exists, it constitutes a real threat to the health-care self governance of all Americans in general, and Medicare enrollees in particular. In fact, the IPAB is the "perfect bridge" between the affordability argument for government-run health care, and the demotion of life to an item in a government budget:
The slowdown in Medicare spending growth in recent years has made the IPAB less relevant – for now. But IPAB’s demise is not a foregone conclusion, especially when Medicare spending growth accelerates again, as it almost inevitably will. For now, , the IPAB remains on the books. Opponents, therefore, must keep up the pressure and look for opportunities to kill it altogether. The basic idea of the IPAB is to impose a cap on Medicare spending and then allow the board’s fifteen members to come up with ways to keep program spending under control. In one sense, it is surprising that the ACA’s authors supported this concept. Those who wrote the law are generally in favor of expanding entitlement programs, not restricting them with caps on spending. But not all spending “caps” are the same. The key feature is how the cap is enforced. A closer look at how the IPAB and its associated cap on Medicare spending show that they are more aligned with the overall philosophy of the ACA than it might first appear. The cap on spending is based on per capita Medicare spending growth. From 2013 to 2017, the target growth rate is the average of the general consumer price index and the CPI for medical care. After 2017, the target growth rate is GDP growth plus one percentage point.
IPAB's Medicare cost-containment ambitions would quickly become a question of whether or not it is cost-efficient to keep an elderly patient alive. The reason is the cost cap, which is defined as a per-capita "GDP growth plus one percentage point". Every person enrolling in Medicare is given a total rest-of-the-life budget for what health care he or she can be eligible for. Once you have used up your lifetime allotment, you have forfeited your right to more health care. 

At this point, if for example you are diagnosed with cancer, all you will get is comfort care to keep you from suffering as the disease consumes you.

It does not matter if you would have a decent chance to beat that cancer, nor does it matter that you might want to stay alive as long as is medically possible. What matters is how long government believes it is fiscally acceptable to keep you alive. 

If Republicans do not repeal IPAB, and every other cost-containment measure that demotes life to an item in the government budget, they will have failed in the mandate they got with the 2016 election.

But even if they succeed in their repeal efforts, the threat of government reducing life to a budget instrument is still present at the state level. We saw this in the 2017 legislative session, where at least two bills sought to create an IPAB-style death panel here in Wyoming. Other states have gone farther down the road toward the demotion of life, with Oregon leading the charge. Not only does the Beaver State have a lax euthanasia law, but a State Senate bill now wants Oregonians to be subjected to a particularly ugly form of eugenics. David Kilada, writing for Oregon Right to Life, explains that Oregon State Senate Bill 494
would allow the starving and dehydrating of patients who suffer from dementia or mental illness. A perfect illustration of the danger this bill presents can be seen in a situation involving an Ashland resident named Nora Harris who suffered from Alzheimer’s disease. After moving into a memory care facility, Nora eventually lost the ability to communicate her wishes. She lost her fine motor skills as well, which prevented her from using utensils. Hungry, she would eat and drink what was offered to her, but her husband sought a court order to require the nursing home to stop assisting her. However, the court would not deny Nora basic sustenance because that would have violated Oregon law. Now Oregon legislators are pushing to remove this legal protection!
Specifically, Kilada notes:
SB 494 removes current safeguards which prohibit surrogates from withholding ordinary food and water from conscious patients with conditions that don’t allow them to make decisions about their own care. Currently, patients like Nora are given help with eating and drinking when they cannot do it themselves. This is not tube feeding or an IV—this is basic, non-medical care for conscious patients.
Strictly speaking, this bill would not create an outright death panel in Oregon, but it would endorse the practice of actively killing patients under a power-of-attorney style construction where health care practitioners can recommend the killing (see especially page 7, line 40 of the bill). 

Before anyone dismisses this as entirely conspiratorial, consider the fact that this bill would apply to Medicaid in Oregon; if the Oregon state government has to contain the costs of its program, it can easily make it mandatory for health care providers to implement IPAB-style cost caps on a person's lifetime health care consumption. Once a Medicaid enrollee hits his individual cost cap, the only remaining option is - yes - his death. 

The Oregon example, the bills presented to the Wyoming legislature this past session, and the IPAB, are all examples of the same line of thinking.They are all expressions of health care statism and its idea that government is a better judge of our lives than God. These examples show how easily the black-coats practice of death care can penetrate our lives, our moral defenses, and establish itself as a "natural" practice of government powers. 

So far, we do not have a death panel in Wyoming. Let us hope our Congressional delegation is wise enough to get rid of the IPAB. Let us hope they understand this without having to be reminded by their constituents. 

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