Is health care a fundamental right?

The House Interim Committee on Health Care held a lively public hearing and work session yesterday on a proposed Constitutional Amendment which would declare access to health care to be a “fundamental right.” If approved by the February special legislative session, it would be voted on by Oregonians in November.

The key language of Legislative Concept 91 reads:

The people of Oregon find that health care is an essential safeguard to human life and dignity and that access to health care is a fundamental right. In order to implement that right, the Legislative Assembly shall establish by law a plan for a system designed to provide every legal resident of the state access to effective and affordable health care on a regular basis.

The hearing started with representatives from Kaiser, Care Oregon and the Oregon Nurses Association testifying in favor of creating this new “fundamental right.”

Then Cascade Policy Institute board member Michael Barton and I testified in opposition. Michael gave the committee a history and philosophy lesson, explaining how the American government was founded on the principle that government does not grant rights, it simply protects our inalienable rights such as those to life, liberty and the pursuit of happiness. He explained that our rights define what we are free to do without interference; they are not goods or services that others must provide for us. He gave each member a copy of his 2006 Cascade Commentary, “Right” to health care violates individual rights, which was published in response to an early version of the current “legislative concept” facing us now.

I followed Michael with a discussion of the political implications. Here is the gist of my testimony:

On a philosophical level, I object to defining health care as a right. On a political level, I understand that government tries to grant such positive rights all the time. In this case, passing this constitutional amendment will make some people feel good. It says that we care deeply about the uninsured, but it only gives intellectual lip service, if that, to the matter of future costs.

More and more people will say “I have a right to not care about the costs, because I have an unqualified right to health care.”

Define health care as a fundamental right and cost control will go out the window – witness the public school system and how the Quality Education Model is now driving massive spending increases for little if any improvement in real quality. I can almost see the just-around-the-corner Quality Health Care Model defining prototype health clinics, with mandated staffing levels, required tests, etc. Innovation will become mired in bureaucratic process.

And who will have the task of controlling the economics? Is this legislature going to assume responsibility for that? An elegantly composed commission? A superhuman future governor? Or do you assume private insurance companies will simply figure it out?

Rather than spend precious political capital trying to create an artificial right to health care, I suggest we spend that capital finding practical ways to drive health care costs down and quality up. Make it easier for more people to afford health care on their own by getting un-needed mandates and insurance regulation out of the way. Then, if you decide that some people still can’t afford it, take a page from the food stamp book, or other such programs where you simply subsidize health care purchases for low-income people. That will distort the economics far less than the route you’re trying to embark on here today.

After our prepared testimony the committee members asked us a number of questions, giving us the opportunity to expand on our position. Chairman Mitch Greenlick seemed to enjoy the back-and-forth; at one point likening it to a good college debate.

Then Rep. Greenlick himself testified in favor of what is really his proposal. The committee then spent a considerable amount of time discussing the pros and cons, before approving it, and the accompanying joint resolution setting the November election (LC 88), on a party line vote.

A key argument against the proposal was made by Rep. Dennis Richardson who observed that, if enacted, a “fundamental right” to health care would seem to trump everything else in the Oregon Constitution. If the legislature comes up with a plan to make good on this “fundamental right” what happens when voters reject the new taxes needed to pay for it?

Since neither education, transportation, criminal justice, or any other state government service is defined as a “fundamental right” in our Constitution, then funding for these services might be cannibalized to fund the one “fundamental right” in that document, health care. But voters won’t be presented with this reality when marking their ballots in November. This potential clash of essential services may make for strange bedfellows in future election battles. Will the teachers union, for example, want to lose funding to the health care providers?

The unintended consequences of this proposal are almost endless. But that’s the way the game is played for now, and the next inning will play out in Salem over the next few weeks. Stay tuned”¦


Steve Buckstein is Senior Policy Analyst and founder of Cascade Policy Institute, a Portland-based think tank.

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Posted by at 02:56 | Posted in Measure 37 | 57 Comments |Email This Post Email This Post |Print This Post Print This Post
  • Jerry

    If health care is a fundamental right, then how could housing, transportation, and eating not be??
    This is not a good bill, obviously. It has not been thought out.
    It is nothing more than a money and power grab by those who could care less about anyone’s health.
    Nothing more.

    • Steve Buckstein

      Jerry, actually the fact that food, for example, is more “fundamental” to life than is health care was brought up at the hearing. Supporters, however, didn’t seem interested in amending the measure to include food. Perhaps that would lead to too many troubling questions during the election debate.

      • dean

        Steve…it pains me to admit it, but I agree with you on this one. Though I would support a broader set of affirmative rights that included food and shelter along with basic health care, singling out health care does not make sense, particularly in the absence of a delivery policy.

        But if anything this should show you and other conservatives that we had better get our heads together over actual solutions and stop pretending our present health care system is sustainable (highest cost, 37th in results, 47 million uninsured).

        • Steve Buckstein

          Dean, I hope your view prevails among your liberal friends in the legislature. They should think through the “health care above everything” message that this flawed amendment would impose. Then, I agree with you that we should have a serious discussion about real solutions instead of creating rights we have no idea how to deliver, let alone fund.

    • David from Eugene

      Jerry

      You raise an interesting question. Can a nation who considers it acceptable for people to sleep under bridges and eat out of garbage cans truly be called civilized?

      • Chris McMullen

        The beauty of he Bill of Rights is that it states rights are inalienable; the government cannot grant nor take away someone’s right to eat out of garbage cans, but it can limit sleeping under bridges if doing so poses a risk to public safety.

        Of course, sleeping under bridges and eating out of garbage cans is a construct of the person in question, not a failure of our society as a whole.

        • David from Eugene

          There is a major difference between eating out of garbage cans because you want to and doing so because you have no other option. Considering that having people eating out of garbage cans because they must is acceptable is a failure of our society. Particularly as we have the resources to provide an adequate, subsistence level standard of living for all our citizens. In many cases it would take little more then the right hand up, unfortunately in other cases we are talking about hand outs.

          • Chris McMullen

            Please David, the mentally ill not withstanding, nobody is forced to eat out of garbage cans. I’ve known many truly needy people and they’re always well taken care of food-wize.

  • Stephen Gregg

    This amendment would have far less if not no traction, if the “left” and “right” simply came to terms on a dual strategy of providing access and controlling costs. It is difficult in my mind to ask someone else to pledge cash to finance someone else’s needs when the underlying costs are without any foreseeable constraint. Meaningfully constrain the costs, and I am confident the “heartless” right would find heart and help the uninsured component. Those who relentlessly push the uninsured issue without credible commitment to the cost issue, simply push their objective further away.

  • Bob Clark

    If our present healthcare system is failing, government is a large part of the reason. For instance, the government mandates hospitals serve the emergency needs of everyone coming to the door. So, what do we see as a result. Hospitals end up pouring large portions of emergency services into helping people who repeatedly overdose on alcohol and other assorted drugs. These people not only stiff the hospital with unpaid bills. They also abuse the hospital staff. Then there’s the obese people who are so glutonous they can no longer take care of themselves. If america is to stay competitive, it needs to let individuals be responsible for their behavior and not exaust limited resources enabling their misbehaviour. The government can not guarantee healthcare for all, because healthcare is driven in large part by individual behavior.

    • David from Eugene

      Bob

      Putting the moral arguments regarding a policy that would permit hospitals to refuse care to those that need it aside for the moment, there is a very practical reason not to adopt such a policy, self preservation. Do you want to die because arriving at a hospital unconscious and unable to prove to an admissions clerk that you could pay, they refused to treat you? I don’t

  • jim karlocik

    What right can be more fundamental than those in our country’s founding documents, including the bill of rights.

    We clearly have the right to a free press. Give me a printing press.

    We have the right to bear arms. Give me a gun.

    We have the right to the pursuit of happiness. Give me 40 acres and a mule.

    Thanks
    JK

  • John Fairplay

    This continues the theme of expanding ways in which people may act without concern about the consequences. If I have a “right” to health care, I may overeat, smoke, drink, etc. without fear that I will be on the hook – economically at least – for any health problems that may result. I cannot be denied the finest treatment available, as doing so would impinge my “right,” and I believe the Courts will uphold the taxpayers of Oregon paying to send me to the Mayo Clinic the next time I have a hangnail. I look forward to having the taxpayers pony up for a new hot tub to help my bad back. It’s my “right.” It will be very freeing for the 10s of thousands of leeches we have here in Oregon.

  • Stephen Gregg

    We may be wasting our breath with all of these well conceived counter-arguments to the “health care is a right” crowd. We are likely arguing with a “fence post” which is not all that productive. They believe that unrestrained access is based in morality, is paramount, and must be served irrespective of the consequences.

    At a practical level, I posit the theory that this monolithic advocacy will not succeed for all the reasons outlined above, and like tax reform, trying over and over without accommodation to the nature of the push-back, will simply push their objective (universal coverage) further away from achievement. In effect their unqualified advocacy will progressively harden the audience’s resistance to engage the subject with each failed thrust. It is too bad, as there are upsides for all of us, if we could find the right recipe for universal coverage.

    • David from Eugene

      Stephen

      The debate is not over whether or not we will have Universal Health Care, because we already have it. The debate is not over who will pick up the costs for those unable to pay, because we are already doing that. The debate is on the form that the system will have and how the costs for that system will be allocated. Whether we will continue with the very expensive and extremely inefficient system we currently have or change to some other system. As the current system is in an ever accelerating death spiral, I think a change is in order.

      Unfortunately too many people do not understand the true subject of the debate and continue to argue over things that have already been decided. Legislative Concept 91 simply provides a codification of the existing reality that no one can be refused health care and provides direction to the Legislature to establish a system that is more effective and affordable then the one we have now.

  • DMF

    Something definitely has to be done about health care. Unless you’re poor, it appears to me the politicians care nothing about your health.

    Our policies make obtaining health insurance impossible for people with limited income or pre exisiting conditions. There are so many mandates, 33 to be exact tied to our health insurance, it has made the premiums prohibitive.

    We need a basic plan that covers major medical, with a high enough deductible we think before we go have that hangnail checked. That deductible could concievable be tied to income for fairness. People with health coverage do take more advantage of health care.Because we are convinced we must feel perfect so we abuse it. Many low income people who qualify for the Oregon Health plan refuse to sign up. This is available to them. Are we to twist their arm and make them go to get a checkup.

    Better yet, if the politicians want to help them all out, why not periodic clinics for checkups. This could be done through the state (ugh) or by tax credits for medical professionals who would volunteer. Then if there was a problem, then see if they need help getting care. You will find, a large majority will not even go for that checkup.

    It seems to me government policies and (help) no matter how well intended have created this juggernaut we now have.

    • Stephen Gregg

      I agree almost completely with your views. As a conservative leaning individual, I have migrated from opposition to “universal coverage” to a more carefully crafted discussion about the “terms and conditions”. However, this clearly has the makings of a slippery slope. I consider “catastrophic” insurance to be an entirely reasonable benefit design for many, many people, and we use the “poor” argument to protect what is over insurance for most of us. In the employed environment, the idea of increasing deductibles with income almost always runs into stiff opposition. “Why should I face less benefits as I become more valuable to the company?” Of course this becomes another argument as to why health insurance should be delinked from employers. With the right incentives, people with more means will and should elect higher risk policies. The idea of a “basic” benefit for all, against the continuum of differing personal needs, seems decidedly unsound. If my adult daughter was “poor on the government’s assessment”, is she foolish in the eyes of public policy to ask me to backstop her with a high deductible policy such that as a healthy individual she can part with less money for an overfed health care industry? Or why should I help her if government is knocking at the door with a hand out? Public policy will never be able to keep up with these nuances.

      • dean

        What I find interesting in the above posts is an implied assumption or perhaps willfull ignorance that the health insurance and health care issues we face have not been faced in many other countries with far greater success, all with MORE, not LESS government intervention. I’ve written this in previous posts, but it apparently bears repeating. According the World Health Organization statistics the United States ranks:

        1) Highest in health care expense as a percent of GDP
        2) 37th in health (not just health care) results
        3) We have the highest number of uninsured in the developed world
        4) It is geting worse, not better. The number of Americans covered by their employers is shrinking, not growing, and many of us (including this self-employed writer) are 1 injury or illness from quick bankruptcy.
        5) We already spend more on government health care funding per capita than Canada, which insures 100% of its citizens while we cover 29% of ours (through direct government covereage).
        6) Private insurance companies use 30% of your premium If you can afford one) for overhead expenses, which is far more than government overhead. And their job is to make money, not to keep you healthy.

        We seem to have the worst of all possible systems. A freer market that depends on private insurance companies is going to continue to be high cost, low delivery, with lots of people left at the curbside.

        A $200 a month catastrophic premium for an individual sounds affordable, but if you earn a bit above minimum wage and work full time at Wallmart, and have a kid or 2, try to make that pencil out.

        Maybe Stephen is right and the Democrats will break their teeth again attempting a serious reform of our system that provides universal coverage affordably with freedom of choice. Maybe not. But at least they are trying.

        Yes, we could follow the farther right wing solution and start tossing people overboard. But you should start with the elderly and chronically ill rather than the poor, since it is the former who drive the costs up for everyone by requiring so much care. As my Greek-born dad used to remind me, the Spartans tossed the old and hopelessly sick over the steepest highest cliff. There’s a winning platform for you.

        • Stephen Gregg

          Dean, if I conveyed malice for Democrats, that is not the intention. You seem to hold some angst for Republicans or the right. I realize “trying” has its good qualities, but repetitious failure is ultimately a disastrous course in the long term, especially when the critical success factors are so obviously absent at the outset. Nobody should accept a highly flawed strategy with the satisfaction that “at least we tried”. I would think we just dig a far deeper and intractable hole for future generations.

          As for whether we have a more or less active government than others in health care, I don’t know that is an easy call. Our government is VERY active in our system. Problem is their activism is misdirected and certainly compromised by a heavy dose of politics. I share your view that we can learn alot by looking at other systems, but unless the hypothetical transfer of a “winning” system involves the acceptance of the industry pay scales of that country, I don’t see the logic that we could replicate the economic results of that country. Perhaps you see that we have the political will to control the personal incomes of the industry. I don’t think we do in a direct regulatory manner but would be willing to support an “experiment” that demonstrated such.

          I am also cautious about the use of “affordability” as it can easily mean to some, simply finding the money from someone else to subsidize my health care premium. That track of increasing the funding is probably in itself inflationary. If “affordability” is meant cutting the underlying costs of the current system, then let’s say it more explicitly that way. Solving the uninsured is connected to controlling costs. The “heavy lifting” is the latter in my estimation, as that issue has been a bothersome political debate for about 40 years.

        • Stephen Gregg

          Dean, to reinforce some of your comments, I agree that insurance as we know it today has a cost structure that needs to be vigorously challenged. It is absurd and can be undertaken in a number of ways. Politically, Democrats have more specific “solutions” for health care than Republicans. But what I find interesting is that agenda seems to be conceding that benefits should be “enriched” with prevention benefits, lower co-pay obligations, etc. and seems to have conceded that all be purchased through private insurance carriers. I surmise that this is a concession and “learning experience” that came out of “HillaryCare”. It is a terrible mistake to give private carriers this kind of security and almost status quo going forward…but that is what the more explicit strategies seem to be advocating. I don’t argue with the 30% load from the insurance function, but it seems like Democratic proposals are willing to lock that in near stone to win the “uninsured” aspect of the debate.

  • Margaret Goodwin

    Obviously, I’m missing something here. What does it mean to have a “right” to healthcare? It’s my understanding that, even today, if someone goes to an emergency room, they will be treated, even if they can’t afford to pay. Is that sufficient to satisfy the “right” to healthcare? Or does it mean that healthcare should be free, since it would be a violation of somebody’s constitutional rights not to give them whatever healthcare they demand? (Of course, we all know there’s no such thing as “free,” rather, this would mean all healthcare would be paid for by the taxpayers.) Is this just a way to try to legislate a single payer system by making _not_ having one a violation of the state constitution?

    How are we going to pay for something so astronomically expensive? — No, don’t tell me; let me guess. We’re going to raise taxes, right? It’s curious that Oregon already has one of the highest state income tax rates in the nation, while being at the low end in terms of average income. Last time I checked, Oregon had the third highest rate in the country of income tax as a percentage of total income. This indicates two things. One, because the average income is so low, you have to raise taxes proportionally more to achieve a significant increase in actual revenue. Two, since we already pay higher income taxes than most, how much can you increase the tax burden on an already overtaxed population without diminishing the average standard of living and causing serious damage to the economy? If we squeeze people enough, working folks will relocate to other states where they can keep enough of their earnings to enjoy a higher standard of living and put away something for the future. (Of course, after they retire, they’ll move back to Oregon to collect all the free healthcare they can use…)

    It’s interesting that you mentioned “legal residents.” According to the 14th amendment, “No state shall … deny to any _person_ within its jurisdiction the equal protection of the laws.” Note that this does not say “citizen” or “legal resident.” What this means is that, once we amend the state constitution to make healthcare a constitutional right, it will necessarily apply to illegal aliens as well as to legal residents. It could be challenged, but this broad interpretation has historically been upheld by higher courts. This legislation could make Oregon a very popular destination, not only for illegal aliens, but for drifters, vagrants, and freeloaders of all varieties, at the same time the tax increases required to pay for it will be squeezing out the working folks.

    This just doesn’t seem like a sustainable solution but, as I said, maybe I’m just missing something.

  • davidg

    This will get trounced at the polls, just like the last universal health care plan on the Oregon ballot a few years ago. Oregon voters just won’t approve a plan or policy statement that has no control on spending. In all its complexity, voters figured that out about Measure 50. In all its simplicity, they will do so again for this.

    Why would the Democrats put such a hopeless issue on the ballot? I think it is mainly just pandering to the many activists in their party on this issue. But it also is a good sign that they can’t come up with a real plan that meets all the many requirements that Dean has said a universal plan must meet. (See Dean’s posts of last week on this subject.) This ballot issue will satisfy the need of many activists to “at least do something” when nobody can really think of anything sensible to do. There are some crude anatomical descriptions of what this exercise would be about, but of course we won’t go there.

    I am encouraged that this is the best universal health plan that anyone in Salem can think of. Of course, it is no plan at all. It will end up going down in flames as it should. Let them put it on the ballot.

  • Jackson

    I have a couple of thoughts on establishing a “fundamental right” for everyone to unlimited healthcare in our Constitution.

    _First:_ People are muddling the concepts of entitlement with right. To acknowledge that I have a right to something in a Constitutional context simply establishes that the government may not deny me access to it. Essentially that the government may not establish a law which denies me or anyone else access. I have no problem with that.

    However, as is usual in Oregon politics, the game is played with semantics. What is being sought by Rep. Greenlick is not recognition of a right – although he couches the issue in those terms. Does anyone doubt he has a right to health care? Does any law preclude anyone from healthcare? The only limitation is one’s capacity to pay for it. There’s the rub Rep. Greenlick wants to address. He wants to establish an *entitlement* in everyone and create a government system which both funds and provides that entitlement.

    _Second:_ The stated objective of government in our traditional republican form of government is to “promote the General Welfare.” There is no inherent objective to *provide* it. The pellmell attempt for government to satisfy entitlements, guarantees, and other needs under the lofty goal of charity or “social justice” leads inexorably to de facto socialism. A system which always leads to bankruptcy.

    _Third:_ We enjoy the greatest system of medical care in the world. We have the greatest, most successful research. We invest millions of public dollars in pure research and we are getting results seen nowhere else. We have the greatest treatment facilities and providers in the world. Given a serious problem, people from all over the world come here for treatment. We have accomplished that through public promotion of private industry and the rewards offered in the free market system for success.

    The system may not be perfect in the sense that not all persons can afford the same level of expertise or treatment. That flaw however will remain in any scheme ultimately imagined. May not be ideally just but it works.

    My opinion is that if it isn’t broke, we shouldn’t mess with it.

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    • dean

      To Stephen above…no, i did not detect malice in your post. Just a sense of blaming those who are actually trying something, while letting the opposition, which offers nothing in the way of serious counter proposals yet uses the 60 vote rule of the senate or the veto to block majority legislation, off the hook.

      My angst with the right is over policy proposals and tactics. I try hard to never let it get personal, though some insist on making it so.

      Yes, the early 90s effort by the Clintons failed, and one lesson learned is that entrenched interests who profit from the present system: well paid medical specialists, insurance companies, and pharmaceutical companies, are not going to lay down and accept a single payer system (i.e. france, Canada) that would be able to control costs by fiat. So the Democrats have settled on a different approach that allows anyone who wants to stay with their present insurance. It is a response to the legitimate concern that people have that Dems were trying to replace a known with an unknown, introducing a serious risk.

      As I understand it, the Dems are proposing:

      1) Requiring private insurers to accept anyone who can pay the basic rate (community rating). No more denying entry based on pre-existing conditions.
      2) Subsidizing insurance for those who can’t afford it by allowing the Bush tax breaks for the richest Americans to expire (and/or by ending the Iraq war).
      3) Make everyone buy in (Obama’s plan does not have this provision except for kids.)
      4) Introduce a new public insurance that can compete with the private offerings (expanded medicare, which should appeal to self-employed like myself)
      5) Repeal the Bush rule that prevents Medicare and Medicaid from negotiating drug prices (big savings available right here).
      6) No one can be kicked off insurance due to loss of a job, injury, disease, and so forth. This is a real risk most of us run daily.

      *IF* the Dems win the White House and expand their majorities in the House and Senate, and *IF* they hit the ground running and get legislation vote ready before the opposition has time to obfuscate, then they can get it done. That would make the Oregon constitutional amendment proposal moot. I don’t think the Dems proposal locks in 30% overhead rates. The public insurance program will provide competition that helps hold overhead down.

      The only coherent argument against the universal plan the dems are offering is that made in the posts above. Why should government take from the wealthy to support the un-wealthy? That is arguing ethics against ethics, the right to tax one to benefit another versus the responsibility citizens of a nation share to each other. I would say the Republicans and libertarians have already lost this argument. Any poll of Americans shows clear majorities agree that health care should be provided to everyone and that taxes on the wealthy to help pay for it are appropriate.

      I agree that writing an entitlement into the Oregon Constitution that has no provision for care delivery is useless. I disagree with Jackson. The system IS broken, and it does need to be fixed.

      One last point to Margaret. If you are travelling in a nother country and you have a medical emergency, would you expect to be denied care because you are a non-citizen? Is it ethically appropriate for the US to deny care to non-citizens so that we can save a few bucks?

      The immigration issue needs to separated from health care.

      • Margaret Goodwin

        Dean, if I were in another country illegally, I would not expect to receive medical care. I would not even go to a hospital because I would expect that, if discovered, I would be immediately deported. If I were on the verge of dying, I would probably go to an emergency room, but wiith the full expectation of deportation as soon as the bleeding was stanched.

        I have rather strong opinions about the Democrat healthcare proposals, but instead of filling up the page here, I’ll just provide a link to my blog post for anyone who’s interested.
        https://notyourdaddy.wordpress.com/2008/01/23/redistribution-of-health/

      • Stephen Gregg

        Dean, where do I start is a challenge. I am not “blaming anyone” even though you elect to frame my posture that way. This is a field of interest that is loaded with “shifting the blame”. My appeal is to rationality: Define the problem (which is a fundamental failure of most health care debate); weigh the alternatives; test the best solutions (no where on the landscape of any of the proposals); and execute on a larger scale. In my experience it is a first rate struggle to insert the meaningful control of costs into the heads of all sorts of people who chose to define the struggle singularly as the uninsured. For the most part the debate is very intellectually dishonest about the cost component of the problem because it does not pay users or providers to overly mess with this subject. In the State of Oregon, without doing any reform, there is a 3 fold variation in uncomplicated like procedures among hospitals in their asking prices for these services. The State has been bureaucratically collecting and analyzing this data for approximately 30 years with virtually no discernable response. The largest unilateral cost shifter in the market is government sponsored care. I had one hospital administrator tell me a couple of years ago that his hospital had not received an increase in reimbursement rates from the Oregon Health Plan since its first year of inception.

        I support the concept of guaranteed issue as a needed insurance reform, but it is a simplistic view to be for this without describing the conditions. I think there are only 3 states in the country that have this provision now and if you do not do it artfully it is a disaster…as was experienced in the State of Washington. The execution there effectively drove all carriers out of the individual market for a number of years and as an individual you literally could not buy individual insurance irrespective of health care condition. Insurers play hardball in selecting favorable risk, but the buyers also have significant games to manipulate as well. This tension between the two is why many feel there is no choice but to “mandate” that all are covered. Unfortunately the downside of mandating in my mind is that the economic interests of the industry clearly wins, and you as the individual will ultimately be “screwed”…unless you think someone else is going to pay your tab. What would be more ideal for the industry’s interests than a universal mandate where thoughtful analysis suggests as much as 50% of its services may be ineffective or unnecessary.

        While I am not at all comfortable with the absence of Republican activism on this subject, I do believe it would be best to center health care reform in community based settings as opposed to untested national crap shoots that are largely irreversible. If you know comprehensively what should be done, I think your burden should be to prove it in a pilot that is independently evaluated. Someone should look at your game plan very closely, affirm that Dean has a good shot, and let’s see him deploy it in Yamhill county with our complete support and enablement. Sort of the “put up or shut up” challenge. In my pursuits the main stream (that being legislature, regulators, payers, providers, unions, etc.) are all absolutely petrified of “outside of the box” experimentation, because they fear the “tipping point” consequences. As one small example, there is worthy national debate about migrating to “defined contribution” from “defined benefits”. Laws and regulations effectively stand in the way of even experimenting with these alternatives. Indeed many vested interests vigorously oppose such considerations. We talk passionately about the need for health care reform, while effectively giving Medicare, public employees, self funded employers an exclusion from the reform. How do you consider health care reform and exclude the very people (public employees) who are to lead on this subject? Let’s face it, it is essential to many of these vested interests that “reform” remain restricted to the uninsured such that it is not disruptive to “my benefits”. If the box is drawn that way, and I believe it is, we will be recyling failure.

        The consistent failure of just about all reform plans of the day, is that they do not have a credible strategy to control costs. Wyden believes emphasizing prevention is the leverage point, and yet academic scholars who look at this matter suggest there is “no credible evidence that investments in prevention, reduce health care spending”. Not to pick overly on him, all of them express trite, populist and unsubstantiated theories.

        My plan which you have reviewed calls for a robust public and private system in competition on a level playing field which you seem to support as well. The key to this is a requirement of a level playing field. If the public segment ends up with indefinite limits to subsidies not shared with the private sector, it will be a highly dysfunctional situation. To get to this level playing field, government sponsored care probably has to come up with about 20% more money on its current lives to bring it into parity with the private sector. That will be a big problem, but if you don’t commit to that the competitive market will never function properly.

        I remain of the view that I don’t think Democratic proposals awarding near security to private insurance market is a good concession….and my roots are in the private sector.

        Enough.

    • David from Eugene

      The system is broke. It is in an ever steeper death spiral. We need to fix it now before things get worse.

  • David

    Why is it acceptable in America to have socialized fire protection, but not socialized health protection? There is no fundamental right in the Constitution that your house not burn down. For that matter, why is it OK to have socialized police protection, socialized military protection, and socialized road construction and maintenance but not socialized medicine? Are land and buildings more important than lives?

    • Steve Buckstein

      David, land and buildings are not necessarily more important than lives, but that’s not really the point here. Fighting fires, building roads, and providing or guaranteeing health care are not constitutional powers; military defense of the country is. So, from a constitutional standpoint, not only should health care not be socialized, but fire protection and road building shouldn’t be socialized either. America was founded on the principle that government should protect our inalienable rights, not provide the goods and services we are free to acquire through voluntary transactions with our fellow citizens.

      • dean

        Steve…the constitution was written by rich white deists, many of them slave owners, at a time when 90% of citizens (white male property owners only) were more or less self sufficient yeomen. It is ridiculous to expect that demographic to have written in overt socialist provisions, especially since industrialization had only just begun and socialism was not even invented yet. Of course their focus was on protecting property…they were mega property owners. Lets not get carried away with genuflecting to them on this point.

        They provided avenues for legislating or amending the constitution because they could not forsee the future any better than we can. Jefferson himself said the constitution should be torn up and re-written for each generation, or words to that effect.

        So whether any particular service or good should be socialized is actually up to us as voters and taxpayers. We do not need to ask the deceased for their approval. Yes, we can acquire health insurance through private providers if we are lucky enough to have a job with bennies, or if we can afford it on our own, and if we don’t have a pre-existing condition. But there is nothing except ourselves preventing us from socializing health insurance, either completely or partially, as we have chosen to do with schools, fire, police, parks, roads, transit and many other aspects of our lives, through our free choice as voters and citizens.

        Having said all that, I still think the legislative proposal is misguided and the wrong avenue for this issue. Those of us who believe it is time to move off dead center on health care need to get busy electing Democrats in 08 and leave amending the Oregon constitution for other purposes.

        • Steve Buckstein

          Dean, those “rich white deists” did a pretty good job creating a governmental structure not seen in the world before their time. It has held up pretty well.

          You’re right that Jefferson thought we needed a revolution every 20 years (hopefully a nonviolent one), and the framers did provide a system for amending the constitution. But to say that it’s ridiculous to expect them to have written an overt socialist document is off the mark. Most governments at that time were, if not technically socialist, at least based on the King either owning virtually everything or controlling virtually everything. To the extent the King didn’t run everything, other nobles did.

          America started out with much more respect for the individual than other governments had. Government control erodes that respect, and I’m simply saying that we should keep the American experiment alive and not yield to increased government control of anything so important as health care.

          • David

            > Dean, those “rich white deists” did a pretty good job creating a
            > governmental structure not seen in the world before their time. It
            > has held up pretty well.

            Steve, maybe the system has worked well for *you*. It is not working for an increasingly large number of people. 1/6th of the country has no health care. What do you expect them to do — just roll over and die?? You have yet to propose a real solution other than to spout words like “free market.” The free market has been tried, and it has failed. In a few years time your Institute will no longer be able to afford health care for its employees and you will see how fast you change your mind, when you find yourself ill and unable to go to a doctor, and unable to buy private health insurance because of preexisting conditions.

          • Chris McMullen

            Our current health care system is anything but free market, David. Government mandates have driven up costs, lessened accessibility and reduced quality.

            Need I mention the HMO act of 1973? 2/3rds of health expenditures are on government programs (Medicare, Medicaid). FDA and hospital over-regulation has driven up costs, not to mention “no-fault” malpractice lawsuits.

            Moreover, the purported “statistics” coming from the WHO and other organizations are very suspect. The WHO has very lax data requirements. Health care in other countries is no utopia. There are major problems in France, Britain and Canada.

            Also, in any health care system, it’s impossible to concurrently have quality, low cost and immediacy. You have to give up one of the three to have the other two.

          • David

            > Moreover, the purported “statistics” coming from the WHO and other
            > organizations are very suspect. The WHO has very lax data requirements.

            If you have proof that the WHO et. al. statistics are suspect, then present it. Otherwise your claim here is meaningless. These statistics have been published in high-standard peer-reviewed journals like The Lancet. In any case, statistics such as life-expectancy, infant mortality rates, and the like are quite hard and we know that the US ranks mediocre in them. Also see Ellen Nolte and C. Martin McKee, Health Affairs, The Public Journal of the Health Sphere 27, no. 1. (2008) 58-71, which found that “the United States ranks last among 19 industrialized nations on preventing deaths by assuring access to effective health care.” The cost? 100,000+ lives/yr.

          • chris mcmullen

            Ohh the Lancet… the publication that ran over-exaggerated civilian casualties in Iraq, using data coming directly from mega-moonbat George Soros. Boy, they sound objective.

            BTW, life expectancy doesn’t mean squat when you take in quality of life. Americans eat too much, drink too much, party too much, overindulge too much. Such is life in the land of plenty. If our life expectancy is shorter, we live a better quality of life and enjoy ourselves more in that span.

            And our higher mortality rate is partly due to the fact we try harder to save premature babies than European nations. Many Euro nations set a birth weight and gestational age limit for withholding care. Cuba, for instance doesn’t count it as a live birth if the baby dies within seven days. We do.

            Also why did the report ignore stats like access to new drugs, cancer survival rates, mortality after by-pass surgery & treatment for high blood pressure?

            BTW, the Commonwealth Fund is another left-leaning organization that is pushing for single-payer healthcare. You got any stats that are from a objective source?

          • Steve Buckstein

            David, my policy proposals are not based on my personal situation. Contrary to your assumption. my institute can’t afford health insurance for our employees now, and never has. Even so, I still don’t buy your argument that the free market has failed and we need government to ride in and save us.

            Not having health insurance is not the same thing as not having health care. In fact, I argue that as a society we have too much health insurance and that health care would be cheaper if we got back using insurance only for the rare, expensive and unpredictable events that true insurance is designed to protect against. Funding all health care needs through insurance is simply pre-paying for routine care in a very expensive way. For those interested in a discussion of this concept, you can read Myth 1 on page 5 of “First Do No Harm” at
            https://www.cascadepolicy.org/pdf/health_ss/I_121.pdf

          • David

            > Not having health insurance is not the same thing as not having health care.

            Fat and happy pundits — all of who have health insurance — like to claim this. It is false. The uninsured do without regular health exams and routine care. They almost always wait — frequently in agony and pain — until their problems are unbearable, at which point they have to rely on high-priced clinics or emergency rooms. They are charged higher rates than the insured, and they are hounded by collection agencies for payment of their bills, to the point where millions of them must declare bankruptcy.

            Have you ever had to live without health insurance, Steve?

          • Anonymous

            “The uninsured do without regular health exams and routine care.”

            News flash: the insured do this as well. Do you think a copay, a deductible and 20 to 50% of the bill actually * encourages* people to see the doctor? I pay through the nose to insure me and my family. Why can’t every one else be responsible?

            “They are charged higher rates than the insured,”

            That is a flat-out lie. Almost every hospital and clinic will give you a discount rate if you are uninsured. You better back up your statements with some facts before blabbing.

            And why shouldn’t they be hounded by collection agencies? Why shouldn’t they have to pay for their health services?

            You might want to quit buying the Daily Kos/Michael Moore agitprop for a while and get educated on the facts.

          • Stephen Gregg

            Anonymous: Let’s discuss hospital discounting practices… I believe the only accurate statement that can be made is that there is considerable variance among hospitals as to how they price their services. In Oregon, at the “top line”, gross charges there is as much as a 3 fold variation among hospitals for the same diagnostic condition. This is documented in a long standing data base collected by the State. That variation, I believe can largely be explained by the highly variable discounting practices of hospitals….the more discounting, the greater the gross charges.

            Anecdotally my daughter in law had two different c-section procedures at Providence-St. V’s hospital, the largest provider of Obstetrics in the State. Two different insurers. First insurer acquired a little short of a 50% discount from charges; the second 25+% for the second c-section. During this period, my wife presented for some treatment at the same hospital, without consideration of insurance. The hospital refused to offer any discount, without her passing through a financial need assessment showing she was limited in what she could pay.

            Since the pricing practices of hospitals are generally highly classified and not at all transparent, not sure anyone can prove what reality would be…and it would likely be different at Salem hospital than Legacy. I have made it a point to follow this matter over the years, and would generally concur that the uninsured are ironically charged more by hospitals than the insured.

            As another anecdote, my wife had some work done at Scripps Medical Center in California. In their case, they did not disclose their discounting practices at the time of service but pressed for personal insurance information even though our deductible was high enough we would be paying for the procedure out of pocket. While we wanted to simply pay the “real charges”, they strongly resisted that until they had an opportunity to process a bill with the carrier to see what the “contract” (there was not one) would yield. Ultimately, it was like pulling teeth, but downstream in the billing process, they conceded that their practice was to offer a 40% discount “for cash”. Rumor has it that the larger carriers get as much as 60% off billed charges.

        • Jerry

          But Dean, are you not white, rich, and deists (liberalism) yourself? Just curious.

      • David

        Steve, we have clearly decided as a society that it is advantageous to the vast majority of us to have socialized fire protection, socialized police protection, socialized road building and maintenance, etc. The Constitution specifies merely the minimum that need be done. Our society has reached a point — gone far past it, in fact — where the majority are now deciding that health care too ought to be guaranteed by government and not by profit-seeking corporations. The corporate system has been tried, and it has failed. It is falling down all around us. Millions are suffering and tens of thousands are dying because we have given corporations control of our health system. It is time to take back that control and give everyone an equal chance at health.

        • Steve Buckstein

          David, even if your analysis about the failure of “corporate control” of our health care system is correct, that control is aided and abetted by a myriad of government rules, regulations, occupational licensing, insurance mandates, etc.

          Before you ask government to cut out the middlemen and run the whole system directly, why not try making those corporations really compete for our health care business. Subsidize those unable to pay if you must, but leave the rest of us free to make our own health care choices, including the choice to decline any or all of the “consumer protections” the government has told us we must buy if we want any health care service at all.

          • David

            > Subsidize those unable to pay if you must

            Steve, you fail to understand the problem. It is not that people need subsidies. Insurance companies will not insure many, many people AT ANY PRICE because they have pre-existing medical conditions.

            What are these people supposed to do?

            The “free market” system of the United States spends far too much money for far too little result. We spend the most (as a pct of GDP) and get mediocre results at best. Maybe the system works for *you*.

            How much longer can the Cascade Policy Institute absorb yearly increases of 10-15% in the cost of your employee’s health care?

          • Steve Buckstein

            David, as I told you above, Cascade does not provide health insurance for its employees and never has. I understand what you’re saying about the dysfunctional health insurance system, I simply disagree with you about the causes, and cures.

  • David

    Jackson, it is far from true that the US has the “greatest health care system in the world.” Check out any of the world’s rankings, such as from WHO — the US comes in usually around the middle, if that high. Health care in the US is, overall, quite mediocre compared to other industrialized countries with socialized health care.

    • Stephen Gregg

      I think all of us should stipulate that the costs of U.S. Health Care is a decreasing value proposition. There are studies from credible sources that as much as 45% of the care rendered may be unnecessary. Putting aside the altruism, it is a commercial business loaded with sellers that want to make more money than last year, whether they be for profit or non profit in origin. To control costs…which most agree is essential, regulatory or free market based systems must deploy strategies that constrain how much these interests take home. That is a very unpleasant task, which politicians will be among the last to want to engage….their business being the awarding of benefits, not constraining income. I cannot connect these dots…we know that costs need to be constrained; we know just about all health care costs in the food chain, can be related to someone’s take home pay; we know that placed in a political framework, it becomes an almost impossible task; and yet so many speak with such confidence that we should deposit this with government and public employees to resolve…as if they can do something which large interest groups will not support.

      • David

        > To control costs…which most agree is essential, regulatory or free
        > market based systems must deploy strategies that constrain how much > these interests take home.

        This is already happening in the US, by the fact that many people cannot afford care, and they do without, and they suffer, and some of them die.

        In any case, countries with single-payer health care, not free market health care, do a better job of providing a higher level of care at a lower cost. Multiple studies have shown this — it’s really not in doubt any more.

        • Stephen Gregg

          David, you may be right. However, it seems to me that the system of another country would be co opted about 100 ways by the politics of U.S. health care before it hit the streets here. Therefore this approach in addition to any “home grown” views on reform can only be seen as speculative. Therefore “proof of concept” should be inserted into the thought process. We would not accept clinical trials in beagles as proof that a drug will work in humans.

          Going in, my strong preference is to provide a “single payer like” alternative, in competition with aggressive private sector choices and let us as individuals select what we want. If you truly want a single payer system, you should have that election. If I prefer a very high deductible insurance system with far more self determination, the option should be equally honored. For either side of this advocacy to impose its will on the other, even in the majority, is likely to kill of the potential success of any solution if significant numbers of people don’t want it.

          I can send you a paper and specific proposal that expands on this view if you are interested.

          • Steve Buckstein

            Stephen, rather than having to send your five-page reform proposal to specific people, I’ll post the URL here so anyone interested can read and comment on it:

            “Bridging the Ideological Divide in Health Care Reform:
            An Actionable Plan for Oregon”
            https://www.cascadepolicy.org/pdf/health_ss/200610_bridging_the_ideological_divide.pdf

          • dean

            To Jerry up above…I am Greek, which is white most of the year but terrorist level swarthy in the sunny season. Definitely not rich and not a deist. Lower middle class agnostic maybe?

            The discussion above has been interesting and constructive. Its encouraging when people can disagree and not degenerate into name calling.

            I have read Stephen’s proposal and it is very appealing. I’m curious that it does not seem to have any political legs. I tend to agree everyone does not want or need the same level or type of insurance, so designing a 3 tier system and allowing people to buy in at whichever level meets their needs is worth trying. My sense is that the Democratic proposals of the 3 main candidates come pretty close to this aproach.

          • Stephen Gregg

            Dean, I appreciate your encouragement. Let me differentiate the materiality of what I am recommending vs. most of the alternatives on the table. The predominant thinking on the table is that there should be a “basic benefit” assured to all. Getting on this slope is highly flawed as it does not recognize variability in need, and assuredly will have tremendous inflationary expectations as to what “basic” is, probably stamping out “catastrophic” insurance entirely. Secondly my proposal calls for defined contribution which mechanically suggests that everyone have an “HSA -Like” Account into which all sources of funds contribute. While there may be adjustment periods, I apply this structure to all including Medicare, employed, self pay, etc. as an voluntary elective to status quo. This is obviously a “hot potato” for many. Most of the discussion today, calls for a “mandate mentality” at the outset, which I believe should be deferred until shown as necessary in a redesigned system. I believe strongly we should move to create a new public service delivery system (Civic Segment) to vigorously compete with the private sector on a level playing field. Much of that structure is in place today and could be jiggered somewhat to fit into this scheme. This new segment in my view, minimizes insurance as a vehicle for financing health care services. Most current proposals are breaking their chops to remove private insurance interests as political barriers by assuring them a place at the trough. Don’t believe this should be afforded that security. As I have said before if you are of a mind to critically examine the cost containment prospects of these proposals they are quite obscure. There are more differences but the ones sited above spell failure in the higher profile proposals in my opinion.

            My preference would be to retain the reform initiative within Oregon and not prematurely defer to whatever Congress would decide. But I do understand how others might hold a different view. Oregon, unfortunately has “dilly dallied” around on this subject to the point, that the window for local initiative may be closing.

            As to the “legs” for my proposal, I am not sure what does have legs within Oregon these days. I engaged a lobbyist about a year or so ago and he has been particularly helpful in getting this proposal in front of legislators. However, as you know there is a whole lot of “clutter” which must sort itself out.

          • dean

            Stephen…I do come down on the side of madates. Otherwise those who opt out still have to be cared for when they show up at the emergency room. Or…if they wait until they get older or sicker and THEN sign up for whichever option is available they cost everyone else.

            Mandates ARE a form of cost control. An imperfect but very important one.

          • Stephen Gregg

            I appreciate the rational for mandates. I don’t encourage this action at the front end of reform, but rather further downstream for the following reasons:

            1. I think we have better than a 50-50 chance of embracing a set of reforms which will not credibly deal with the cost component. Mandates will be largely irreversible and will both reward and obligate us to ineffective reform and become obstructions to yet another likely reform effort.
            2. When you get into the thick of the mandate discussion at the legislative level, that discussion quickly consumes almost all the available air in the room, squeezing out other important essential elements of reform.
            3. Mandate what? becomes the primary discussion…which is a basic benefit definition, which is a typically an inflated, one benefit design for all squeezing out any possibility for catastrophic coverage and the possible desire of “minimizing” rather than “maximizing” the insurance vehicle for financing virtually all health care spending.
            4. Mandating benefits is NOT cost control, it is a method of achieving improved allocation of costs which is laudable. It theoretically should make premiums more “affordable” (which is not at all the same thing as cost control. Quite the reverse, by “spreading things around” better, it eases the pain, and probably is inflationary)
            5. Don’t think we have had any discussion about other ways that could be deployed to encourage people to be insured vs. uninsured (Differentiation in Waiting periods, Access to specialists, etc.)
            6. I would support a discussion that “reframed” the mandate discussion to something similar to 401K programs where an individual has the incentive to initiate a matching program up to a certain total. Obviously for the unable, safety net policies would apply. Once the individual fund was established, the individual had significant influence on what was purchased. If States can in effect dictate their 2/3rds Federal match for Medicaid, why not extend the same leverage to the individual where perhaps I put up 1/3 and the others had to step up. In that way I would both be incented to maximize my contribution (for future needs) and minimize my short term outputs.

          • dean

            Stephen…if you get a chance, please read an article in the American Prospect by Robert Kutner on the problems with the individual insurance mandate that have cropped up in Massascussets. Link is below.

            https://www.prospect.org/cs/articles?article=a_health_law_with_holes

            Kutner’s article supports your caution on mandates at the front end.

          • Stephen Gregg

            Good article and summary. I am somewhat familiar with what has been happening in Mass. Another problem apparently is that when the state assistance migrates from total subsidy to requiring almost any individual contribution, even with a mandate and penalties they are having problems getting enrollment. Oregon has had similar cost sharing problems in its history. The $296 penalty on employers seems very light and most outside observers have identified that issue, but I am assuming that is what comes out of a highly involved political process. There are some “loaded” comments in the article referring to “good benefits”, meaning lots of insurance for everything…which in my contrarian mind is not necessarily good from a cost perspective. At the bottom line the obvious rub is that the suggested bill of $5000 a year for a premium with deductibles, and going up fast is simply “not worth it” or deemed “unaffordable” irrespective of who we ask to pay for it. And of course being “out of control” does not invite willing cooperation. If most people are healthy at any given time, and do not derive a whole lot of use (there was a figure that 1/3 of the population makes no claim on the system in any given year), and yet the premium exceeds the mortgage payment, support for the costs of the system is eroding on all fronts. There are also studies where significant numbers of employers in full consultation with their employees are jointly deciding to drop health insurance. None of this is good, but it points to the view that we have to move the management of costs to the center-point of discussion from a subordinated position. As stated before “allocation” is NOT cost control. To my knowledge there is nothing in the plan to make costs less expensive at Mass General or Brigham Women’s Hospital, etc. and thus the plan pretty obviously to me cannot succeed. I am always surprised that people are surprised about failure, when it is so predictable at the front end. Oregon has its own versions of this behavior. Putting aside the gobbly gook, these things fail almost always because the reform did not succeed in controlling costs.

  • Prettyanndadored

    pros and cons ?

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