Monday, November 9, 2009

Politically Powerful Dinner Guests

Let's say that you are into the health care reform debate in a big way. Let's also say that a Democrat leader from the Senate is your Thanksgiving dinner guest this year. (Let's also pretend momentarily that your fellow hosts have not forbidden political discourse--which they actually have for the sake of peace and harmony.) What questions would you have to ask your guest? Here are mine:
  1. The U.S. spends considerably more per capita on health care. Leaving aside the assertion of disparate outcomes, how much is the spending influenced by demand factors such as demographics (particularly age and other factors), lifestyle choices, wealth and income effects, geography and population density (see also the demographics link); by supply factors such as pharmaceutical (PDF) and capital equipment expenses (and associated research and development expense), labor expense (and associated regulatory costs, such as licensing, the Fair Labor Standards Act, etc.), and facilities expense (and associated regulatory code compliance expense); and by price factors such as state insurance mandates (PDF), Federal regulations, insurance market structure, foreign price controls on pharmaceuticals, and financial market performance (both for access to credit and for investment income purposes)? Is the comparison influenced by currency exchange rates, or is a more stable method of exchange utilized?
  2. Where does the Constitution grant Congress the authority to compel a private citizen to purchase health insurance? Does this conceptually abrogate the freedom of the private citizen to contract with providers of goods and services? What is the limit to what Congress may compel the private citizen to purchase? Can Congress compel a private citizen to associate with any group, regardless of whether the mission and values of the group are antithetical to the beliefs of the private citizen? If we pierce the veil, isn't the "tax" upon the private citizen for failing to purchase health insurance really a penalty or fine? What does the concept of "liberty" mean, and does it include the freedom to not act just as much as it includes the freedom to act.
  3. What is the contribution to the rate of growth of private sector health care costs that is attributable to price caps enforced for public sector health costs? (Mathematically, if the growth rate of the public sector half of the health care spending is artificially lowered, then the growth rate of the remaining private sector half must be artifically higher in order to balance to the average growth rate of the entire amount spent--which I assume is presently based on demand, not on government decree. In equation form, P1 * Q1 + P2 * Q2 = Pavg * Qavg. where P is price, Q is quantity, 1 is the public sector, and 2 is the private sector.)
  4. What is the contribution to the expense of health care costs in general and on insurance premiums in particular due to government regulation, such as state mandates (PDF), prohibition on interstate commerce in insurance policies, and Medicare and other Federal rules for providers and insurers?
  5. What are the desired effects of health insurance reform on Medicare, and what is the intended and estimated impact on the $36.4 trillion unfunded liability (pg. 69, infinite time horizon)?
  6. With Medicare fraud in the billions of dollars, can the Federal government contain fraud in a Federally sponsored/managed insurer?
  7. Why refuse to extend the Hyde Amendment to insurance subsidies contemplated in congressional health reform bills?
  8. Why refuse to use the Systematic Alien Verification for Entitlement (SAVE) Program to prevent illegal aliens from utilizing Federal spending contemplated in congressional health reform bills?
  9. How do ten years of revenues and six (House bill) or seven (Senate bill) years of expenditure produce a stable, long-term program?

I doubt that I could get many Federal politicians (of any party) to answer these questions without prevarication. If you watch enough of the BBC series "Yes, Minister", the reasons become evident rather quickly.

I think I'll stick to eating and drinking this Thanksgiving.


  1. So what are the writer's concrete, informed, politically feasible constructive suggestions? What can one contribute? Personally, I've done tons of reading from many sources, to find the ones I trust, have gotten involved with advocacy groups I believe in, write letters to local editors and send key info to my legislators with whose staff I occasionally meet personally.

  2. "[C]oncrete, informed, politically feasible constructive suggestions"? That's a tall order. Our elected officials are having trouble doing this, so I don't hope to convince you one way or the other.

    The problem is vast in scope and complex in nature. Reducing it to political soundbites (like "death panels") and demonizing insurers has been a disservice from many politicians and media services.

    As you imply, the first action is to take time to understand the problem and the extent of the desired solution. If the desired solution is similarly vast and complex, the amount of information required to make the exact reform decision will be similarly vast and complex.

    I do not trust man's ability to quickly redesign a system as vast and complex as healthcare. I favor an incremental approach that is aware of the larger system but more focused on correcting parts of the system that are obviously not working, and measuring the success of these smaller solutions. My questions imply what factors I think need to be addressed.

    My questions are aimed at identifying how much information the elected decision maker has, and whether reform efforts are based on (more or less) complete or incomplete information. I do not feel that the answers to my questions are being communicated clearly from the decision makers through the media to the voters, and that decisions are being based on somewhat other than the facts (e.g., ideology) or on false premises or conclusions drawn from the facts.

    I have answered some of my own questions through my own research, but other answers require access to data of sufficient quality (which may not exist) and study methods that are beyond my time or ability. The government and private organizations attempt to answer some of these questions, but often conflict in their observed facts, premises, and conclusions. Many are biased by ideology, by capability (or lack thereof), or simply by perspective. Therefore it is important to know what information the decision maker is trusting and using.

    My first job is to elect the right people to be decision makers. My second job is to let them know how I think. My third job is to hold them accountable for the quality of their decision making processes and the outcome of their decisions.

    I don't hope to convince my legislator that I am right. I only hope to be part of sufficiently large responses that my legislator fears losing the next election.


Comments are welcome, but must be courteous and thoughtful. I reserve the right to delete comments that do not possess these characteristics.