The ACA: Practical Application of the Ends versus Means Issue

To sum up:

As is characteristic of virtually all political decisions, in health care policy, we cannot choose ends. We can only choose means. We are not choosing and cannot choose between Wonderful Affordable Health Care for All (WAHCA) (1) and Misery For All But The Rich. All we can do is chose to support or oppose a particular next step, in this case, continuation or repeal/fundamental modification of the Affordable Care Act.

The ACA is not, in itself, WAHCA. Do not go on until you, dear reader, grasp this. Voting for the ACA was not voting for WAHCA. Passing the ACA did not achieve WAHCA. WAHCA is an *end*. The ACA is a *means*. We all may *hope* that  the ACA results  in better, cheaper health care – but that depends entirely on those pesky details of *how it works in practice*. You know, those details we had to pass the bill to see.

What the ACA is in itself is a giant, complicated law that might (eventually and with extensive modifications – even its proponents, when they’re being serious, admit it doesn’t work as written) achieve better health care, across some theoretical average measure of some definition of health care, than the previous blended free market/state system. Of course, it might not – so far, as the saying goes, there seems to be an awful lot of chips flyin’ but not a lot of wood gettin’ cut.

trolley-prob-basic

And that is all. Support for the ACA doesn’t mean you love poor people more that someone who opposes it. Opposing it doesn’t mean you are an insensitive hater. It doesn’t make one a better person, more moral or more enlightened, to support the ACA. It doesn’t make one a worse person, less moral or less enlightened, to oppose it.

Further, more to the point, to oppose or want extensive modifications to the ACA does NOT EQUAL opposing good health care for all. One can (I do, for one) SUPPORT the idea of good health care for all. Because my background includes extensive math, insurance and business experience, and because of the manifest experience of the City of Chicago, from whose braintrust this bill arose and by whose hands it was formed, I reach the conclusion that the ACA will not achieve the goal of WAHCA, and in fact, was not primarily intended to.

trolley-prob-2Why this is so – why the ACA is extremely unlikely to work, if by work we mean actually provide better, cheaper health care to more people, falls into 3 general categories:

1. Math & Business: as discussed here  and here at length, there is simply not enough profit in health care so that removing it will stop prices from going up. Simply put, the total profits from health care in America – you can look it up, try any stock site – is an order of magnitude less than the cost of  providing healthcare to the +/- 35 million people the ACA is attempting to add. Big Pharma and hospital chains are often very profitable (of course, they often are not – that’s what’s behind all the merger mania. One bad bet on a new drug can put even a big pharmaceutical into the red.)

The simplest way to understand this for the any non-business types: in all service industries – and health care is a service industry – the biggest single ongoing cost is people. Doctors, nurses, technicians as well as all the admin people must get paid. Doctors, nurses and technicians get paid a lot.

And we want it that way! You want the dude with 15 years of schooling and years of practice working on you and your loved ones. Nobody sane is putting in the kind of hours and effort required to be a brain surgeon or trauma nurse to make $50K a year. So pay them!

But – and here’s the thing – after you’ve removed all the profits and cut salaries to all the executives (2), you need to start shutting down facilities and curtailing technology investment OR fire people OR cut salaries drastically. Or – costs and prices go up. It is a fantasy, and an ignorant fantasy at that, to suppose it will work any other way.

2. What we mean by health care and what constitutes an acceptable level 0f health care to be provided to all needs to be defined. That means limited – what a program will or will not pay for. This should not even need to be said, but it clearly has failed to be grasped. Not even the US Government can pay for open-ended health care for everybody. It’s just extremely unpopular to talk about what the program won’t pay for – so nobody talks about it.

Imagine a program where there’s no budget and no specific goal stated – well? If I said, go buy a car. No budget or anything, no limits on what I’ll pay for, just try to be reasonable, OK?  You, being enlightened and fair-minded and all, might get a good solid Toyota, possibly a Prius. What happens when your next-door neighbor shows up in a Tesla? How do you feel? And the neighbor on the other side shows up in a Ferrari? Hey, maybe 9 out of 10 people would get a Ford on the honor system (doubtful), but – you trust everybody?

It works the same for health care. We all know people who do this – patients will demand an MRI for every sprained ankle, antibiotics for every flu symptom, the latest and greatest treatment regime even in cases where there’s no measurable benefit. Further, a lot of doctors want to be on the cutting edge. They want the greatest toys, even if the 2nd greatest toys provide 99.5% of the benefit at a fraction of the cost. Hospital administrators want to say they offer all the latest and greatest tech. People who sell tech want to convince everybody their new model is the best, way better than last year’s model.  And everybody whose neighbor got the cool stuff they didn’t get will feel cheated.

And so on, people being people. Not everybody, not always, but enough to keep the spiral – the one we’re living in – going.(3)

So, stuff gets rationed. Behind closed doors, it is happening now. Rationed health care is a ubiquitous feature of all socialized medicine, even though it is rarely advertised as such (4). Say you need a procedure that is unusual, or has a low success rate, or is just super-expensive. I know a man who was pushing 70 and had some unusual, hard to diagnose heart problems. He was sent to specialists and got tests and, a year and about $1M in medical care later, he’s doing OK. So: do you want to spend the cost of a year’s healthcare to a 1,000 healthy young people on one old man?  Yes? No?

The reality is that something like 95% of the benefits of health care can be had for less than half of the total expenditures. All those vaccinations, pre-natal care, well-baby stuff, routine problems like infections and even broken bones – these are not expensive problems except in very rare cases. Any health care program worthy of the name should cover all these things – no one will dispute this.

Everybody knows young people who rarely if ever get sick. Yet everybody also knows old people who spend the last decade of their lives in and out of hospitals or under expensive treatment regimes. And most people have one or two acquaintances who seem to have lost the genetic lottery or gotten otherwise unlucky, who are never well and under constant medical care.

How do we handle this? Never said it was going to be easy, but failure to face it head-on just means surrendering the decision to doctors and insurance company functionaries (and bank accounts) in a free market system, or to bureaucrats (and bank accounts) under socialized medicine. In London – I’ve seen this myself – there are entire neighborhoods full of private doctors, who charge a pretty penny for their services. They exist even though health care is free for everybody in England. Free doesn’t mean you’ll get everything you need when you need it.

So, the first feature in any viable national health plan I’m looking for is how things will get rationed, and what will NOT be covered. None of the advocates of the ACA have ever made it a point to discuss this anywhere I’ve seen.

trolley-prob-3

3. That Toddlin’ Town. This objection is more controversial, but it shouldn’t be. It is amazing to me that more is not made of the fact that the outgoing administration is of, by and for the people of Chicago. Quick recap: Chicago has the highest paid teachers in America – and some of the worst schools. They have among the most restrictive gun control laws (there’s not a single legitimate gun shop in the city) – and a sickening level of gun violence. They have had among America’s most enlightened Liberal governments for over a century – and a legendary level of corruption, including the open secret that the city was run by the Mob up until about 1991, and many of the people who gained power then are still in power now.

There’s no such thing as a fair election in Chicago, and hasn’t been for over a century. ‘Reformers’ have a habit of ending up behind bars; judges have a habit of throwing out cases against the politically connected.(5)  Dead people vote; live people who vote wrong have their ballot boxes thrown in the river.

Chicago is one of my favorite towns to visit. Michigan Avenue and Millennium Park are beautiful and fun, and the whole Loop area is invigorating. But I’ve also been down to the University of Chicago – and you just don’t walk around in that neighborhood. It’s more segregated than than any place down south I’ve ever seen, more along rich/connected versus poor/useful victims lines than race, strictly speaking. America looks more like Chicago now than it did 8 years ago.

Thus, when we are told we need to pass the ACA in order to see what’s in it, a sane person would object. When we are told that we can keep our plan if we like our plan – a bald-faced lie, evident even at the time – we should suspect something is up. And when the cost savings and universal enrollment don’t occur, but the power grab and massive bureaucracy do, we should wonder what the real point of the law was.

So, while I see serious problems – fatal flaws, in my view – on more technical business, math and design aspects of the law, I also suspect that the prime goal of the bill was always the centralization of power – the perennial issue for all kings, mobs and mafias. That, the ACA made huge strides toward achieving.

So, start over from scratch or, if necessary, amend the living heck out of the ACA. It’s just a dumb law, not some virtue shibboleth. And I care about poor people as much as you do.

  1. Acronym under development – this is a prototype. Tried Wonderful Healthcare for Everybody at Very Little Cost (WHEVLC) – and even its mother couldn’t love that. WAHCA can be said with an exclamation point – WAHCA! – which gives it a little of that je ne sais quoi  joie de vie Continental action, there.
  2. Under the repeatedly and continuously disproven Marxist theory that beneficial activities happen by magic and that anybody sincere and enlightened enough can run a business operation as well as the capitalist dog who now has the job.
  3. In a free market, the desire to stay in business and make some money counteract this to some extent, and will put people out of business if it gets too crazy. Evil, evil profits doing a good thing – don’t tell anybody!
  4. Often wondered: if rationing health care by who can pay for it is such a monstrous evil, why is rationing health care by what some bureaucrat somewhere thinks is important OK? It amounts to the same thing: Daddy Warbucks gets the unusual treatment when he wants it by paying for it; Polly Poorperson dies after waiting in the queue for months for the same treatment, because somebody decided somewhere that her disease was too unusual or expensive or her fault or offers too little benefit for the buck, so treatment for it are just not available. Talk to some English people if you don’t believe me – routine, cheap stuff is readily available to everybody! Woohoo! Just don’t get something rare or expensive unless you can pay for it.
  5. The last made man to run Chicago was Fred Roti, arrested by the FBI in 1991, whose father was Bruno “the Bomber” Roti – a man who killed people for the Mob, when not getting government jobs for his many children, including Fred. Before then, it was somebody named Capone and his buddies. While the Mob seems to have gone into Cosimo Medici mode – you know, run everything but lay low – for the time being, it is too much to expect a century plus of bad habit to be changed by one coddled community organizer – assuming he’d even want to turn on the people who got him elected in the first place.  Instead, he brought them with him to the white House, and let them run things.
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Author: Joseph Moore

Enough with the smarty-pants Dante quote. Just some opinionated blogger dude.

5 thoughts on “The ACA: Practical Application of the Ends versus Means Issue”

    1. I’m fond of the model where the Sisters of Mercy would come to town and build a hospital where they wouldn’t turn anybody away. But people aren’t thinking basic care delivered voluntarily by people out of the goodness of their hearts.

      What’s changed, I think, is that people now think that if anything goes wrong, it’s somebody else’s fault. Instead of being pleasantly surprised if we live to 70, we think something’s wrong if we don’t make it to 100.

  1. But but… I’ve been assured by the Pope and Mark Shea himself that health care is a right! How can there be any problems with getting it?

    Though the trolley problem is just supposed to be a way for people to grasp a no-win scenario or the “all bad options” scenario. But when trying to fight extreme consequenalism, we should take care to not run too far off the opposing side into moral equivalency.

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