Principled Opposition and the Affordable Care Act

[rowyn]

A recurring sentiment I keep seeing on Twitter is 'Those conservatives oppose the ACA because they want poor people to suffer!' That's about the nicest way I see it phrased. Most of the other ways are more hyperbolic. 'I didn't think that real evil -- the kind of monsters who want to make people suffer -- existed on a large scale in the world. But then I realized a large fraction of the voting population wants the ACA repealed.'

I don't feel strongly about the ACA, to be honest. It's of modest personal benefit to me in a few ways. I suppose there are people who choose their policy positions based on whether or not those policies benefit them personally. I have never been that person. I want my government's policies to benefit the population as a whole.

Here are my health care ideals:

* Incentivize high quality care
* Incentivize the development and exploitation of effective new treatments, drugs, vaccines, etc.
* Incentivize breakthroughs: revolutionary care
* Disincentivize fraudulent and ineffective treatments, drugs, etc.
* Make high-quality care accessible to everyone

These are all good things.

They cannot all be accomplished simultaneously. You cannot just push all the sliders to 100% and Acheivement Unlocked: Perfect Healthcare.

You can minmax it. Regulation deters fraud (good!), and it also slows and sometimes prevents innovation (bad!) But all regulation is not created equal. You want the regulations that do the most good and the least harm. It is totally possible to make regulations that do no good (unless you count 'protecting the market of existent companies' as a good) and lots of harm. It's not possible to make regulation that does zero harm, but that doesn't mean it can't be minimized.

The truth is, health care in the real world has long since passed the point where I have any clue what policies are doing best on my sliders above. I don't really want to argue the specific details of the ACA or health care policies.

Mostly what I want to say is:

* I do not think people are evil and selfish if they want the ACA repealed. Most of them believe one or more of the following:
-- the free market will encourage more smart, dedicated people to enter and remain in healthcare professions.
-- heavy government regulation leads to corruption
-- the free market will provide a wider variety of healthcare options for more people
-- the free market will encourage more innovation and advancement in healthcare.

Likewise:

* I do not think people are evil and selfish if they want the ACA to continue. They believe one or more of the following:
-- the ACA helps more people get access to care
-- healthcare in the US without the ACA was a balkanized disaster that left tens of millions uninsured and was an accounting nightmare for medical professionals and financially ruinous for the ill and really anything is an improvement.
-- government involvement in healthcare will not deter innovation and/or will spur it. And/or innovation is less important than access.

My point is not "the arguments for each side above are all true and if you disagree with them you are an idiot". They may all be wrong! But people who believe them are not evil or stupid or insane. They are acting on a combination of facts and heuristics to try to encompass an enormously complicated system.

I am personally okay with the ACA being repealed or not. I can't tell how much good vs bad it is doing and feel like it's probably roughly equal.

I am pretty sure I have said all this before, more eloquently and with more evidence, and all the people who say "the only reason anyone opposes the ACA is because they think poor people deserve to die" are going to ignore me this time too.

So I guess I am writing this whole rant for the three people who already know everything in it but just want to hear someone else say it. So they know they're not alone. So they know not everyone on the Internet thinks they're evil monsters.

You're not an evil monster. It's okay.

Comments

[tuftears.livejournal.com]

That's exactly what I was thinking.

I think it's almost certainly better if basic health care is universal because sickness tends to spread. Similar thoughts on vaccines, vaccines need to be universal to truly prevent the diseases they are meant to stop, or infections will spread. Economies of scale apply too: any individual payer has far less discriminatory power (the ability to influence the seller) than the government as a whole.

If you're the seller, of course, your incentives are to maximize profit, so you lobby government to get rid of universal health care.

[elbren]

exactly. if my neighbor gets smallpox, I want her treated, even if she doesn't have a dime to her name and has never had a job. humans are social animals, and pretending health is an individual, not community, concern is inefficient and unwise.
I'm sure you meant by "universal" "everyone who can be safely vaccinated". vaccines aren't safe for the immuno-compromised.

[level-head.livejournal.com]

Hah! The most typing I've done in a long while. But there is much more to say about this. The upshot: The parts that are good can be done without the 98% of it that is bad. And that's what alternative plans are trying to accomplish.

By the way, people with my disease (CIDP from food poisoning) must not get flu or pneumonia shots. I learned this from an info sheet handed to me in the hospital after my shot that said this. I mentioned that and showed them the page the page they'd given me, and they said "oops."

My prescriptions are now regularly screwed up, sometimes at great pain and great cost to my quality of life. And I am able to watch this carefully, keeping-track on spreadsheets. Most patients are not. And these healthcare workers are good people. They're just dealing with an insane system.

===|==============/ Keith DeHavelle

[level-head.livejournal.com]

The problem with the PPACA is that it is 2,700 pages of basic law that should have been about 100 pages. It is laden with hundreds of provisions that have little or nothing to do with good healthcare, and became (along with the 2,000 page Dodd-Frank financial act passed about the same time) a vehicle for everything that one political side wanted to accomplish.

And this is simply the basic law. On this monstrous skeleton, tens of thousands of pages of regulations were written (this is still going on). They publish the regulations, people complain en masse, are generally ignored, and the new regulations created by unelected bureaucrats with no background in health care become law. This law includes jail time and penalties for violations of things Congress would have never seen even if they had read the 2,700 pages.

Care for those who can not afford it can be set up as a separate thing. There was much of this already as emergency rooms are required to take you and treat you and not even ask if you are a citizen or whether you are in the country legally. But set this up as a separate fund and handle it. The costs are clear enough.

Care for those with pre-existing conditions is also easy to set up as a separate fund that compensates the insurers for their enormous losses. The costs will be high, but clear and isolated.

But so much of the PPACA uses these two "accomplishments" as a cover for provisions that really stink, for insurers, the insured, for patients, and for healthcare workers. And it has left tens of millions of people without insurance.

I talk to a lot of doctors, nurses, and insurance people, and I review lots of healthcare bills. (I have been hospitalized since last July, though I am hoping to be released very soon.) I also am involved in healthcare professionally, with agencies, hospitals, and medical non-profits as clients. I sit on the board of a medical foundation (they won't let me quit even though I cannot attend meetings except by phone. I regularly have meetings (phone meetings, now) with people who run this entities, including county agencies whose primary patients are the poor and "undocumented."

The PPACA is almost universally despised by them, though many supported it as an idea. Many professionals are bailing out of healthcare, or becoming healthcare bureaucrats if they can (very few can).

This new package of horrific provisions is a multi-trillion-dollar liability sold as a "cost savings" through several techniques:

• Making the taxation and other revenue sources start years before the costs started, so that they could say that over 10 years it was a slight cost savings.

• Making absolutely unreasonable assumptions (which the budget offices must accept). They've been shown to be wildly wrong.

• Costing out only the crude and healthcare-related portion of the PPACA itself, since the tens of thousands of supporting regulations were not written yet.

Since that time, parts of the law have been arbitrarily delayed to preserve one side's chances of being elected to anything. And even so, the result has been a colossal failure measured by the tens of millions left uninsured, the skyrocketing costs to taxpayers and premium payers, and the costs to employers and especially the (once) employed.

PPACA sets up incentives to keep full-time workers cut down to less than 30 hours per week, and fewer than 50 workers. They often have to get a second "full-time" low-paying part-time job, which makes the total jobs numbers artificially inflate. The two jobs combined often pay less than what they'd had.

PPACA forces incentives on businesses to stay small. The hours and other limits are about to be reduced further.

If you graph all of the costs and revenue over the first ten years, the period of time used to sell it, it was obvious that the total costs were about to blast through the total revenue in the following year and would climb mightily in years that followed. And even those costs went from "a slight savings" to "oops, we miscalculated by $1.2 trillion."

Even that admission is far understating the grim reality.

===|==============/ Keith DeHavelle

[tuftears.livejournal.com]

I'd be fine with 'replace with better system' but 'rolling back to old days of denial on pre-existing conditions' not so much.