By Hadley Arkes
Monday, January 16, 2017
Even though Chief Justice John Roberts engineered a decision to save Obamacare, the Constitution did cast up a barrier to it. For in 2010 the Constitution delivered, for the 56th time, through war and peace, a midterm election. That election brought the news of how sharply the American people recoiled from Obamacare.
That election could not end the so-called Affordable Care Act, but it brought a Republican House determined to start nursing systematic critiques of Obamacare. Now, with a Republican Congress ready to act, and a president willing to sign its measures into law, there are several plausible schemes for replacing Obamacare.
They all draw in one way or another on mechanisms of the “market,” with plans fitted to the needs and wants of the patients themselves, rather than plans overloaded with provisions for Viagra and transgender surgery. All of these Republican plans are aimed at the salutary end of dismantling a political control of medicine, directed from the center, at the national level.
Except, of course, only the most careful steps managed and led from the national level can dismantle this scheme of federal control. We are warned now that every such step will be politically charged.
Suddenly we hear of a political minefield for Republicans if too many people lose coverage, even though the new beneficiaries see this insurance as steadily diminishing in quality and escalating in costs. Why, then, is the air filled with all of these warnings of an imminent crisis, designed to scare the Republicans into the kind of pause that becomes debilitating?
At the bottom of it all lies the question: Why do we assume that the American people will be thrown into a panic if faced with the need to take care of themselves, and see doctors—gasp—without insurance? Has it suddenly become unthinkable that ordinary Americans, doctors, or businessmen could summon the wit to find other ways of attending to their medical needs as they did in the past, when their world was not thickly woven with layers of insurance?
The Distant Planet Where Americans Paid Their Bills
A flashback to a real scene in the 1940s may bring that world back to us, but it may suddenly appear like a report from a distant planet. Flashbacks of these kind, to the “way we used to be,” come to me often as I take the long drive from Amherst, Massachusetts to Washington DC, for I often listen along the way to those comedy shows on radio that I heard as a child in wartime 1940s.
One that particularly comes to mind now came in a show with Edgar Bergen and Charlie McCarthy in 1943. Popular star Don Ameche was serving as the announcer. At the end of the program he said it would be especially apt at that time to “say a good word” for doctors. So many doctors had been drawn as medics to the battlefield that the doctors left at home, usually older men, were stretched thin in covering patients. In light of that fact, Ameche mentioned three things Americans could do for the doctors.
First, try to give a clear sense of the problem that has been bothering you. Second, try to get to the doctor’s office—don’t expect him always to make it to your home on a “house call.” Third: You should really pay him. For these doctors have the same expenses their patients have, as with grocers and plumbers.
It is hard to hear that recording, which dates back 70 years, without being jolted with a sense of our distance from that world—a world wanting in Internet and smartphones, but somehow more richly provisioned with people more anchored in hard truths. Yet it was also a world with a more generous measure of understanding as doctors made accommodations for patients of lesser means.
The move to medical insurance came to the fore in these same war years: price controls blocked employers from offering higher wages for the workers they wanted to keep, so some employers offered to cover medical expenses to enlarge compensation to workers while getting around those wartime controls.
We Still Have Hints We Can Do This
Now costs have escalated since various companies have to move medical bills through layers of insurance, with staff added just to keep track of the insurance. As the old line used to have it, we could just imagine what would happen to the cost of groceries if a dramatic rise in prices brought forth a clamor for “food insurance.” The proverbial “middlemen” would be displaced by layers of administrators clearing the bills through levels of insurance.
This convention of insurance has been so woven into our lives, so absorbed now in our sense of the world, that it will require some intervening steps to preserve levels of insurance for people who would feel endangered without it. That is especially the case if they bear those “pre-existing conditions” that make them more expensive to insure.
Yet if employers and private businesses were in the forefront of offering insurance, why do we suppose that private businesses would be bereft of imagination in offering medical services to employees even without insurance? The Mercer Survey found in 2014 that 29 percent of employers with 5,000 or more employees provided an “onsite or near-site” clinic offering services in primary care. About 72 percent of these firms reported they had cultivated a serious interest in trying to manage employees’ “health risks” and “chronic conditions.”
Even apart from this concern, the sprawling problems of delivering medical care have sparked other companies to enter the market to find some niche. It shouldn’t be surprising that the first incentives were seen by companies that began as pharmacies, notably Walgreens and CVS. The appeal quickly extended to Walmart, Kroger, and Target.
These firms started by offering walk-in clinics. They have not exactly been high-tech operations, but they can offer ready treatments in delivering flu shots, treating leg sprains, and even offering checkups. CVS had about 1,000 locations in 31 states in 2013, and reported more than 18 million visits that year. The plan was to expand to 1,500 clinics by 2017. Walmart has set a flat price of $40 per visit. Drugs, vaccines, and workups in labs will bring additional fees, but competition promises to keep those costs within the reach of ordinary folk.
Even Advanced Health Care Could Benefit
None of this, of course, involves open-heart surgery or surgeries of any kind. Also, so far these small clinics may not retain a complete record of each patient to ward off drugs that may be at war with one another. But even with hospitals and advanced equipment, there may be a staggering variance of costs for what may appear to be the same procedure.
In 2013, a patient in the Bayonne Hospital Center in New Jersey faced a charge of $99,690 for her treatment for chronic obstructive pulmonary disease (COPD). Just 30 miles away, at the Lincoln Medical Center in the Bronx, the same treatment had a price tag of about $7,000.
The comparisons are deceptive, of course. Both may have the same name, but differences in levels of skill and experience may make the larger cost, at times, a better bargain. We just don’t know, and no one in Washington with a command control of medical care could possibly know either. The market will send up useful signals when prices are made public, and they may simply lead into other layers of comparison as people look to know more.
It would be folly, then, to suggest that there is some easy fix for a world of services so variegated in their gravity and complexity. But layers of insurance that conceal and distort costs have complicated and befogged this world. Many young people have preferred to live without that insurance, and to pay the Obamacare penalty rather than taking on the escalating costs of the new insurance, with the stamp of official approval. It may be no small task to wean away others who find a sense of safety in the presence of insurance.
But my point is a fairly simple one: Why is conventional opinion so quick to assume that the American people are witless, wanting in imagination and initiative to deploy if schemes of insurance become scrambled overnight and we all need to get our bearings anew? Why is it assumed that doctors, hospitals, and businesses will not show any sense of inventiveness as they find ways of treating the sick, managing the care of patients, or responding to emergencies?
When have we ceased being the people Tocqueville described, the people who are not clueless in getting on with their lives when government is not there to direct them? Why, then, the handwringing in the media over the ills bound to come crashing in on us if Republicans get on with their charge and mercifully put Obamacare away?