Tuesday, January 17, 2017

Yes, Americans Could Live Without Government-Defined Health Insurance

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?

The Worst Perversion

By Kevin D. Williamson
Tuesday, January 17, 2017

The Obama administration was full of scandal, though we have a lazy and partisan news media that is determined to see no scandal in it.

The lame-duck columns have been nearly unanimous on the point: Barack Obama is remarkable among recent presidents for having been utterly untouched by scandal, personal or political.

The personal can be conceded: There is no serious allegation that President Obama suffered from the liberated appetites of a Bill Clinton, and the White House interns have by all accounts gone unmolested. But this is hardly remarkable: There were no such allegations about George W. Bush, either, or about George H. W. Bush, or about Ronald Reagan, or Jimmy Carter. Richard Nixon’s name is a byword for scandal, but not scandal of that sort. Nixon’s shocking personal perversion was his taste for cottage cheese with ketchup.

So, three cheers for Barack Obama’s manful efforts to live up to the standard of Gerald Ford. Well done.

The political issue is a different question entirely.

Not only was the Obama administration marked by scandal of the most serious sort — perverting the machinery of the state for political ends — it was on that front, which is the most important one, the most scandal-scarred administration in modern presidential history.

For your consideration:

Under the Obama administration’s watch, the Internal Revenue Service and other federal agencies from the BATF to the NLRB were illegally used to target and harass the president’s political enemies. The IRS targeting scandal was the most high-profile of these, but others are just as worrisome. Federal investigations and congressional oversight were obstructed, and investigators were lied to outright — a serious crime. The administration protected the wrongdoers and saw to it that they retired with generous federal pensions rather than serving federal sentences for their crimes.

The Obama administration oversaw the illegal sale of arms to Mexican traffickers for purposes that to this date have not been adequately explained, and those guns have been used to murder American law-enforcement officers.

President Obama’s secretary of state was involved in a high-profile case in which she improperly set up a private e-mail system to evade ordinary governmental oversight; she and her associates routinely misled investigators, obstructed investigations, and hid or destroyed evidence. These are all serious crimes.

The Obama administration made ransom payments to the Iranian government and lied about having done so.

Under the Obama administration, the Secret Service has been a one-agency scandal factory, from drunk agents driving their cars into White House barriers to getting mixed up with hookers in Cartagena.

Under the guise of developing “green” energy projects, the Obama administration shunted money to politically connected cronys at Solyndra and elsewhere.

Obama’s men at the Veterans Administration oversaw a system in which our servicemen lost their lives to bureaucratic incompetence and medical neglect, and then falsified records to cover it up.

Under the flimsiest of national-security pretexts, the Obama administration used the Department of Justice to spy on Fox News reporter James Rosen. It also spied on the Associated Press.

The Obama administration’s attorney general, Eric Holder, left office while being held in contempt of Congress for inhibiting the investigation of other Obama administration scandals.

But, no: No embarrassing stain on a blue dress.

Without minimizing the authentic personal degeneracy of Bill Clinton, sexual scandals are minor concerns. They become large public scandals because the numbskulls understand sex and can relate to sexual infidelity. If you’ve ever tried explaining to someone how futures trading works and watched his expression turn to that of a taxidermied mule deer, then you know why it is Bill Clinton, and not Hillary Clinton, who is the face of scandal.

It is one thing to have a degenerate president. It is something else — something far worse — to have a degenerate government. Barack Obama may have spent the past eight years as sober as a Sunday morning (his main vice, we are told, is sneaking cigarettes) and straight as a No. 2 pencil, but he leaves behind a government that is perverted.

A liberal society with decent government requires that the pursuit of political power be insulated from the exercise of political power. That is why we have a Hatch Act and why the various dreams of the would-be campaign-finance police — who would have congressmen and presidents write the rules under which congressmen and presidents may be criticized and challenged — are in reality nightmares. (Here, let us say a word of thanks for the First Amendment and Citizens United.) Having an IRS that sorts nonprofits by their political stances in order to facilitate the harassment of political rivals is in real terms far worse than anything Bill Clinton got up to with Monica Lewinsky, and far worse than the shenanigans that Gordon Liddy and the rest of the Nixon henchmen got up to in the Watergate. The BATF harassment of True the Vote and other Obama-administration enemies is the stuff of which banana republics are made. Using the machinery of the state to seek political power and to aggrandize the political power one holds is the most destructive form of political corruption there is. A sane society would prosecute it the way we prosecute murder or armed robbery. It is a scandal and more than that: It is an assault on the foundations of a free society.

The fact that the same people at CNN who were colluding with the Clinton campaign cannot see a scandal in the Obama administration does not mean that no scandal was there.

For the Democrats and their media partisans, scandals — like homelessness and war casualties — are something that happens to other people.

Fulfilling the Promise of Obamacare Repeal

By Chris Jacobs
Tuesday, January 17, 2017

Two months ago, the American people gave lawmakers a clear mandate: Save our nation’s health-care system from the harmful effects of Obamacare. They’re sick of exorbitant premium increases. They’re frustrated with insurer drop-outs and narrow provider networks that stifle access. They want change, and they want it now.

Congress’s votes last week on a budget were the first steps toward repeal. Last January, Congress passed, and President Obama vetoed, a reconciliation bill that would eliminate more than $1 trillion in Obamacare tax increases and wind down spending on the law’s new entitlements by the time Congress can pass more sensible health-care reforms.

Now, with Republicans set to take control of all the White House, that bill could be passed again and signed into law. Some have argued that doing so this year would disrupt the health-care industry, prompting insurers to exit more markets and leaving the American people in the lurch. But these critics should first acknowledge that Obamacare is leaving millions of Americans in the lurch right now. In one-third of counties, Americans have a “choice” of only one insurer on their Exchange.

That said, conservatives must proceed carefully when unraveling the government mandates crippling our health-care system. Thankfully, as I outline in a report released today, Congress and the incoming Administration have numerous tools at their disposal to bring the American people relief.

As it repeals Obamacare, Congress should work to expand the scope of last year’s reconciliation bill to include the law’s costly insurance mandates. Because reconciliation legislation must involve matters primarily of a budgetary nature, critics argue that the process cannot be used to repeal Obamacare’s insurance regulations, and that leaving the regulations in place without the subsidies will collapse insurance markets. But Congress did not attempt to repeal the major insurance regulations during last year’s debate; it avoided the issue entirely. Consistent with past practice, Senate procedure, and the significant fiscal impact of the major regulations, it should seek to incorporate them into the measure this time around.

Congress should also include provisions in the reconciliation bill freezing enrollment in Obamacare’s Medicaid expansion upon its enactment. Currently eligible beneficiaries should be held harmless, but lawmakers should begin a path to allow those on Medicaid to transition off the rolls and into work. In a similar vein, Congress should also explore freezing enrollment in Obamacare’s insurance subsidies, provided doing so will not de-stabilize insurance markets.

The Trump administration has an important part to play as well, as it can provide regulatory flexibility to insurers and states — even within Obamacare’s confines. For instance, Obamacare gives the secretary of health and human services the sole authority to determine the time and length of the law’s open-enrollment periods. In both 2016 and 2017, those periods stretched on for three months, meaning that for at least one-quarter of the year, any American could sign up for insurance — no questions asked — immediately following a severe medical incident.

To guard against adverse selection — whereby more sick individuals than healthy ones sign up for coverage, raising insurance premiums for everyone — the Trump administration can significantly shorten enrollment periods. Next year’s open enrollment should last no more than 30 days if logistics will permit. Similar actions would restrict special enrollment periods that individuals have gamed under Obamacare, purchasing coverage outside open enrollment, racking up medical bills, and then cancelling their coverage. The Trump administration can eliminate special enrollment periods not required by statute, and require verification prior to enrollment in all other cases.

Another place for regulatory flexibility lies in the 3.5 percent “user fee” assessed for all those purchasing coverage on the federal exchange. In regulations released last month, the Obama administration essentially admitted that the actual cost of running the federal Exchange has dropped below 3.5 percent of premiums, but kept the “user fee” at current levels to increase funds for enrollment and outreach. The Trump administration should lower premiums by cutting user fees to the amount necessary for critical exchange functions, rather than spending hard-earned premium dollars promoting the partisan agenda the law represents.

The Trump administration can take other actions within the scope of Obamacare to provide a stable path to repeal. It can withdraw the mandated coverage of contraceptive services that raises premiums while forcing individuals and organizations to violate their deeply held religious beliefs. It can expand and revise the scope of essential health benefits, actuarial value, and medical-loss-ratio requirements to provide more flexibility for insurers. It can immediately withdraw guidance issued by the Obama Administration in December 2015 that paradoxically made an Obamacare “state innovation waiver” program less flexible for states. And it can build upon legislation Congress passed last month, which allowed small businesses to reimburse their employees’ insurance premiums without facing thousands of dollars in crippling fines, by extending the same flexibility to all employers.

Congress and the Trump administration have many tools at their disposal to provide an orderly, stable transition toward a new, better system of health care — one that focuses on reducing costs rather than expanding government control. They can and should use every one of these tools to bring about that change, fulfilling the promise of repeal.

Putin, Obama — and Trump

By Victor Davis Hanson
Tuesday, January 17, 2017

For eight years, the Obama administration misjudged Vladimir Putin’s Russia, as it misjudged most of the Middle East, China, and the rest of the world as well. Obama got wise to Russia only when Putin imperiled not just U.S. strategic interests and government records but also supposedly went so far as to tamper with sacrosanct Democratic-party secrets, thereby endangering the legacy of Barack Obama.

Putin was probably bewildered by Obama’s media-driven and belated concern, given that the Russians, like the Chinese, had in the past hacked U.S. government documents that were far more sensitive than the information it may have mined and leaked in 2016 — and they received nothing but an occasional Obama “cut it out” whine. Neurotic passive-aggression doesn’t merely bother the Russians; it apparently incites and emboldens them.

Obama’s strange approach to Putin since 2009 apparently has run something like the following. Putin surely was understandably angry with the U.S. under the cowboy imperialist George W. Bush, according to the logic of the “reset.” After all, Obama by 2009 was criticizing Bush more than he was Putin for the supposed ills of the world. But Barack Obama was not quite an American nationalist who sought to advance U.S. interests.

Instead, he posed as a new sort of soft-power moralistic politician — not seen since Jimmy Carter — far more interested in rectifying the supposed damage rather than the continuing good that his country has done. If Putin by 2008 was angry at Bush for his belated pushback over Georgia, at least he was not as miffed at Bush as Obama himself was.

Reset-button policy then started with the implicit agreement that Russia and the Obama administration both had legitimate grievances against a prior U.S. president — a bizarre experience for even an old hand like Putin. (Putin probably thought that the occupation and reconstruction of Iraq were a disaster not on ethical or even strategic grounds but because the U.S. had purportedly let the country devolve into something like what Chechnya was before Putin’s iron grip.)

In theory, Obama would captivate Putin with his nontraditional background and soaring rhetoric, the same way he had charmed urban progressive elites at home and Western European socialists abroad. One or two more Cairo speeches would assure Putin that a new America was more interested in confessing its past sins to the Islamic world than confronting its terrorism. And Obama would continue to show his bona fides by cancelling out Bush initiatives such as missile defense in Eastern Europe, muting criticism of Russian territorial expansionism, and tabling the updating and expansion of the American nuclear arsenal. All the while, Obama would serve occasional verbal cocktails for Putin’s delight — such as the hot-mic promise to be even “more flexible” after his 2012 reelection, the invitation of Russia into the Middle East to get the Obama administration off the hook from enforcing red lines over Syrian WMD use, and the theatrical scorn for Mitt Romney’s supposedly ossified Cold War–era worries about Russian aggression.

As Putin was charmed, appeased, and supposedly brought on board, Obama increasingly felt free to enlighten him (as he does almost everyone) about how his new America envisioned a Westernized politically correct world. Russians naturally would not object to U.S. influence if it was reformist and cultural rather than nationalist, economic, and political — and if it sought to advance universal progressive ideals rather than strictly American agendas. Then, in its own self-interest, a grateful Russia would begin to enact at home something akin to Obama’s helpful initiatives: open up its society, with reforms modeled after those of the liberal Western states in Europe.

Putin quickly sized up this naïf. His cynicism and cunning told him that Obama was superficially magnanimous mostly out of a desire to avoid confrontations. And as a Russian, he was revolted by the otherworldly and unsolicited advice from a pampered former American academic. Putin continued to crack down at home and soon dressed up his oppression with a propagandistic anti-American worldview: America’s liberal culture reflected not freedom but license; its global capitalism promoted cultural decadence and should not serve as anyone’s blueprint.

As the West would pursue atheism, indulgence, and globalism, Putin would return Russia to Orthodoxy, toughness, and fervent nationalism — a czarist appeal that would resonate with other autocracies abroad and mask his own oppressions, crony profiteering, and economic mismanagement at home. Note that despite crashing oil prices and Russian economic crises, Putin believed (much as Mussolini did) that at least for a time, a strong leader in a weak country can exercise more global clout than a weak leader in a strong country — and that Russians could for a while longer put up with poverty and lack of freedom if they were at least feared or respected abroad. He also guessed that just as the world was finally nauseated by Woodrow Wilson’s six months of moralistic preening at Versailles, so too it would tire of the smug homilies of Barack Obama, Hillary Clinton, and John Kerry.

Putin grew even more surprised at Obama’s periodic red lines, deadlines, and step-over lines, whose easy violations might unite global aggressors in the shared belief that America was hopelessly adrift, easy to manipulate, obnoxious in its platitudinous sermonizing, and certainly not the sort of strong-horse power that any aggressors should fear.

Perhaps initially Putin assumed that Obama’s lead-from-behind redistributionist foreign policy (the bookend to his “you didn’t build that” domestic recalibration) was some sort of clever plot to suggest that a weak United States could be taken advantage of — and then Obama would strike hard when Putin fell for the bait and overreached. But once Putin realized that Obama was serious in his fantasies, he lost all respect for his benefactor, especially as an increasingly petulant and politically enfeebled Obama compensated by teasing Putin as a macho class cut-up — just as he had often caricatured domestic critics who failed to appreciate his godhead.

Putin offered America’s enemies and fence-sitting opportunists a worldview that was antithetical to Obama’s. Lead-from-behind foreign policy was just provocative enough to discombobulate a few things overseas but never strong or confident enough to stay on to fix them. When China, Iran, North Korea, ISIS, or other provocateurs challenged the U.S., Putin was at best either indifferent and at worst supportive of our enemies, on the general theory that anything the U.S. sought to achieve, Russia would be wise to oppose.

Putin soon seemed to argue that the former Soviet Republics had approximately the same relation to Russia as the Caribbean, Puerto Rico, and the Virgin Islands have to the United States. Russia was simply defining and protecting its legitimate sphere of influence, as the post-colonial U.S. had done (albeit without the historic costs in blood and treasure).

Russia had once lost a million civilians at the siege of Leningrad when Hitler’s Army Group North raced through the Baltic States (picking up volunteers as it went) and met up with the Finns. At Sevastopol, General Erich von Manstein’s Eleventh Army may well have inflicted 100,000 Russian Crimean casualties in a successful but nihilistic effort to take and nearly destroy the fortress. The Kiev Pocket and destruction of the Southwestern Front of the Red Army in the Ukraine in September 1941 (700,000 Russians killed, captured, or missing) may have been the largest encirclement and mass destruction of an army in military history.

For Putin, these are not ancient events but rather proof of why former Soviet bloodlands were as much Russian as Puerto Rico was considered American. We find such reasoning tortured, given Ukrainian and Crimean desires to be free; Putin insists that Russian ghosts still flitter over such hallowed ground.

Reconstruction of Putin’s mindset is not justification for his domestic thuggery or foreign expansionism at the expense of free peoples. But it does remind us that he is particularly ill-suited to listen to pat lectures from American sermonizers whose unwillingness to rely on force to back up their sanctimony is as extreme as their military assets are overwhelming. Putin would probably be less provoked by a warning from someone deemed strong than he would be by obsequious outreach from someone considered weak.

There were areas where Obama might have sought out Putin in ways advantageous to the U.S., such as wooing him away from Iran or playing him off against China or lining him up against North Korea. But ironically, Obama was probably more interested in inflating the Persian and Shiite regional profile than was Putin himself.

If Obama wished to invite Putin into the Middle East, then at least he might have made an effort to align him with Israel, the Gulf States, Egypt, and Jordan, in pursuit of their shared goal of wiping out radical Islamic terrorism. In the process, these powers might have grown increasingly hostile to Syria, Hezbollah, and Iran. But Obama was probably more anti-Israeli than Putin, and he also disliked the moderate Sunni autocracies more than Putin himself did. As far as China, Putin was delighted that Obama treated Chinese aggression in the Spratly Islands as Obama had treated his own in Ukraine: creased-brow angst about bad behavior followed by indifference.

The irony of the failed reset was that in comparative terms the U.S. — given its newfound fossil-fuel wealth and energy independence, the rapid implosion of the European Union, and its continuing technological superiority — should have been in an unusually strong position as the leader of the West. Unhinged nuclear proliferation, such as in Pakistan and North Korea and soon in Iran, is always more of a long-term threat to a proximate Russia than to a distant America. And Russia’s unassimilated and much larger Muslim population is always a far more existential threat to Moscow than even radical Islamic terrorism is at home to the U.S.

In other words, there were realist avenues for cooperation that hinged on a strong and nationalist U.S. clearly delineating areas where cooperation benefitted both countries (and the world). Other spheres in which there could be no American–Russian consensus could by default have been left to sort themselves out in a may-the-best-man-win fashion, hopefully peaceably.

Such détente would have worked only if Obama had forgone all the arc-of-history speechifying and the adolescent putdowns, meant to project strength in the absence of quiet toughness.

Let us hope that Donald Trump, Rex Tillerson, and Jim Mattis know this and thus keep mostly silent, remind Putin privately (without trashing a former president) that the aberrant age of Obama is over, carry huge sticks, work with Putin where and when it is in our interest, acknowledge his help, seek to thwart common enemies — and quietly find ways to utilize overwhelming American military and economic strength to discourage him from doing something unwise for both countries.