Welcome to the Free Market in Medicine

(Updated, see below.)

This article at Talking Points Memo about a doctor in Arizona was in my inbox this morning:

More than half of AAPS members have stopped accepting Medicaid payments, [executive director of the American Association of Physicians and Surgeons Dr. Jane] Orient says, though she stresses that they'll still see patients if they either pay for themselves or come to a free charity clinic. A smaller number of her membership is also bucking the private insurance industry, asking for direct payments from customers and telling them to seek reimbursements from their insurers on their own.

They see themselves as the front lines in the fight against a "plan ... to destroy the current infrastructure," as Orient put it in a recent interview with TPM. Winning that fight starts with convincing their peers and patients to break away from the system set up under the health care reform law.

"Coercion, central planning, socialism if you will does not work. It kills the incentive to work. It misallocates all of the resources so that everybody is worse off than they would have been if they had just allowed free men and women to make their own decisions," she said. "The remedy is for patients and physicians is to decline to participate in the system, go for a true free-market alternative."

 Healthcare is very expensive. Dr. Jane Orient is willing, as a doctor, to take what the market will give her. Let the market set the price. The vast majority of Americans can't afford medical care her way, but she doesn't care, though some members of her association will donate time at free charity clinics. She despises -- fears -- socialism. Like fellow AAPS member, Senator Rand Paul, she regards Obamacare as a form of slavery.

These doctors reject Medicare and Medicaid patients and feel government-run healthcare systems are evil incarnate. They are a great, free-standing example of believers in the free market. An tenet of their philosophy is that there is no right to healthcare.

What does "no right to healthcare" mean in a free market context? It means if you don't have enough money to participate in a medical free market, you will be denied service. That's how this works. If it doesn't work this way, it isn't a free market.

No money, no healthcare, it's that simple. Poor people? Suffer and die, you're not welcome here. And don't think that "free charity clinics" and ERs take care of poor peoples' needs. That's just a fig leaf.

I'm not sure where the Hippocratic Oath comes in here, but all doctors take the Oath. I guess some think it applies only to people with money, plus the few unsavory people they come into contact with while they're being good and righteous once a month at a charity clinic.

There's a reason -- prior to Obamacare -- millions upon millions of Americans had no health insurance, while millions more had extremely weak "catastrophic" health insurance with extremely high co-pays and lifetime caps that means you have insurance until you don't, regardless of the consequences.

This is the free market libertarians revere. It's not a world I want to live in. Do you?

Queuing up at the free clinic. At least it's not socialism!

Let's be clear: These are doctors who won't participate -- or claim they won't -- in Obamacare. The part of Obamacare that gives most of the poor a shot at healthcare -- that's Medicaid -- these doctors won't participate in. I suppose for a doctor in a red state that refused the Medicaid expansion paid for by the federal government, that'll be an easy thing to do.

Update. I listened more carefully to Rand Paul's remarkable "if you think healthcare is a right, you believe in slavery" statement, in which he implies that healthcare-as-right would lead to people knocking down his doors and demanding service. Then I caught the rhetorical twist at the end, where he said that, in exchange for surgical privileges at his hospital back when he practiced medicine, he agreed to serve 100% of people who came into the ER. Speaking of the Hippocratic Oath, Paul said, "Since the beginning of modern medicine, we have always provided 100% access. I do it in exchange for privileges. I do it because I believe in the Hippocratic Oath....we've always provided 100% free access."

Which is it, Rand Paul, a right to healthcare is slavery, or "we've always provided 100% free access?" You can't have it both ways. Now, if the federal government offers hospitals money to help pay for that "100% free access," then how is that different from accepting Medicaid to help defray costs, as well? I wonder how much rhetorical trickery and hypocrisy are built into Dr. Jane Orient and her AASP's stance on no third-party money. Are their hospitals rejecting behind-the-scenes federal money? If we looked, I think I know the answer we'd find.

Leaving It All to Market Forces

Remind me again why we have cracks in the system for people to fall through.

Paul Krugman has an insightful blog post today called "Unacceptable Realities," in which he lays into those who refuse to accept Obamacare and the Fed's monetary policy as workable initiatives that might just make things better. Not perfect, but better.

On both the healthcare and inflation fronts, what you have to conclude is that there are a large number of people who find reality — the reality that governments are actually pretty good at providing health insurance, that fiat money can be a useful tool of economic management rather than the road to socialist disaster — just unacceptable. I think that in both cases it has to do with the underlying desire to see market outcomes as moral imperatives.

That last line just grabbed me. First, it's a defensible position that markets are innately efficient and, left alone, with find their own levels. It's gospel to the libertarians, gold bugs, and laissez-faire capitalists. I don't buy it, but it's defensible.

Liberals, in general, believe that markets are not efficient and, in fact, are easily manipulated by those who know how. For us --I'm in this camp -- markets have to be regulated, in some cases, made to do right, in order to function on behalf of societal goals. Conservatives, in general, believe that government is not to be trusted with these things -- in fact, can make things worse -- and since markets are efficient, just let things get decided by them.

As I said, I don't buy this efficient-markets nonsense because there's plenty of proof unregulated markets can completely implode, i.e. the mortgage market between 2002 and 2008. But a case can be made. Fine.

When evidence shows that markets can fail, efficient-market advocates can only say, "Yeah, but government would be worse!" So Obamacare can never work for them. It'll always be evil.

And that's the point here: For the hard-right, it's a moral imperative that drives them. Markets are great because they do create winners and losers by their very design. If we don't have underpaid poor people, then it's a market failure. Poor people prove that the marketplace made its decision. The only way, in fact, a developed and quite rich country has any poor people is because we've devised our markets to produce them. And, yes, if we wanted to defeat poverty, we'd have to mess with the labor market indeed, or augment it so much by tax and/or safety-net policies that government accomplishes the same thing.

And that thing is to redistribute wealth. And that makes conservative heads explode. Why? Is it defensible to allow human suffering when it's avoidable? I don't think so. That's my moral imperative.

Here's a general outline of my proposition:

1. Establish a higher minimum wage, say $15. Schedule it to be enacted in stages, if you want, so as not to cause undo chaos.
2. As a nation, embrace labor unionization. That will raise wages, benefits.
3. Structure the earned-income tax credit in such a way that every man, woman, and child in the U.S. gets enough money to be at 125% of the poverty level.
4. Structure unemployment insurance such that an unemployed person who can work is at that same 125% of the poverty level.
5. Disabled people will be provided with an income of 125% of the poverty level.

Require people to work or be looking for work if they are capable of working. I have no problem with that. Now, how do we pay for this? First, if the level of guaranteed income is high enough, we can eliminate both unemployment insurance and food stamps. There are other forms of welfare that can be folded into the pot to pay for this, as well. I could imagine many state and local aid programs for the homeless could be ended. Perhaps WIC isn't necessary if all families have the money to provide proper diet for themselves and their infants. Free and reduced lunch programx might no longer be needed. All this, of course, only if the level of guaranteed income is high enough.

There's a lot of bureaucracy that will then become unnecessary. Add those savings in, too. Now let's say that there's still more funding needed for this set of interacting programs. Just tax wealth enough to make up the difference. If the top 1% or the top .1% feel ripped off, so be it. They have acquired an inordinate amount of the total wealth of the U.S., and they can afford to spread some of it around. As a liberal this is what I call a moral imperative.

Imagine what happens when we undertake such a program of wealth redistribution.

1. The economy gets stimulated as the velocity of money increases.
2. Imagine the impact on the homeless situation. People literally can come in from the cold.
3. People will spend more on housing and furnishings.That's good for the economy.
4. Imagine a society with a vastly reduced misery index. Just imagine it.
5. When matched with an effective healthcare program -- Obamacare is a nice start -- we can begin to see an end to the deleterious effects of stress and bad diet on the poor, with declining IQs and learning capabilities. This will help end to cycle of generational poverty.

Who loses? The super wealthy take a hit, one they can afford. Otherwise, I'm trying to think who else loses. The middle class? No, because the main effect on it will be an expansion, as fewer people slip out of the middle class and more have a chance to join it from below.

And just what is the moral hazard here? That some surfer somewhere is going to get over on us, or some lazy African-American figures out how never to work? Aside from the stereotypes involved -- surfers and African-Americans are no more lazy than you and I -- so what? So what if a few people get something they haven't earned or have no intention of trying to earn? We can just add them in as the rare few who have decided to find their own level and not seek to improve themselves. At least they'll be consumers.

You know, Denmark works a lot like what I just described, and the Danes are not a bunch of lazy ne'er-do-wells. They're a prosperous and hard-working nation who are dedicated to establishing and maintaining a successful -- and humane -- society. We can do it, too. It's the right and moral thing to do.

Those nasty Danes. How dare they be healthy, happy and hard-working, cycling
to work and all (55% of Copenhagen commutes by bicycle). Tough life.

  
I'm going to post this now and add links later that support my position and/or stupify my opponents. But I will add that I just heard Barack Obama on Chris Matthews saying that we have a great tradition of rugged individualism in this country, which makes it a place where, if you work hard, you can make it, or, if you're lucky, really, really make it. But that's only part of the picture, Obama reminded us. The government is us, and there are things the government can do better than we can ourselves. We can't, as individuals, put a man on the moon, win a war like WWII, or clean up after a major hurricane. We need some real scale for those things, and that's what government provides.

And there's another part of our great nation that we are currently have a hard time with, and that's a sense of community. A community is made up of individuals united by commonality. My feeling is that community is the basis for most of what mankind can produce. None of us does much on our own. We need each other. If that's the case, the better everyone in our community does, the better off all of us are.

That's what I'm saying.

Is "The End of Days" Rattling Public Policy?

An artist's rendering of the Tea Party at the Rapture.

The other night I met an elderly couple at a party, where I had a chance to meet people that don't ordinarily run in my circles. Since I live in a blue-blue area (SF North Bay town of Sonoma) in a blue state (CA), I don't run into many people who believe that Obama is going to put microchips in our heads and then round us up into FEMA camps located all around the country.

Yet this is what this elderly couple believed. They were fiercely evangelical Christians who reminded me that my admiration for the New Testament -- I feel there's a compelling argument that we humanists could use Christ and his teachings of tolerance, humility, empathy, and charity as a moral model -- might be a little misplaced: Until they reminded me, I had forgotten that Revelation is one of the books of the New Testament. Some parts, say the Gospels, are cool enough, but Revelation is pretty whackadoodle stuff indeed.

To the End of Days crowd, Barack Obama is a close approximation of one of the Four Horsemen of the Apocalypse, when the Kenyan Socialist Muslim is not determined outright to be the Anti-Christ.

I mean, Obamacare. Right? Total apocalyptic stuff, you know.

So, it got me thinking. How much does a belief that the Last Judgment is just around the corner affect public policy? I don't mean that evangelical Christian conservatives gather together at think tanks in Washington DC and apply "the world is ending next Thursday" to the policy statements they issue. Wait. Maybe I mean just that.

Seriously, though, have you thought much of the composition of that far-right portion of the Republican Party base? Aren't they largely southern, white, undereducated Christian males along with their wives that respect paternal authority? Don't they get a decent dose of the Grand Theory of the Apocalypse every Sunday from the pulpit?

What would be the policy implications for the Republican Party as a whole?

• If I thought Barack Obama's policies were ushering in the End of Days, I'd fight fiercely to prevent him from any policy victories, even when he's leaning more right than most Democrats are comfortable with. After all, Obamacare is socialized, government-controlling medicine. If you actually believed that, it's not a stretch to believe Obama wants everyone to get health insurance so he can expedite getting those microchips in everybody's head. Especially those pesky millennials, better bug 'em while they're young.
• No wonder the fringe are crazy about the 2nd Amendment. If you thought the war to end the world was going to break out soon, even if you knew Jesus Christ was going to be the Allied Commander-in-Chief of all evangelical we're-saved-you're-so-screwed-you-Jesus-hating-liberal-retards, wouldn't you tend to believe "who needs guns Jesus is gonna kill them all except us anyway" I mean wouldn't you think? No, to really be on General Jesus' side, you need a massive arsenal -- and be ready to use it -- to prove which army you're part of.
• Wouldn't you hate the poor, too, because they're the losers God didn't pick to be his Christian soldiers? (The wife-part of the evangelical pair said that the possibility of war, pestilence, misery, and Hell itself are the price we pay for free will. If we couldn't do something stupid that would mean we'd end up in Hell for all eternity, what would be the purpose of the whole exercise anyway? I pointed out that I didn't want any part of a God that would devise such a  horrid scheme, but I digress.) Being part of the blessed saved in a free-will contest requires winners and losers. The blessed saved have the guns and money, so the poor are obviously already on the way to Hell. Why not hurry up the process, by, for instance, cutting Social Security and Medicare?
• Climate change? You betcha, only it's God's will and part of his End-of-Days script. Why resist it? You'll be in Heaven with Him after the Rapture anyway. So, until then, drill, baby, drill!
• Support immigration reform? Hell no, it's just a scheme to get the undocumented out of the shadows so Obama can turn them into his bot army to go up against the Christian soldiers in battle before the Last Judgment. I mean, the blessed saved are going to triumph, but why give 'em an inch? They always take a mile anyway, so screw 'em. That's what Jesus would do.

You get my drift. Remember that former Iranian President Mahmoud Ahmadinejad was a member of a Islamic cult that believed in an "end of days" scenario? Notice how he was talking about wiping Israel off the face of the map and how he worked so hard to refine uranium and build a bomb and develop long-range missiles? Well, Muslims were headed to paradise just around the corner, so why not blow up the Jews before it's too late? When he left the presidency, that kind of talk dried up (a rival of his won the election). Now they're making nice. Go figure.

Holy crap, I just did some googling and found this recent article from The Daily Beast confirming that I'm onto something here, something possibly widespread. From the article:

They believe America teeters on the brink of destruction, and hold as an article of faith that liberals, gays, Democrats, atheists and the United Nations are to blame. This “end-times” world-view is a foundational precept of the evangelical movement, from which many of the so-called Tea Party favorites spring. Scholars call it apocalypticism.

Of course, the Tea Party is not just composed of members of the Christian right. Many are genuine libertarians. Some nurse an unreconstructed Confederate grudge, while others harbor a thinly disguised racism. However, the real energy, the animating force for the movement comes from evangelicals, of whom Ted Cruz, Michelle Bachmann and Sarah Palin are the most strident. These are the modern-day ”apocalyptic prophets.”

Although the issues are secular, the prophets’ anti-Obamacare rhetoric rings with religious, end-times cadences. So to understand why they invoke chaos, we need to know where their ideas about an “apocalypse” came from.

Most theologians, including the revered Albert Schweitzer, believe John the Baptist and Jesus of Nazareth were Jewish apocalypticists. Simply put, these first-century prophets believed they were living in the “end times” before God would send his representative, the “Son of Man” (taken from a rather obscure passage in the Book of Daniel), to overthrow the forces of evil and establish God’s justice on earth. Apocalypse literally translates as “the revealing” of God’s will. For these early prophets the Kingdom of God was not to be a church, but a military and political kingdom on earth.

 Read the whole article, though I have to throw this little nugget out to you, as well:

“. . . I’m a believer in Jesus Christ, as I look at the End Times scripture, this says to me that the leaf is on the fig tree and we are to understand the signs of the times, which is your ministry, we are to understand where we are in God’s End Times history. Rather than seeing this as a negative . . . we need to rejoice, Maranatha Come Lord Jesus, His day is at hand. And so what we see up is down and right is called wrong, when this is happening, we were told this, that these days would be as the days of Noah. We are seeing that in our time.” - Michelle Bachmann, Oct. 5, 2013

Game, set, match. The far-right evangelical apocalypticists are wagging the dog. We are so screwed until they stop.

Which sooner or later they will. So says Jonathan Capehart in a WaPo article called "The GOP might as well be dead."

Which they will be if Michelle Bachmann gets her way. But they shall rise again, at the End of Days...

According to a Tea Party source, this is a picture of
what liberals will look like after the Apocalypse.

Chris Christie -- leading GOPer for 2016 -- Is a Serial Flip-Flopper

Chris Christie: straight-shooter or bull-shooter?

So-so popular governor Chris Christie surged in the polls after Hurricane Sandy. No one should deny that his performance was masterful and really showed his political skills. Still, political skills might not help a moderate Republican win either the 2016 nomination or the presidency. Ask John McCain and Mitt Romney.

Can Chris Christie bullshit his way to the presidency in 2016? Again, ask Mitt Romney. And don't answer that Mitt Romney was a horrible candidate. He was, but remember, he also got himself elected governor of a blue state, Massachusetts, no mean feat. It was tacking to the right that didn't work out for Mitt.

And that's the minefield Chris Christie has to cross. Maybe he's come up with a solution now that he's safely elected to a second term: flip-flop now and get it behind him. If so, he's already made substantial progress.

He campaigned for governor as being in favor of immigration reform and a path to citizenship for the undocumented and gave lip service to the New Jersey DREAM Act. He won 51 percent of the Hispanic vote. Just recently, Christie has threatened to veto the version making its way through the NJ Assembly, saying he has problems with it. Classy, Chris.

He's done the same with climate change, saying he believes in it but denying that it had anything to do with Hurricane Sandy. Sounds familiar. The NJ Star-Ledger:

Christie withdrew New Jersey from a regional treaty on climate change, and robbed our state’s clean-energy fund of $1 billion to balance his budgets. Now, he refuses to acknowledge any role climate change might play in a storm like Sandy, calling it "a scientific discussion and debate that I’m simply not engaged in."

Real classy, Chris. Making headway in the flip-flop department, flipping on the Hispanics and the environmentalists. I get it. What do they have to do with the 2016 Republican nomination? Nothing.

I see how this works. He's done the same thing on gun control:

New Jersey Gov. Chris Christie has had such a remarkable change of heart on the Second Amendment over in the past six months that he actually vetoed part of his own gun-control agenda. The governor enraged anti-gun groups when he rejected three of the Democrat-controlled Legislature’s radical bills on Friday night.

Mr. Christie, who is running for re-election this year, used a conditional veto to rewrite the most extreme bills that came out of the Legislature this year. The key controversial one would have identified gun owners on a “smart card” such as a driver’s license. There was also a training requirement just to own a firearm and a ban on private exchanges.

The governor also vetoed a bill to ban .50-caliber firearms, which are never used in crimes, even though he called for this same measure earlier this year. The Legislature can accept the rewritten bills, find a two-thirds majority to override or the full veto stands, which is most likely. 

I can't blame you, Gov. Christie. It's savvy politics to avoid that etch-a-sketch moment, and doing it well in advance is also smart. But my question is: Do you look good wind-surfing?

Raising the Minimum Wage Is Really Popular, Except Among [.......]

A recent poll in the New York Times makes very clear how all cohorts of the American people favor not just an increase in the minimum wage but a meaningful one. The graph demonstrating this is not easy to copy and share online, so visit the page.

Everyone favors a raise to either $9.00 or $10.10 from the current $7.75. The only substantial resistance is among Republicans, conservatives, and people who make $75 to $100k. Even there, the majority favor a raise of one kind or another.

Why, again, are we not doing this yesterday?

Just a guess: Opposition to raising the minimum wage is very strong within the Tea Party, also known as the far-right Republican base. This minority scares the crap out of anything resembling a moderate Republican. So, no monies for you poor people. Sorry! We'd rather have someone to feel superior to, losers. (Tea Partiers also think of themselves as losers, or potential losers when the gays, blacks, Hispanics and women finally take over, but that's another post.)

Which one of these folks is a Tea Partier against raising the minimum wage?

Americans Want a Higher Minimum Wage. Why Don't We Get One?

An Ohio Walmart is having a food drive for its workers. Real good, America.

Paul Krugman makes the case again today for a higher minimum wage and reminds us that all political classes of citizens -- even Republicans -- favor it. Why won't it happen?

That's why.

For fun, read this conservative argument against a higher minimum wage. Notice how its central tenet is that minimum-wage workers qualify for government assistance and tax credits. In other words, don't make Walmart and McDonald's pay for their labor, let the taxpayers do it! Beginning of the lead graph:

Steve Coll has a comment in this week’s New Yorker calling for a higher federal minimum wage. He points out that it’s awfully hard for a family of four to live on the current minimum wage, which would produce a family income of about $15,000 a year. That is certainly true, but Mr. Coll leaves out a few things. A family of four with an annual income of $15,000 would be eligible for food stamps amounting to $7,584 and an earned income tax credit of $5,372. That raises the family income to $27,911, which is quite an improvement. The family would also be eligible for Medicaid, school lunch and breakfast programs, perhaps housing assistance and other forms of help.

And here I thought conservatives hated government spending and waste, fraud, and abuse. Oh well, what do I know?

Why Do We Spend More on Football Than the Arts?

Music is not wrecking these kids...

An article I just read in the New York Times called "The Real Humanities Crisis" by Notre Dame professor Gary Gutting made two strong points. First, along with the economic collapse of the middle class, we're also experiencing a collapse of the "cultural middle class." Second, as a society we make spending choices that run counter to common sense, such as government spending on football rather than a symphony orchestra.

Fair treatment for writers and artists is an even more difficult matter, which will ultimately require a major change in how we think about support for the arts. Fortunately, however, we already have an excellent model, in our support of athletics. Despite our general preference for capitalism, our support for sports is essentially socialist, with local and state governments providing enormous support for professional teams. To cite just one striking example, the Minnesota State Legislature recently appropriated over $500 million to help build the Vikings a new stadium. At the same time, the Minnesota Orchestra is close to financial disaster because it can’t erase a $6 million deficit. If the Legislature had diverted only 10 percent of its support for football, it would have covered that deficit for the next eight years.

Indeed. How does Gutting think we can strengthen our regard for humanities in our cultural middle class? Education, and it's a two-fer, if you follow his logic.

We could open up a large number of fulfilling jobs for humanists if (as I’ve previously suggested) we developed an elite, professional faculty in our K-12 schools. Provide good salaries and good working conditions, and many humanists would find teaching immensely rewarding. Meeting the needs of this part of the cultural middle class could, in fact, be the key to saving our schools. At the same time, colleges should rethink their dependence on adjuncts, who often differ from regular faculty members more in their poor pay and work conditions than in academic quality. If adjuncts don’t meet the standards to be part of the regular faculty, they shouldn’t be hired. If they do, they should be treated the same.

Here's how this works: More students would go into the humanities if quality jobs awaited them. These well-trained, well-paid teachers would not only strengthen the economic middle class but also improve the schools that will provide the well-educated future members of our currently strained -- some would say dying -- middle class.

Here's where my priorities align with the author's: almost in every respect. I admire teachers (was one myself for twenty years), I've never thought our public schools are failing (in an environment of high immigration we've actually been holding our own), though I understand the giant disparities between schools in affluent neighborhoods and poor, often urban ones. I've always viewed with suspicion and alarm the move toward constant testing (as a way to determine either teacher competence or student achievement) because it's caused us to spend far too much time on reading and math to the detriment of music and the arts, as well as history and social sciences. I feel the humanities help develop the whole child and, as studies have shown, actually improve that part of the brain that supports critical thinking, the imagination, and visualization skills that open the door to understanding math and the sciences.

Reading, and language in general, by the way, is taught more in the home than anywhere else, a sad fact in that homes mired in generational poverty will produce a steady stream of language-challenged underachievers who will rarely outperform their lucky counterparts on the "good" side of the tracks.

So I'm ready to endorse the proposals of Gary Gutting. Let's put our educational institutions on a sound economic footing, develop an army of humanist educators ready to support the growth of the whole child, get the colleges ready to take our kids on the last journey to adulthood ready to participate in a cultural world, not merely a business-oriented one, and let's have our schools support sports in the context where they belong, one of growing healthy human beings, not as a disproportionally funded training ground for the lucky few who make it to the professional level.

A final point: How many of you grew up in this culturally interesting middle-class world? I sure did, and it sure existed all around me in the 50s, 60s, and 70s when I grew up. Maybe I was just lucky to grow up in one of those households that taught me, in the natural course of living, all the vocabulary I'd ever need to succeed in school and eventual careers. Along with that, I was inculcated with an appreciation of the varied tapestry of life, music, and the arts, not to mention political thought. So were most of my friends in my decidedly middle class neighborhood. We grew up ready for life. What we did with it was something else. Some of my friends turned out to be losers, some turned out, literally, to be rock stars. Others, myself included, have led successful lives, with more or less creativity and individualism in the mix.

Why wouldn't we want to sustain or improve on that world? I certainly would, and I hope our government, on all levels, recognizes the need to grow culture and not stomp it into the ground because we can't afford it. We can't afford not to have it. It's what makes life worth living.

Spend as much on literature, music, and art as football? Why not?