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Tuesday, April 5, 2011

Disentangling the House Republican Health Care Budget: Redistribution, Government and Federalism

0 comments Posted by Find Insurance Online at 10:35 PM

There is a saying in politics. “Elections have consequences.” In 2011, the impact of the 2010 election was particularly obvious in that the Republicans had gained control of the legislatures of Wisconsin and Ohio as well as the U.S. House of Representatives. While the governments of Wisconsin and Ohio were going after public-sector unions (or restricting them to reduce government deficits), the House Republicans had their eyes on health-care. Rep. Paul Ryan, an up and coming Republican from Janesville Wisconsin—a town with high unemployment after the auto plant there closed—was producing a budget that he claimed would cut $5 trillion over 10 years. His proposal reflected, or conflated, two salient traditional Republican aims: to shift power from the U.S. Governments to those of the states and to reduce the size of government. These are distinct, albeit not disparate, goals. Shifting power does not in itself imply or mandate a reduction in the size of government. For example, in shifting public health-care policy, an expansion of government could result if enough states develop programs further-reaching than what Congress had enacted. Of course, as per the nature of federalism, particularly in an empire-scale instance, the resulting health-care programs would differ from republic to republic, given the innate heterogeneity that exists at such a scale.

Because restoring a balance of power to a federal system is distinct from decreasing (or increasing, for that matter) the size of government, it is important to distinguish them in Rep. Ryan’s proposal.

The New York Times points to the two aims in observing that “while saving large sums for the federal government, the proposals on Medicaid and Medicare could shift some costs to beneficiaries and to the states.” Shifting costs to the beneficiaries involves or implies a reduction in the size of government, while shifting costs to the states impacts the balance of power in the federal system. It is in the public interest for such items to be distinguished in debate and legislative votes because the people could want one without the other.

Under Ryan’s proposal, according to the paper, “Medicaid would be transformed into a block grant, with a lump sum of federal money given to the states to care for low-income people. States would be given more discretion over use of the money than they have under the current federal-state partnership.” Even though increased discretion adds to the power of state governments relative to the federal, or general, government, block grants maintain state dependence. In fact, if health-care is not among the enumerated powers of the U.S. Government, it could be argued that lump sum payments to the states for health-care are unconstitutional; otherwise, spending for the general welfare would eviscerate even having enumerated powers at all.

Regarding the “size of government,” The New York Times reports that “(f)or future Medicare beneficiaries — people now under 55 — Mr. Ryan’s proposal calls for the federal government to contribute a specified amount of money toward the premium for private health coverage. Under the traditional Medicare program, the government reimburses doctors and hospitals directly.” The “specified amount” element is “less government” than is an open-ended entitlement.

At the time of Rep. Ryan’s proposal, Medicaid and Medicare were open-ended entitlements. Anyone who met the eligibility criteria was entitled to benefits. Under a fixed lump sum, Republicans say the federal government could better predict and control its costs under Medicaid and Medicare, which as of the beginning of 2011 insured more than 100 million people and accounted for more than one-fifth of the federal budget. Unless the states would pick up the added costs (which would shift the taxing and spending federal balance), beneficiaries of these programs would be at risk for more of the costs if health-care costs rise.

Rep. Jan Schakowsky, a Democrat and a former executive director of the Illinois State Council of Senior Citizens, said “Mr. Ryan and the Republicans are declaring war on entitlements — and war on the elderly and the poor. . . . Beneficiaries will end up paying more.” The New York Times also reports that as of 2011, “(a)bout half of Medicaid recipients are children. Nearly two-thirds of the money spent on Medicaid benefits is [sic] for low-income people who are 65 and older or disabled.” For his part, Rep. Ryan said “he was not cutting Medicaid and Medicare, but rather slowing their growth rate. Furthermore, he insisted that if health costs for a group of patients exceeded the federal payment in a given year, the insurer would have to absorb the cost.” Finally, Rep. Ryan “claimed his proposal is equitable because Medicare would pay less on behalf of higher-income beneficiaries, and they would pay more of the cost of their health coverage.”

Whether the beneficiaries or insurance companies pick up the slack, the fact that public funds would not be used means that government would be reduced from what it otherwise would be. Yet if the states pick up the slack, the balance of federalism rather than the size of government would be changed. Moreover, in addition to the size of government (and federalism) elements, the matter of redistributive justice is involved. It is no wonder that these elements are conflated in the public sphere.

I contend that legislative representatives have an obligation to more clearly distinguish the elements of federalism, the size of government, and redistribution in public policy proposals. A desire to shift power to the states can be better distinguished from the questions of redistributive justice and the related matter of the size of government (and latter two can be better distinguished, since, for example, government could be expanded in a way that helps or hurts the poor, for example). Democracy itself would be improved were the people, either directly via a referendum or indirectly through representatives, able to decide on the three elements one by one. In fact, a decision for greater federalism would mean that questions of the size of government and redistribution would be decided on both the state and the federal level.

Click to add a question or comment on the impact of the Republican budget on health-care policy and federalism.

Source: http://www.nytimes.com/2011/04/05/health/policy/05health.html?_r=1&hp

Saturday, April 2, 2011

On the Ethics of Arizona Medicaid Charging Smokers and the Obese an Extra Fee

0 comments Posted by Find Insurance Online at 4:35 AM

MSNBC reports that “Arizona's cash-strapped Medicaid program is considering adding a $50 tax on single patients who smoke, have diabetes or are overweight. Arizona Health Care Cost Containment program spokeswoman Monica Coury says the tax is intended to push patients to take better care of themselves. Coury says the issue is getting at the cost of health care while trying to stretch dollars and get people to take better care. ‘If you're not going to manage those things and take some personal responsibility, and in turn that costs the state more money, then you need to have some skin in the game,’ Coury said. . . . ‘You need to be responsible for the fact that your smoking costs us more.’ . . . State Sen. Kyrsten Sinema of Phoenix says it isn't fair to charge diabetics $50. Sinema says the fee fines people who may have medical conditions beyond their control. . . . The changes are part of a major revamp of Arizona's Medicaid program to find funds to restore transplant coverage — eliminated amid much controversy [in the fall of 2010].”

Ethical Analysis:

Focusing here on the ethical dimension of the proposed changes, I lay aside here the worthy question of whether the proposed changes are the optimal way to restore transplant coverage, or, more generally, to make up the funding shortfall facing Arizona’s Medicaid program. Ethically speaking, Coury’s reference to personal responsibility clashes head-on with Sinema’s claim of the conditions being beyond the patients’ control. Responsibility presumes that the agent has control over that which he or she is to be responsible. It makes no sense, for example, to hold President Obama responsible for the weather (unless the federal government has a top-secret way of controlling and changing the weather over U.S. territory).

In terms of smoking, the question is perhaps whether a drug addict has control of his or her addiction. To be addicted, according to the World English Dictionary, is to be dependent on something. Meriam-Webster’s Medical Dictionary asserts that dependence in turn involves being “unduly subject to the influence of another.” The question is thus whether being “unduly subject to” implies or involves the loss of control as opposed to merely control being more difficult. The qualifier of “unduly” suggests being subject to something excessively, according to the World English Dictionary. This does not signify the loss of control. Therefore, ethically speaking, smokers can be held responsible for their addiction to nicotine even though it is very difficult for them to quit. That smokers have quit demonstrates that those who do not quit cannot fall back on the fallacy that they have no control over their addiction. So to the extent that the smokers cost others, it is ethical to charge smokers more.

With regard to diabetes and obesity, a distinction can be made in terms of control. Losing weight, if only from restricting the quantity (and types) of food ingested, is within a person’s interval of control unless the excess weight if due to a disease and cannot be lost without risking the loss of minimal nourishment and health. I suspect that this qualification is misapplied by overweight people who presume that their “condition” is a result of an illness when over-eating (as well as a refusal to exercise) is the actual cause. Such persons, doubtless the overwhelming majority of obese people, can be distinguished ethically from those whose excessive weight is caused by a disease and cannot be lost without risk to one’s health and perhaps even life.

Apart from the illness caveat, the argument that overweight people have no control over their excess weight is effectively countered by the success that people have had in losing weight. Prima facie, one can reduce one’s consumption even in the midst of a presumed overwhelming urge to eat more. Therefore, it is ethical to hold overweight people responsible for their weight, and thus to charge them more if they cost others more. Diabetics are a more complex case.

Regarding obesity and (the ensuing?) diabetes, it may be that once a patient has the disease, nothing she could do would cure her of the disease. Otherwise, the person’s failure to reduce his weight while diabetic would be a basis for holding the person responsible not only for remaining overweight, but also for suffering from worsening diabetes. Furthermore, if being overweight is necessary for the onset of the disease, the diabetic could be presumed to be responsible for having developed the disease, and thus properly charged more for having it treated. However, to the extent that overweight people do not necessarily become diabetic, it may not be reasonable to assume that an overweight person should have acted to avert what is a mere possibility. In terms of a diabetic’s choices, if losing weight lessens or eliminates the (chances of, or continuance of) the sickness and the diabetic does not lose weight, a diabetic could rightly be held responsible and thus properly charged for the extra cost borne by others.

A few nuances should be made transparent. First, if the charges are not merely to reimburse others for the increased cost, but also to manipulate the “offender” to change his or her ways, it can be asked whether such manipulation is itself ethical and effective. If a person believes that his addiction, eating habits, or disease is a “condition” rather than a result of his choice, then it is unlikely that he would suppose that having to pay more would have anything to do with even a potential change in his “condition.” In other words, a link in the chain of reasoning presumed in the manipulation would not exist for the person to be manipulated. Moreover, manipulation itself may be unethical unless, as in Kant’s categorical imperative, the rational being to be manipulated is treated not merely as a means, but also as an end in herself. If the end includes the patient recovering, this criterion may well be satisfied in Arizona’s proposal. In such a case, the noxious smell of manipulation may still pass the smell test.

Second, throughout this analysis, I have been assuming that the additional charges can be afforded by the patients and/or their insurance companies. If a patient cannot afford the extra fee and still provide for necessities such as food, shelter and obviously health care, as well as incidentals, then a basic human rights factor intercedes and it could be quite unethical to impose the fine/fee. Relatedly, to the extent that Arizona’s proposal involves reducing the number of enrollees in Medicaid, the goal itself may be unethical from the standpoint of the human right to survival, or life.

Third, if smokers and obese people are to be held responsible for their choices in health-care policy, it would be unethical to be selective in leaving out other choices that have negative consequences in terms of health (and cost). Even so, consistency zealously pursued can put the government into all of our lives with the result being that we have lost our liberty. That is, we might ask ourselves whether there is not a slippery slope involved in opening up our various decisions to governmental overview and charges. The imposition itself could be regarded as unethical, especially in a free society. Yet being forced to pay for the egregious choices made by others, such as by smokers and obese people, can also be regarded as involving an unethical transfer of responsibility. Accordingly, it is well and good, ethically speaking, that a society makes judgment calls respecting how far “egregious” extends. Being a matter of judgment and balance, there is no pre-established line in the sand to be sought in making this determination.

In conclusion, my ethical analysis supports the proposition that smokers and overweight people can be held accountable for their smoking and obesity, respectively, and perhaps even for being diabetic to the extent that mitigating the illness is within the patient’s previous or, more strongly, current control. This conclusion is of course beset by conditions. However, they do not deprive my conclusion of its main thrust—namely, that society has an ethical basis, and thus a right, to hold smokers and overweight people responsible for their inherently unhealthy choices by imposing an extra fee for government-supported health-care. To treat either smokers or the obese as somehow simply affected by, rather than as the agents of, their smoking or obesity is to engage in the subterfuge of an ideological agenda in the guise of science. Such a cloak is of course highly unethical.

Click to add a question or comment on the ethics of Arizona public health-care charing patients extra for smoking and obesity.

Source: http://www.msnbc.msn.com/id/42379077/ns/health-health_care/

Thursday, February 3, 2011

TARP Paying Off: But What about the Foreclosures?

0 comments Posted by Find Insurance Online at 9:55 AM

TARP, the “bank bailout,” was the first big issue facing the Obama administration before its roughly $800 billion stimulus plan and its health insurance overhaul that stoked the rise of the Tea Party movement. After supporting TARP, several Republicans lost elections largely because of their votes. For many Americans, TARP is more than a vote; it is a symbol of big government at its worst, intervening in private markets with taxpayers’ billions to save Wall Street plutocrats while average Americans struggle to make mortgage payments. “This is the best federal program of any real size to be despised by the public like this,” said Douglas J. Elliott, a former investment banker now associated with the Brookings Institution. “It was probably the only effective method available to us to keep from having a financial meltdown much worse than we actually had. Had that happened, unemployment would be substantially higher than it is now, the deficit would have gone up even more than it has,” Mr. Elliott added. “But it really cuts against the grain for a public that is so angry at banks to think that something that so plainly helped the banks could also be good for the public.” Furthermore, the TARP could conceivably earn taxpayers a profit. Whatever the final losses from housing, auto companies, A.I.G. or smaller banks, those will be offset by taxpayers’ profits from the big banks that have been the focus of their ire since 2008. Treasury reckons that taxpayers will lose less than $50 billion at worst, but at best could break even or even make money. Its best-case assumptions, however, assume that A.I.G. and the auto companies will remain profitable and that Treasury will get a good price as it sells its corporate shares in coming years.

Anger at fat cats getting bailed out even as they were complicit in the financial crisis has blinded the public to the priorities in the TARP—saving the banks rather than troubled home-owners.Treasury has been ready to use up to $50 billion to help modify mortgages for people facing foreclosure, but its initiatives have been such a failure that little has been spent. Yet little of the protest against the TARP going to the banks has been directed in favor of the home-owners. It has hardly been even considered that a law might be passed to make foreclosures illegal. The right to life, liberty and the pursuit of happiness surely includes the right to shelter. A person’s house should not be treated as a mere commodity of a market, to be transferred at will. In other words, in our blind devotion to the sanctity of contract, we are settling for less security on things that could be considered rights because they are necessary to being able to live. The same problem exists in basic health-care. Do we really want to hang life in the balance? The priorities in TARP are telling for what was relegated. Rather than pointing in jealousy to those who were privileged in TARP, we might have been more concerned about who was left out. So I am not so inclined to celebrate breaking even on TARP—but primarily because the complicit bankers got a windfall that they did not deserve.

Source: http://www.nytimes.com/2010/10/01/business/01tarp.html?_r=1&hp

Sustenance and Property Rights vs. State of Nature

0 comments Posted by Find Insurance Online at 9:53 AM

In the fall of 2010, I heard the following comment on Fox News: “The government should spend more on the war in Afghanistan in order to fight terrorism. The problem is that the government has gotten into entitlements” (e.g. food stamps, public housing, social security, medicare, medicaid). This is distinct from saying that the federal government should concentrate on foreign policy and military, with entitlements being funded and decided by the states. Such a statement would be for federalism rather than about priorities. Too often, it is difficult to discern whether republican office-holders are more interested in greater federalism or a different sense of government in general. The republicans are not saying they want a smaller government, for they want more military spending. I believe the republican vision is for a different sort of government, rather than for a return to federalism (i.e., more of a balance of power/domains between the state governments and the U.S. Government). Republicans believe that government (regardless of the level) exists to fund foreign affairs and war…not to fund poor people. That is, military contractors rather than poor people. I think this political ideology is fairly unique in the world today. Certainly most Europeans in the E.U. view redistributive rights for the basics needed for living as a legitimate part of government. In contrast, many in the U.S. believe that the market mechanism (i.e., resources as commodities produced and distributed by private enterprise) trumps basic needs (as the market does not guarantee that the needs are met, whereas a redistributive sustenance right does). Perhaps the basic question is whether any citizen of the United States should be allowed to go without necessities (basic food, shelter and health-care). In other words, it can and indeed should be asked whether the right to survival (i.e., life) is part of the social contract of the American political society. I suggest that the media and our representatives ought to participate in a sustained debate on this question directly, rather than deviating to particular hot-button issues.

According to James Madison in Federalist #51, “the weaker individual is not secured against the violence of the stronger” in the state of nature. Nor is the weaker secured against starvation and sickness. Life, as Thomas Hobbes writes, is “solitary, poor, nasty, brutish and short” in the state of nature. The social contract undergirding a political society is meant to alleviate the fear of the want of necessities (and self-defense) while working for the happiness of the members. In other words, there is a right to shelter, food and medical care in a social contract that takes its members out of the state of nature; otherwise, the society is marginal as an answer to the insecurity that exists in the state of nature.

Therefore, I contend that those Americans who want to extend the Bush tax cuts for those making over $200,000 and cut unemployment compensation are essentially enabling their greed to compromise the social contract. If that contract is weakened and some members of society placed back in the state of nature, then it is important for the wealthy to realize that their own right of property is based on that social contract. In other words, cutting off food and shelter for others may free them up to take your property, for they are no longer protected by the social contract against the state of nature. If sustenance as a right is abridged, then so too is the right of property, because neither sustenance nor property is guaranteed in the state of nature.

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