A Shiny, New Health Care Machine

When President Obama signs the new health care bill into law it will be a historic day for all Americans. The enactment of the Health Care Reform bill will mark the day when another great step was taken to relieve many Americans of the responsibility of providing for themselves, their loved ones, and their neighbors. Because the federal government will take up the task of ensuring access to health care to those unable, and in some cases unwilling to provide it for themselves, many Americans will now be able to go about their business feeling less encumbered by the obligation to help others less fortunate than themselves; or feel burdened by the ill luck of others. Paying one's taxes will be enough to alleviate the conscience of many. Scrooge, no doubt, would be relieved. It will also mark the day when health care ceased to be simply a social, moral, and financial issue, and became an officially political one. The struggle over health care has in many ways only just begun. Many concessions were made and issues ceded. Those issues and concessions will be revisited. Many battles will be fought again. Neither will the dikes erected to contain and limit government control over health care endure for very long. The struggles over health care will outlast us all.

Additionally, many businesses face the new year with trepidation as they try and figure out how the new health care law is going to affect them and their bottom lines. The costs are not clear yet, but for many businesses, those costs will be significant. Many workers employed by those businesses, if they are not apprehensive about their futures, should be. More than a few of them will lose their jobs because their employer will be reluctant, unable, or unwilling to afford the costs of keeping them. Many that don't lose their jobs or suffer a cut in hours, if nothing else, should be pessimistic about their prospects for a raise. Still others will not get a job because businesses will not be able to afford the costs of hiring them. Some businesses will no doubt have to shut their doors.

The costs imposed by the new health care law will be difficult to bear in these hard economic times: a situation now less likely to improve any time soon. More significantly, the expense imposed by the new health care law will have to be borne each month and each year by businesses as long as they are in business. While businesses may be able to plan for the future, they cannot know the future. Whatever the new year brings, their health care costs will not go down, but most likely go up. The easiest way to reduce or control those costs will be to shed workers or cut hours. The second easiest way will be not to hire any new workers.

A shiny new machine now exists in Washington and many are looking forward to seeing what that machine can do. Many on the left believe that the new machine belongs to them. It doesn't. They should start preparing themselves for the day when that machine is no longer under their control.

U.S. Inc.

With the passage of the health care legislation all but assured, it must be concluded that it has been a good year for the CEO of the United States. Although the U.S. is in the red, it has made a number of impressive deals and acquisitions. It has acquired controlling interest in a major automobile manufacturer and secured seats on the boards of others. It is also on the boards of several large banks and investment companies. If things go according to plan, it will soon gain partnership in a great number of hospitals and clinics all over the country and establish the largest health insurance company in the nation. The future looks bright for further expansion and acquisitions.

There will be no dividends for stockholders though. The company did not make a profit this year. Not only did it fail to make a profit this year, the company has failed to make a profit for many years. In fact, it has lost much more money than many had expected and is expected to loose even more in the years ahead. The company does not expect to make a profit anytime soon. This is not an issue of particular concern to the board however, or the stockholders, because the CEO was able to secure operating capital from foreign investors to fund the company's operation and expansion. The CEO has assured the stockholders that revenues will increase and many of the expenditures will be recouped through better and more efficient management and streamlined operation. There is also optimism on the board and among shareholders that the investments made will pay for themselves, if not generate substantial profits, in the years to come after the turmoil and dislocation of those acquisitions subside.

Fortunately for the CEO, neither the board of directors nor the shareholders are at all insistent on making a profit. Indeed, they don't seem to mind one bit if they wind up losing money on the deals. For some odd reason, many of the shareholders do not appreciate that it is their money that is being spent. They are satisfied to believe that what the company owns, they own. And if losing money gets them an interest in the company's operation, even if only symbolically, they are happy to lose it. And since in theory what the company owns they own; the more the company owns, the more they own. To many that is a thing worth more than money: certainly worth more than other people's money,

By most measures, it has been a bad year or so for the company. There is concern that the company faces a loss in its global market shares amidst growing competition world wide. Profits have declined, and expenditures have increased. The company's operations are in the red. There is tension on the board of directors and the CFO is apprehensive about the books. The Legal division is preparing itself for what should prove to be a busy and contentious next few years. There is also concern that politics will play a role in the company's management and its operations might become skewed due to political favoritism and company politics. But this is not a major concern among the board or the shareholders at the moment. Even with all the financial and legal liabilities the company has acquired, the growing red ink on the books, the managerial hurdles that still need to be navigated, and the dissension amongst the board and shareholders, it cannot be denied that the CEO of the Unites States has had a very good year, if somewhat bruising. Whether it was a good year for the United States remains to be seen.

National Legal Care Reform

When the Health Care bill is finally passed, and by all accounts it will be soon, it is likely that Obama and Congress will begin a search for a new dragon to slay. Perhaps after bailing out the economy, providing cars, jobs, and quality, affordable, health care to all Americans, (I am still waiting on my government funded girlfriend), they will see fit to embark upon a campaign for legal care reform.

Like health care, the vast majority of Americans have access to at least a minimum of legal service. When someone is ill and cannot afford to see a doctor, or visit their local health care clinic, they can go to the emergency room. There they are assured they will get at least a semblance of medical care. When someone is arrested or accused, they have access to legal care. If they cannot afford an attorney, one will be provided for them. A public defender will provide at least a semblance of legal care. Like health care, at least until the Health Care Reform bill becomes law, and most likely even after, the quality of legal care one can obtain is predicated on how much one is able to pay for it.

Just as there are horror stories regarding the slipshod health care sometimes provided to the poor and uninsured, there are horror stories to be told concerning the slipshod legal care received by the poor and those unable to pay. People sometimes die due to the poor health care they receive. People, in Texas at least, sometimes die due to the poor legal care they receive. The wealthy provide themselves legal insurance by keeping attorneys on retainer. Though the vast majority of Americans cannot afford that luxury, they should at least have the right to consult an attorney and have adequate, affordable legal care when they need to, rather than just when they are arrested.

For a long time the quality and availability of health care to the poor and uninsured was deemed adequate. Recently, that care was deemed to be not only inadequate, but unfair. It was decided that it would best for everyone involved if all people had access to the same quality care as that available to the insured when injured and ill. The theory is that providing basic health insurance to those heretofore unable to obtain it would be the responsible and ethical thing to do. More importantly, we would be a better, healthier society due to the care that health insurance would be able to provide. We would also be a wealthier society, if only in a manner of speaking, from all the money that would be saved through the practice of preventive medicine by creating and maintaining a healthier public.

The same logic can be applied to the legal industry. In criminal cases, an attorney will be provided if one is unable to afford one. Little is said about the quality of the legal care a court appointed attorney might provide. Only competency is required, not quality or enthusiasm. In that sense, there is little difference between a court appointed attorney and an emergency room. If anything, the quality of care provided in an emergency room often exceeds the quality of service provided by a court appointed attorney. A doctor will often work harder to keep an uninsured patient alive than a public defender will work to keep an innocent client out of prison. This is a disparity that should not be overlooked. Like health, liberty is one the most important things a person can have and one of the most terrible things to lose.

In civil cases, those unable to pay for legal representation can at times rely upon legal aid or pro bono work by civil lawyers. But in neither does one choose the lawyer he wants to represent him. One takes whomever he is fortunate to get, if one is lucky enough to get anyone at all. The truly lucky ones get a lawyer motivated by the case and interested in achieving justice for his client. The less fortunate may get someone who is merely satisfying his or her state bar requirement.

While even the best of lives can be diminished due to poor health, they can also be diminished by the lack of liberty and poverty. In the mind of a citizen, the choice between illness or injury and bankruptcy or incarceration would be an unpleasant one to make. Just as people have suffered, and even died due to the poor and unenthusiastic care hospitals sometimes provide to those unable to pay, many innocent people have been imprisoned and impoverished due their inability to afford good legal care. Many others have received sentences that could have been significantly reduced if they had received quality legal care. A few in Texas might be alive today if they had had better legal representation.

In regards to civil cases, the disparity between the wealthy and the poor is even more pronounced. While, depending on one's perspective, the stakes in civil court are less than those in criminal court, that does not mean they are not important or even vital to those involved. Many risk houses, children, livelihoods, and more in civil cases. Losers in civil court may not go to jail, at least not immediately, but they risk being impoverished, deprived, and severely burdened. The quality of legal care available to the average individual in civil court by pro bono attorneys and such groups as Legal Aid is dwarfed be the legal care available to the wealthy. Wealthy plaintiffs, if they cannot outright crush their opponents, can chisel them into submission. Moreover, the better the legal representation, the better the odds of victory. The prospects of the poor in a civil suit are slim indeed unless there is the possibility of a settlement large enough to attract a quality attorney. It is true that the wealthy sometimes lose in court. It is also true the wealthy sometimes die in the hospital. But whether one is going to the hospital or going to court, it is indisputably better to be rich.

Another benefit of providing free legal care is that it would greatly mitigate the acrimony, frustration, and bitterness that frequently leads to violence by those who feel they are being strong armed, cheated, and ignored. The possibility of mediating and litigating disputes that free legal care would provide would go a long way towards reducing the baleful temptation to take matters into one's own hands; an act that often leads to crime. Crime in turn costs money. If nothing else, free legal care might reduce traffic in emergency rooms as well as lighten Judge Judy's case load.

Just as the benefits of liberty can be undermined in the presence of ill health, the benefits good health can be undermined in the absence of liberty. Why would a just and compassionate society allow this disparity to exist? Why would a society so sensitive to the travails of the medically uninsured be so indifferent to the suffering and misery that inadequate legal care causes today in the U.S.? Perhaps it is simply too soon to ask the government to address every disparity and injustice in the U.S. It might also have something to do with the fact that there are many more lawyers in the country than there are physicians.

I suspect that if we had fewer lawyers on Capitol Hill and more doctors and health care professionals, we would be having a very different discussion about how to keep health care costs down and extend medical care to those unable to afford it. Who knows, we might even see the issue of tort reform revisited. Malpractice law and the need to carry malpractice insurance are huge burdens on the health care industry; one that is passed along to health care consumers. Because we have so many lawyers in Washington, the chances to reduce health care costs by removing or lightening the myriad of financial and legal burdens the health care industry has to bear is unlikely at best. We can always hope that because we have so many lawyers in Washington, we have a decent chance of getting tort reform or a national legal care bill introduced. But because we have so many lawyers in Washington, it is quite unlikely we will never see any such bill passed or even proposed. If nothing else, it would be fascinating to see the response of the legal profession to a government attempt to coopt it.

The Cost of Favor

As the vote over national health care looms in the Senate, a list of concessions made to secure votes from senators and the support of interest groups and industry was published in this morning's Dallas Morning News. Blue Cross Blue Shield of Nebraska got an exemption from the annual fees proposed in the legislation. Also in Nebraska, a physician owned hospital was exempted from the annual "fees" that will be charged to future hospitals. Senator Baucus, D-Montana, secured exemption for 2,900 residents of Libby, Montana allowing them to sign up for medicare. Senator Dodd, D-Conn. made out better. He was able to obtain $100 million for a new hospital in his state. Senator Mary Landrieu, D-La., made out equally well, securing $100 million in federal money for her state. Senator Bernie Sanders, I-Vt., who provided a key vote on the legislation, perhaps made out best of all. He was able to obtain $10 billion for community health centers in his state. The list goes on, and the total goes up.

Interest groups also made out well. Longshoremen were able to obtain protection from new taxes proposed on high risk professions in exchange for their support. Bio tech drug manufacturers won a 12 year exemption from competition, as well as protection from cheaper, generic foreign drugs: an odd concession for a bill that its supporters claim will lower the cost of prescription drugs. Many other exemptions, tax breaks, and loopholes for various industries and professions given to secure their support lay obscured in the Health Care Bill under consideration.

Clearly, votes are not cheap in Washington. Neither is support from industries and professions affected by legislation. It sometimes takes a lot of money to get people to do the right thing. It sometimes takes even more money to get senators to do the right thing; especially if the right thing is a matter of contention. There are many professions where people are paid incentives for their favor: some respectable, some not so respectable. It is disturbing to think Congress is one.

It would be wonderful if someday Congress decided to publish an addendum with each bill after it became law. The addendum would itemize the costs and outlays, if any, of securing the votes of the individual members who supported the bill. It would certainly make for interesting reading as well as help posterity understand the sometimes quixotic behavior of congressmen.

Health Care Pyramid

It was reported that health care legislation was advanced in the Senate and that a vote will be held shortly. It is hoped the vote will occur before Christmas. It is anticipated that the bill will pass. Some in the Senate no doubt feel that its passage will be a welcome present to their constituents. If nothing else, it will give them a little time off. A host of last minute amendments and deals have made the final vote possible although they have created a maze of compromises and amendments guaranteed to ensure that the issue will be revisited often in the future.

The House and Senate bills still must be reconciled, so the deal is not quite done yet. Both bills would compel almost everyone to possess or purchase some form of health insurance. The House bill requires coverage individually or through an employer. The Senate bill simply threatens people with increased taxes if they choose not to purchase insurance. Neither bill would deny coverage or increase premiums due to pre-existing conditions. This is because the government has the luxury of not needing to make a profit to stay in business. Private insurance companies do. Requiring them to insure people almost guaranteed to generate a loss essentially amounts to a tax on insurance companies. The House bill would require businesses that employ more than 50 employees to pay $750 per employee if the government opts to subsidize coverage. What the costs would be if the government does not subsidize coverage is unclear. Congress will also squeeze business by collecting fees from those that receive government subsidies. Presumably those that do not receive government contracts or subsidies will be similarly compelled, if not now, then in the future.

The Senate bill would raise income taxes, and coerce $20 billion from medical device manufacturers. It will also compel individuals and small businesses who do not have, or pay insurance, to get it or face fines. Like the Hose bill, small businesses with more than 50 employees will have to pay a "fee" of $750 per employee. They too, face penalties should they choose not to comply. Like feudal lords of old, the government will charge fees from those who would ply their trade on its land. It would be extraordinary if those fees were not passed along to consumers: just the thing for a sagging economy.

Both bills compel individuals to acquire insurance themselves or through their employers or be fined. In the House bill, everyone would be required to obtain insurance or pay a penalty. The penalty proposed is 2.5%. It can be assumed that penalty will go up: taxes and fines always do. The "very poor" can obtain wavers. But, since poverty is a moving target, the costs of providing wavers will shift over the years. For a bill that is claimed to be demanded by the public, it contains an awful lot of compulsion, fines, and threats.

Many other issues and items need to be reconciled, such as coverage for elective procedures, abortion, and illegal immigrants. None of those are issues that will be resolved in any meaningful sense of the word. They will cause headaches for generations to come. If Congress decides to extend coverage to illegal immigrants, it can be expected that it will be an expense that will only increase in cost since it will provide still another incentive for people to sneak into the country. Interestingly, though illegal immigrants will not receive coverage under the health care bill proposed by Congress, they will be not be pursued. As their numbers increase, so will the demands that they receive some kind of coverage. That care will have to be paid for by someone. If nothing else, providing coverage will help the clinics and hospitals that treat them to recoup some of their losses as well help guarantee job security to those who make a living advocating for immigrant rights.

The complexities of both bills is staggering. It is unlikely that there is anyone in Washington who understands them in their entirety. Both bills will cost hundreds of billions of dollars, which makes the fact that so few, if any, understand every thing in them all the more troubling. What is consistent in both bills is the effort to strong arm the private sector into making good on the government's promise to provide health care for everyone. National health care may be portrayed an an issue of justice or fairness, but it is also a political and social liability rife with coercion and opportunism that will be haggled over in perpetuity.

There is a misapprehension by many that the government will provide free, or at least "affordable" health care. The bills under discussion do nothing of the sort. Health care will cost billions. Raising taxes on the "rich", and levying taxes, fees, and penalties on business may obscure the costs in the mind of taxpayers, but it does not reduce them. Trillions will be spent on health care. That money will need to come from somewhere. It would take an economic recovery of near biblical proportion to increase tax revenue enough to compensate for the cost of everything being proposed in Washington. If tax revenue does not increase sufficiently, taxes will have to be raised or the money borrowed. Spending could be reduced, but that is the least likely option. What is certain is that the American public is going to pay for national health care one way or another. If we don't, our children will. The Chinese are not going to pay for it. They might loan us the money, but they are not going to pay for it.

The ardor with which the president and his supporters in Congress are pursuing national health care is alarming. It is almost as if they fear that if American people think too long about it, or examine it too closely, they will change their mind. But if the bills are sound, they should be able to withstand scrutiny and debate. Moreover, if there is a genuine demand for health care reform, as is being claimed by many in Washington, that demand will not ebb over several months, or even a year. The country has persevered for a long time without national health care, it should be able to last a few more months, even a year or two if that is what it takes to produce effective and desirable legislation. The zeal for its quick passage indicates an impatience out of place for so important an issue.

The ancient Pharaohs built magnificent pyramids as monuments to their greatness and to ensure they would not be forgotten. Over the years, many presidents have sought to create monuments of their own. Presidents such as Theodore Roosevelt, Woodrow Wilson, LBJ, and FDR, have sought to create testimonies to themselves and enshrine their names in history. To simply execute the law and defend the Constitution is no longer enough to satisfy the ambitions of those who would be president. They must have a pyramid. Clinton failed in his effort to build a pyramid. Obama is determined to succeed with his. It is likely he will succeed if only because so many people want a new pyramid. And if one is to be built, many in Congress want their names inscribed on it.

I only hope national health care works as Obama says it will. I am starting to feel ill.