Matt Evans: Are You Comfortable With A Fully Private Health Care System?


The news about Donald Trump suddenly got quieter, somehow, after he admitted that he wants a national healthcare system that is more socialized than Obamacare.

One would think that, at this point, Trump’s popularity would nose dive.  After all, Republicans say they hate Obamacare.

A big frustration I have with fellow Republicans on their criticism of Obamacare is that few of them can articulate specific things they would do differently.  Republicans conceded the principle – that government should be in the healthcare business – a long time ago.  They’ve been moving towards more socialized care ever since.  The reason their resistance doesn’t inspire Americans is because they’re not offering a concrete alternative.  A lousy plan that actually exists usually gets chosen over a really good set of ideas that nobody has actually organized into a plan.

That’s just how government works.

Let’s look at the pre-Obamacare reality

  • Over half of all hospital revenue came from Medicare or Medicaid payments. In other words, over half of hospital care in the USA was already socialized care.
  • In 1986, President Reagan passed the EMTALA, which required any Hospital that received Medicare dollars to provide free emergency room care to anyone, regardless of ability to pay, immigrant status, etc. By the way, this treatment is not compensated in any way. Hospitals just have to suck up the costs.

In a recent year, 55% of Emergency room care went uncompensated, e.g., the hospital and physicians providing that care simply never got paid for it.  However, overall, only about 6% of hospital treatment goes uncompensated.  In other words, Emergency Room care tends to be a small (<15%) percentage of overall hospital costs.

A continual problem with government is wrecking big things when trying to mess with small things.  In order to go after a tiny chunk of uninsured people, the ACA wrecks insurance for everyone.

(my employer sponsored insurance costs me more and pays out much less, and is a much bigger hassle to deal with on a day to day basis than it was in 2012.  My employer self-insured and provided me with a “Cadillac” plan.  That’s one reason I took that job 15 years ago.  Now all that is gone.  Thanks, ACA)

The statistic that over half of all emergency room care is uncompensated sounds alarming – until you realize what a small percentage of overall hospital business comes from ER care.  People have often said, “you already have socialized care because you’re paying for ER visits for people that have no health insurance”.

Well, in a sense, that’s true.  But the much larger aspect of socialized care in this country, by volume, is Medicare and Medicaid – which no Republican plans on getting rid of.

So, let’s be honest.  Everyone in the GOP seems to be supporting some degree of socialized care.

So what’s an alternative?  What would a fully private health care system look like?

Well, by fully private, I mean we’d need to get rid of Medicare, Medicaid, and EMTALA.  And of course, Obamacare.

I’m comfortable with that.

And replace them with what?

How about: absolutely nothing.  Or better yet, how about: whatever you want, at the local, state, or voluntary level.

I’m comfortable with that too.

For one thing, the federal government shouldn’t be doing any of these things to begin with.  Like ACA, this stuff has been found constitutional only under executive threat, but nobody actually believes this stuff is or should be within the federal government’s enumerated constitutional powers. (A lot of people _want_ it, but nobody credible actually thinks any of it fits with the intent of the constitution)

But we’d need to go further than just dismantling those programs.

About the only good thing about ACA is that it makes it easier to get health insurance that isn’t tied to your employment, and makes it easy to keep that health insurance when you switch jobs.

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#ffffff” txt_color=”#000000″]A lousy plan that actually exists usually gets chosen over a really good set of ideas that nobody has actually organized into a plan.  [/mks_pullquote]

Employer-sponsored health care is also a problem government created.  The democrats put in wage-freeze laws during WW2, meaning that to compete for labor, industry had to find non-wage based ways of attracting (and keeping) employees.  This is when large companies started offering health care benefits to employees.  A few decades later, apparently as a handout to large businesses, government made such health care arrangements tax-preferred, both for business owners and for employees.

So if we wanted to really get government out of health care, we’d also change the tax laws that prefer certain healthcare and employment relationships over others.

Finally, if we wanted to get the government out of healthcare, we’d open up the supply of potential health care providers by relaxing (or removing) government licensure of who may practice what aspects of medicine.  There are all kinds of insidious costs associated with providing, and thus receiving, medical care.  For instance, in some places, if you break your glasses, you can’t buy another identical pair without having another eye exam first.  That’s a canonical example of occupational rent-seeking, and there’s no reason to keep laws like that on the books.

Many of these rules are state laws, and not federal law.  For instance, state law nominally controls who may or may not practice medicine in a given state; there doesn’t appear to be any federal regulation of who can and cannot be a medical care practitioner.

And this is encouraging, because the Jeffersonian model of national government was that each state would be its own experiment in self-governance.  If the citizens of Oregon really want socialized care, they should absolutely do it – for their state.  If the citizens of Wyoming want no government safety net of any kind, they should have the freedom to make their laws accordingly.

North Dakota, for its part, has a fair bit of rural populism left, and some people-focused socialism.  I could envision North Dakotans having laws that say anyone hurt doing agricultural work gets put back together, regardless of ability to pay, and that the state pays for it.  If that’s what the voters want, and the state constitution allows for such a thing, great, let’s have that law.  South Dakota and Minnesota are just a few minutes away…

Regarding national law – anytime someone makes the case for stopping a federal program, folks retort with various predictions of gloom and destruction.  Ending the federal tanning salon means-testing program (I hope I made that up), they say, would immediately turn the whole country into a Mad Max movie.

Of course, they are wrong, and that is ridiculous.  The national health care “system” I described was precisely the law of the land for most of US history.  Obamacare is only a few years old.  EMTAT is 30 years old.  Medicare and Medicaid didn’t exist until 1965.  Was the United States a third world country in the 1950s?  Many Americans of all political persuasions think the 50s and 60s were one of the greatest periods in US history.

In fact, if you look at life expectancy for American white males in the 20th century, you see that the majority of life expectancy improvement is in people who don’t die early.  While the aggregate life expectancy (the age an infant could hope to make it to) has increased dramatically from Age 47 to Age 75, that data is heavily biased by people who died very early in life.  Once someone makes it to 65, in 1900, they’d on average live an additional 12 years.  In 2000, they’d live, on average, an additional 16 years.  Additionally, the majority of the life expectancy gains happened before 1960.

So the point is, we could eliminate Obamacare, Medicare, Medicaid, and, EMTALA, and we’d only be “rolling back” to the federal legal climate of 1965.  And furthermore, even if we think those programs are responsible for 100% of life expectancy gains in the last 50 years (which, of course, they are not), there’d actually be almost no change in life expectancy.

So, to review, the current Republican front runner’s plan for dealing with Obamacare is to give us something more socialized than Obamacare.

No thanks.

Give me the federal healthcare laws from 1950, please.  America in 1950 wasn’t a Mad Max movie; it was pretty fabulous.  I want the medical technology from today, but I want the personal attention, affordable costs, lack of meddling from big Pharma, lack of meddling and profiteering from giant HMOs, and total lack of federal involvement we had back then.

Would that really be so bad?

Wouldn’t this be a more Republican position than whatever crazy hand-wavy thing Trump is suggesting?