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The President Misleads, Again, On the “Government Option”

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The “Government Option,” if part of the radical overhaul of American medicine that is being pushed by the Obama/Pelosi/Reid wing of the Democratic Party, would quickly become the dumping ground for every private sector employer who is tired of paying the health care costs of his employees. I explained this at length in my column this week, and nearly every employer I talk to confirms that the moment a “Government Option” is put into place, they will look at it as a way of offloading the spiraling costs of employee health care.

With that inevitability in mind, read the presiden’ts comments to CNBC yesterday:[# More #]

We’ve said that if you’ve got a plan in the private sector that you’re happy with, you’ve got a doctor you’re happy with, you keep that person. We are not going to be messing with that. What I have said is setting up a public option that would compete with the private sector, but, if it was offering a better product, would give a additional choice to consumers, that’s going to keep insurance companies honest. Now, I understand why insurance companies wouldn’t want it, because if they’re making huge profits and there’s no competition, then why wouldn’t they want to keep that? I understand it, I’m sympathetic. But I think the average American says to themselves, `Why is it that all these members of Congress, including all the Republican members of Congress, they have essentially a public option, they essentially have the ability to look at a menu of choices and exercise those choices; why shouldn’t ordinary Americans have that as well?’ And I think that that kind of approach is sensible. But what I’ve also said is let’s just make sure that, you know, we’re open-minded.

First, the opening statement is simply false. The vast majority of Americans with employer-provided health care don’t pick their insurance plan or at best they pick from aong a limited set of options provided by their employer. Millions of them will be forced into the “Government Option” if it is established, and thus the president’s promise is just flat out untrue.

Second, there is huge competition among health insurance plans right now. Just look at the number and types of plans offered by brokers around the country. There is intense competition between these private firms. Once a “Government Option”exists that private sector competition will be crippled as the subsidized “Government Option” draws huge numbers of employers to it, draining clients from the private plans, pushing them to the brink.

Finally, contrary to what the president said and must know to be false, the “members of Congress” don’t have anything like “essentially a public option.” They have the Federal Employees Health Benefits Plan, which is a subsidized benefit of huge value that allows an annual selection by every federal employee of any of the scores of competing health care plans open to enrollment, regardless of pre-existing condition. What the members of Congress have is a subsidy and a guarantee of acceptance into any plan they want. That’s not the “Government Option” being offered up by Obamacare.

How can you trust the president on anything he says about health care when so short a passage as the one above contains such extraordinary whoppers?

By way of contrast to the president’s froth on this subject, here’s a detailed and sharp analysis of our situation which I received yesterday from Dr. M.E. in North Carolina. The health care delivery system is not efficient, he notes, and for the variety of reasons he details. But the “Government Option” will indeed make it much much worse:

Dear Hugh:

Thank you for the opportunity you have presented over recent weeks for my colleagues and me to express our concerns about the deeply misguided efforts and intentions of our national government in the area of health care. Our jobs are all about balancing risk and cost against potential for benefit, and over time our habits become so ingrained that we apply the same thinking to outward communications. If you want to hear from doctors what they think on an issue you must provide them a low cost, low risk chance of at least a moderate degree of benefit (food helps, too). A note which might help to mold the perspective of such an esteemed and skilled spokesman as yourself, as well as your readers and listeners, is such a chance.

So here I am, a family practice and emergency medicine physician in a small North Carolina town, writing out one doc’s point of view. Like most of my colleagues and co-workers, I am anticipating a turn for the worse should our current national executive and legislative leaders get their hooks further into our health care industry. It seems to me a tremendous fantasy on their part to suggest that the significant problems with which we currently struggle, problems which have been substantially created by government intervention, will somehow be resolved by more intense government intervention. But I suppose that is the essence of the liberal mindset.

We ought to start by considering some common ground. All of us-health care professionals, researchers, hospital administrators, politicians, and the general public-want everyone to get all the quality health care service they may ever need. In addition, we want them to get that service from skilled, intelligent, enthusiastic, visionary and ethical professionals who are diligently committed to the highest standards in all that they do. We want our facilities to be perfectly clean and modern at all times, containing only the latest and best equipment. Record-keeping should be completely accurate and private. Medical research should continue at the maximum possible rate and intensity so as to avoid any delay in the accumulation of our knowledge and refinement of our therapies.

The fact is, however, that we, as a culture, have already made a tacit commitment to these goals and standards without making any plan to pay for the effort. Most of my patients and their families do not only hope for the best possible care regardless of their personal resources-they expect it. As a people, we have little or no tolerance for any behavior by health care professionals which we deem to be even slightly beneath the ideal. I’ve had patients complain about the presence of a fly or spider in the exam room as though such a finding indicates a low standard of cleanliness in our facilities. The complications and near-impossibility of maintaining completely accurate and private medical documentation during ongoing management of a patient’s needs are largely ignored-it must be done!! Any appeal to the expense of high-quality, ethical medical research as an explanation for the cost of drugs or equipment is fruitless-we’re talking about lives and health of real people, not business!!

Regardless of our preferences, rational thinking obliges us to accept limits to what we can provide in this work. We simply cannot afford to fund the ideal system that is our goal. Isn’t that patently obvious? All the players in the current system-patients, their caregivers, facilities, healthcare professionals, government, researchers, etc-want or need more money (a lot more money) to get us closer to the ideal, and the groups paying the bills (employers, insurance purchasers and, of course, American taxpayers) are already spending more than they want to or can afford. As a nation we cannot fund a “right” to unlimited health care for all and our current attempts to do so are, economically and socially, nothing but a big pair of concrete boots.

Such thoughts raise the concept of rationing. No one likes to think about rationing the public support for health care, including doctors, but it has been, is and always will be a necessity. The real point of the debate is not whether to ration, but how to accomplish rationing that gets us as close to the ideal as we are willing to afford and that does so without limiting each individual’s ability to provide for his own needs. Right now we ration by the perverse whim of economic opportunity: Joe qualified for disability years ago and pays no taxes but he gets, on the public dime, an MRI, orthopedic evaluation, replacement of his bad knee and months of rehabilitative therapy so he can maintain his mobility. Fred, on the other hand, works fifty hours weekly on two knees in worse shape than Joe’s, pays a quarter of his income in taxes (in part to fund Joe’s knee replacement) and won’t even see his family doctor for help because his employer provides no meaningful health insurance benefit and he knows he cannot afford anything beyond a primary care office visit. Fred is glad that Joe got the care he needed, but he still can’t walk very well and will likely lose his job eventually when he can’t keep up.

We doctors (and others intimately involved in health care) know that there is a great disparity between the public perception of medical decision-making and its reality. We want to believe that every doctor-patient encounter revolves around some pressing, sincere medical need and that the problem with our current system is a common lack of resources and infrastructure to help the doctor and patient properly address that need. Though I have certainly been involved with many cases in which reasonable patients and their families are struggling to find the means to obtain significant and necessary medical care, it is much more common to be confronted by needy, demanding patients (and their families) who insist on expensive evaluations and therapies which are unlikely to benefit their minor, non-medical problems and for which they will pay nearly nothing. Though it would be difficult to prove by rigorous study, I strongly suspect that the majority of patient visits to Emergency Rooms and primary care offices across our country would not be made if patients had personal control and responsibility for even a quarter of the money involved, even if they could afford the expenditures out of their own pockets. At the same time, those who must pay all of the expenses of their own care due to lack of coverage routinely get by with little or no medical attention until their conditions resolve under their own management or become severe, disabling and even life-threatening.

These messy injustices, which we physicians see constantly, are the predictable product of our national government’s increasing interference over decades in our people’s provision of a basic good for themselves-personal health care. Our current system of health care may not be run by the national government but it certainly is dominated by it, and the inequities and inadequacies of the system can largely be blamed on the regulatory, bureaucratic, legal and financial influences and controls of that entity. We have ample evidence that the government is lousy at distributing our resources toward health care in a reasonable and fair way, and we should not be surprised: Government leaders are highly motivated to give their constituencies what they want, and what they want is more health care. The only way government can attempt to provide this is to spend more money or to require that providers do more for the same money, hence the acceleration of financial outlay and the proliferation of regulations and controls over recent decades. Unfortunately, both these efforts are manifestly incapable of producing what we really need: High-quality, low-cost health care distributed as widely as we can manage and afford.

So, if the government should be extracted from the driver’s seat, who should take its place? If we cannot depend on a “government option” to meet our medical needs, on whom should we depend? What do we do to preserve the good qualities of our health care system while solving the problems?

First, we must reject the sentimental (and unconstitutional) notion that we have a “right” to health care. We should acknowledge that we don’t want to abandon those in need among us, and we should make the best provision for them that we can, but we must stop pretending that we are willing and able to supply whatever it takes to meet whatever needs may develop. We have to decide how much we are willing to spend via the public coffers then spend it as wisely and fairly as we can manage.

Second, we must recognize that no one will ever be in a better position to make health care decisions than the patient with help from his doctor and family. Standards can be set and should be respected based on our best knowledge at the time, but ultimately we must confine the authority and responsibility of medical decision-making to this small circle.

Third, we must never underestimate the importance of a solid connection between the decision-maker and the cost. The worst abuses in medicine take place when those choosing methods of evaluation and treatment are separated financially from those paying the bills. Both patients and providers can be guilty of gross waste in the management of medical problems when they experience no financial consequences for coverage of the options. Indeed, this is one of the principle pitfalls of government involvement: The government frequently formulates programs which sever the link between choosing and paying for a service, typically in the name of a “right” to health care and with an erroneous assumption that patients and their providers will only do what is truly and clearly necessary. Wasteful practices then run amok and the taxpayer is stuck with the bills.

Combining these three requirements would lead to a system in which we, as a people, choose to set aside resources for funding of health care needs at a level commensurate with our ability and willingness, distribute the funds amongst ourselves in some equitable way and then allow individuals and families to spend those funds for health care expenses in whatever manner they deem appropriate. This would allow for public support of health care while preserving a connection between decision-making and financial responsibility as everyone would understand, better than they do now, that the support offered is limited. By this method everyone could have opportunity for basic preventative and illness care, we would encourage individual initiative in the acquisition of additional coverage from the private sector, and politicians would be motivated by pressure from their constituencies to minimize any government interference which increases cost while providing little benefit. Doctors and hospitals would also be incentivized to provide high quality care for low cost as patients would be more discriminating about how they spend their limited public and personal financing. Most importantly, we would all be more inclined toward wise and efficient use of services while at the same time taking better care of ourselves and our loved ones so as to reduce our need for health care.

Many will likely object to all this thinking on the grounds that refusing a “right” to health care and establishing limits for the public contribution to an individual’s medical needs will require us to say “no” to sick people. While such an objection confirms an accurate understanding of the situation, it also serves to illustrate the basic problem we face: We want everyone to have every medical service they might ever need, but our willingness and resources are limited. As wealthy, skilled, knowledgeable and well-intentioned we may be, the American people are not God and we must seek out the most efficient and effective means possible for delivering our limited support. The fact is that we are saying “no” to sick people all the time right now-we’re just doing it in an unreasonable, unjust, frequently accidental and random fashion which helps us to ignore and avoid our responsibility for the situation but prevents us from advancing toward our health care goals as a nation.

These “reforms” described above will ultimately be necessary to get us as close to our ideal as possible. Consider also that these changes will happen eventually: We can either adopt them purposefully now, or we can wait until ever-increasing government intervention and entitlements destroy our healthcare system and bankrupt our country, at which point they will fall quite naturally into place. Purposeful adoption definitely seems wiser, safer and more American to me.

Sincerely, and with appreciation,

Dr. M_____ E_______


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