The President has spoken to the nation several times on health care and he has insisted on a great many things. Most recently he assured us – we the people – that his health care plan won’t increase costs, it won’t threaten senior citizens, will not result in rationing of services, and will not include anything for those in the US illegally. Since we will all one day be senior citizens, let’s discuss the issue of senior care; specifically, the idea of denying care to a senior.
The fear that has been voiced is that once the government has control of all health care – either directly or through regulatory oversight – the bureaucrats will try to control the flow of dollars, and in order to control costs, would eventually begin to deny expensive healthcare to the very old. This led to the term ‘death panels’ being bandied about in the press and the President responding that there is simply no thought of such a thing and that he was trying to make things better, and he then invoked his own grandmother, asking the rhetorical question to the effect ‘do you think that I would let such a thing to my own grandmother?’
President Obama, I am quite certain, would not let such a thing happen to his grandmother if she were alive and facing such a situation. But it is an important point, because an accurate understanding of the issue can only come after we pull apart how government bureaucracies work.
First, there will be a bureaucracy. No amount of promises by either the President or the Congress can prevent this from developing into a large bureaucracy, larger than the current Department of Health and Human Services, which is huge. Why is that? Once the Legislature passes a healthcare bill, the bill has to be funded and then given over to the Executive branch to ‘execute.’ The Executive branch will then execute the bill through the Department of Health and Human Services (HHS). This new bill will, of necessity levy new tasks on HHS, without eliminating any of their current tasks. That means they will need to grow.
Second, no matter how extensive any bill is (and the one that has received the most press is some 1,300 pages long) it cannot address anything even close to all the possible issues that will emerge each year as the department distributes, or oversees the spending of, hundreds of billions of dollars to various hospitals, doctors and the like. The process for doing so will be left to – literally – tens of thousands of government service employees – bureaucrats. Most of these people will have no healthcare experience. They will be trained in everything under the sun, but few will be trained in any field of medicine, because that is not their job: their job is managing a government program and overseeing the distribution of money.
Third, as soon as they start distributing this money, issues – small and large – will arise. Decisions will be made and they will become policy. The policies will eventually be collected and become the rules and regulations of the department and then the policy of the administration. These become the guidance under which a doctor will receive money to provide healthcare, and thus, obviously, the guidance under which the doctor will NOT receive money to provide healthcare. These rules will fill thousands and thousands of pages. I would encourage anyone who thinks that this will be straightforward to go to the Health and Human Services homepage and surf through the relatively few of their regulations they have on line.
Fourth, once a set of regulations have been in effect, and are operating normally, they develop the force of law. The department has been given the authority to execute the legislation (law) passed by Congress and thus the regulations and policies of the department have that same force behind them. If a citizen wants to challenge a policy of the department they can. There will be review boards, and if they fail to satisfy the citizen complainant, then the citizen can appeal to their Congressman or take the department to court. These types of actions take place routinely in regard to a wide range of government services. Of course, the difference is that we are now talking about healthcare, where time can be of great importance.
Finally, despite what anyone may say during a press conference or a prepared speech, the whole point of this effort is to change the healthcare system in the US. It certainly isn’t being done to leave it the same. And the government, in the office of HHS, has only one real method to affect change: control how money is spent. This will be done through two principal methods: regulations, and actual payments. Both will focus on when certain types of care will and won’t be provided, and when provided, how much the government will pay the provider for that service. So, HHS will decide, directly or indirectly, how much money the doctor will get for providing you healthcare; and it will decide what level of care the hospital will provide you.
And so we are back to someone’s grandmother, if not President Obama’s. While the President’s grandmother is dead, may she rest in peace, I think it is safe to say that, if she were alive, with a grandson who is President she would probably receive some special care. In fact, she probably would receive special care just from having a grandson and a granddaughter-in-law who are both very successful, very prominent lawyers, and I applaud their success and all that that success brings with it.
But will everyone’s grandmother receive the same level of attention? Remember, the issue isn’t healthcare, the issue is a bureaucracy that happens to be a) huge and b) controlling your healthcare. We can speculate about this bureaucracy somehow acting differently from all the other bureaucracies, as if somehow we have poured some secret sauce over it and it has come out different. But is that likely? Isn’t it more likely that this new healthcare bureaucracy will be much like the other bureaucracies when it comes to service, response time, or concern about individual problems? Think of any arguments you may have had with the following: the Post Office, the Department of Motor Vehicles, of if you were ever in the military, the Pay Office.
Take the case of Randy Stroup, of Dexter, Oregon. In 2008 Mr. Stroup, suffering from prostate cancer, was denied service by the Oregon Health Plan. The state plan does not provide life prolonging care unless there is a better than 5% chance that the patient will survive more than 5 years. But the state did offer assisted suicide.
The fact is that the President – any President – can say what he likes about how one of the bureaucracies in the government is going to function, but his real ability to control the development and promulgation of rules, regulations and policies is very limited, and, of course, ends when he leaves office. No one in Congress or the White House ever designed the bureaucracies that now oversee Social Security, Medicaid/Medicare, Housing and Urban Development, or Agriculture. But they all did develop into large, complex and normally unresponsive bureaucracies. And the more money they manage, the larger and more complex and unresponsive has been the bureaucracy that developed after it. An expanded government healthcare program will be no different, and it will have by far the largest budget of any department in the US government, quickly approaching twice the size of the Defense Department. And unless your grandson happens to be President, you probably shouldn’t assume the system would be responsive to your concerns.
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