A Philosopher's Blog

Philosophical Essays on Many Subjects

Insurance

Medicare for All?

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While the United States has the best health care money can buy, it is also fraught with problems. One of the most obvious problem is that many Americans cannot afford to buy that health care—many lack health insurance and others lack adequate insurance despite Obamacare. This lack of insurance has at least two major negative impacts: the health of the uninsured is at risk and health care institutions suffer financially. Another effect is that of medical bankruptcy; though probably not as widespread as the left claims it is still worthy of concern. Because of these problems, it is hardly surprising that some Democrats and others on the left have proposed expanding Medicare to cover all Americans.

Stethoscope.
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On the positive side, such an expansion would provide everyone with health insurance. This would benefit those without insurance and would also help health care institutions financially since medical services would eb paid for. Also, since the system already exists, it would not need to be created from scratch: the state would mostly just need to scale up the existing system. As would be suspected, such a system is also ideologically appealing to the left. While there are clear advantages to expanding Medicare to cover everyone, a rational assessment requires looking beyond just the positive aspects and, as much as possible, without the glasses of ideology.

Perhaps the most obvious concern is the cost of such a program. Those who already pay for insurance would, presumably, not feel any financial impact from the switch—unless the cost of Medicare for all was significantly higher than what they already pay for insurance. Which it might well be.  There are numerous plans for paying for the expansion, but it seems fair to say that many of them are distorted by ideological concerns and wishful thinking. Such an expansion would obviously be expensive—but also obviously not beyond the ability of people to pay for it. As always, the main issue is who will be footing the bill. The cost could have various negative impacts on the economy and individuals, and these need proper consideration.

A second concern is the impact on the health insurance industry. While some might be tempted to think that only the fat cats of the industry would lose out, the fact is that the insurance industry is made up of a range of people who depend on their job to survive. Switching to Medicare for all would effectively eliminate the private health insurance industry and put many people out of work through the direct and indirect effect of this elimination. It is also worth considering the other economic aspects of this elimination, such as on the stock market. While it should not be assumed that this cost will be too high relative to the benefits, this cost needs to be properly considered.

A third concern is fraud. While fraud does occur with private health insurance, Medicare has proven to be a cash cow for fraudsters. In 2014 about 10% of Medicare’s total budget was lost to fraud. Expanding Medicare to everyone would turn the cash cow into a cash herd—which is something to be worried about. Fraud could and should be addressed even if Medicare is not expanded, but the cost of fraud must be included in the calculations used to assess the merits of expanding Medicare.

A fourth concern is usually advanced by conservatives, namely that the elimination of the for-profit motivation and providing care to all will somehow ruin the quality of health care with socialism. One reply is to note that health care will remain for-profit: Medicare for all does not nationalize health care institutions, just the insurance industry. That said, it could be argued that with one entity paying all the bills costs will increase and quality will decrease—but what is needed is evidence for these claims. If they are true, then this would be a problem.

While Medicare for all is a popular idea, it would be unwise to let its appeal blind people to a rational assessment of the costs and benefits of such a plan. It might turn out to be a good idea, but that is not a matter to be settled by political slogans or ideological posturing.

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The High Price of Being Shot

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In the naivety of my youth, I believed that people would not be charged for medical treatment resulting from being wounded by criminals. After all, my younger self reasoned, their injuries were the fault of someone else and it would be unjust to expect them to pay for the misdeeds of another. Learning that this was not the case was just one of the many disappointments when it came to the matter of justice and ethics. As such, I was not surprised when I learned that shooting victims were presented with the bills for their treatment. However, I was somewhat surprised by the high cost of being shot.

Dr. Joseph Sakran, who had been shot in his youth, co-authored a study of what shooting victims are charged for their treatment. Since gunshot wounds range from relatively minor grazing wounds to massive internal damage, the costs vary considerably. While the average is $5,000 the cost can go up to $100,000. These costs are generally covered by insurance, but victims who lack proper coverage become victims once again: they must either pay for the treatment or pass on the cost as part of the uncompensated care. When the cost is passed on, the patient can suffer from severely damaged credit and, of course, the cost is passed on others in the form of premium increases. There can be costs beyond the initial medical bills, such as ongoing medical bills, the loss of income, and the psychological harm.

In addition to medical expenses of those who are shot, there are also the costs of the police response, the impact on employers, and the dollar value of those who are killed rather than wounded (and do not forget that dying in the hospital obviously does not automatically clear the bill). While estimating the exact cost is difficult, a mass shooting like the Pulse Nightclub shooting will probably end up costing almost $400 million. While mass shootings, such as the recent one in Las Vegas, get the attention of the media, gunshot wounds are a regular occurrence in the United States with an estimated cost of $600 million per day. While some will dispute the exact numbers, what is indisputable is that getting shot is expensive for the victim and society. As such, it would be rational to try to reduce the number of shootings and to address the high cost of being shot.

While the rational approach to such a massive health crisis would be to undertake a scientific study to find solutions, the 1996 Dickey Amendment bans the use of federal funding for gun research. There is also very little good data about gun injuries and deaths—and this is quite intentional. Efforts to improve the collection of data are dealt with by such things as the Dickey Amendment. Efforts to impose more gun control, even when there is overwhelming public support for such things as universal background checks, are routinely blocked. While this serves as a beautiful object lesson in how much say the people have in this democracy, it also shows that trying to address the high cost of getting shot by reducing shootings is a noble fool’s errand. As such, the only practical options involve finding ways to offset the medical costs of victims. Naturally, victims can bring civil suits—but this is not a reliable and effective way to ensure that the medical expenses are covered. After all, mass shooters are rarely wealthy enough to pay all the bills and often perish in their attack.

Some victims have attempted to address their medical bills in the same way others who lack insurance have tried—by setting up GoFundMe pages to get donations. While this option is problematic in many ways, the main problem is that it is not very reliable. This, of course, lays aside the moral problem of having people begging so they can pay for being victims of a shooting. To address this problem, I will make two modest proposals.

My first proposal is that gun owners be required to purchase a modestly priced insurance policy that is analogous to vehicle insurance. In the United States, people are generally required to have insurance to cover the damage they might inflict while operating a dangerous piece of machinery. This helps pool the risk (as insurance is supposed to do) and puts the cost on the operators of the machines rather than on those who they might harm. The same should apply to guns—they are dangerous machines that can do considerable harm and it makes sense that the owners should bear the cost of the insurance. Naturally, as with vehicles, owners can also be victims.

It could be objected that owning a firearm is a right and hence the state has no right to impose such a requirement. The easy and obvious reply is that the right to keep and bear arms is a negative right rather than a positive right. A positive right is one in which a person is entitled to be provided with the means to use that right (such as how people are provided with free ballots when they go to vote). A negative right means the person must provide the means of exercising their right, but it is (generally) wrong to prevent them from exercising that right. So, just as the state is not required to ensure that people get free guns and ammunition, it is not required to allow gun ownership without insurance—provided that the requirement does not impose an unreasonable infringement on the right.

Another easy and obvious reply is that rights do not free a person from responsibility. In the case of speech, people cannot simply say anything without consequence. In the case of the gun insurance, people would be acting in a responsible manner—they would be balancing their right with a rational amount of responsibility. To refuse to have such insurance is to insist on rights without responsibility—something conservatives normally rail against. As such, both liberals and conservatives should approve of this idea.

My second proposal, which is consistent with the first, is that there be a modest state fee added to the cost of each firearm, accessory and ammunition box. This money would go into a state pool to help pay the medical expenses of the uninsured who are injured in shootings. Yes, I know that this money would probably be misused by most states, probably to bankroll the re-election of incumbents. The justification is, of course, that the people who buy the guns that could hurt people should bear the cost for the medical expenses of those who are hurt. People already pay sales taxes on such items, this would merely earmark some money to help offset the cost of people exercising their second amendment rights. To go back to the vehicle analogy, it makes perfect sense to add a fee onto the cost of gas to pay for roads and other infrastructure—that way the people who are using it are helping to pay for it. Likewise for guns.

An obvious objection is that this fee would be paid by people who will never engage in gun crime. This is a reasonable concern, analogous to other concerns about paying into anything that one is not directly responsible for. There are two reasonable replies. One is that the funds generated could cover medical expenses involving any firearm crime or accident and anyone can have an accident with a gun. Another is the responsibility argument: while I, as a gun owner, will probably never engage in a gun crime, being able to exercise my right to own guns allows people who will engage in gun crimes to engage in those crimes. For example, the Las Vegas shooter was operating under the protection of the same gun rights that protect me up until the moment he started firing. This fee would be my share of the responsibility for allowing the threat of gun violence to endanger everyone in the United States. Such a modest fee would be a very small price to pay for having such a dangerous right. Otherwise, I would be selfishly expecting everyone else to bear the cost of my right, which would not be right. So, to appeal to principled conservatives, this would be a way for taking responsibility for one’s rights. As people love to say, freedom isn’t free.

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Emergency Rooms & Obamacare

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Typical scene at a local emergency room
(Photo credit: Wikipedia)

On the face of it, the idea seems reasonable enough: if a person has health insurance, then she is less likely to use the emergency room. To expand on this a bit, what seems sensible is that a person with health insurance will be more likely to use primary care and thus less likely to need to use the emergency room. It also seems to make sense that a person with insurance would get more preventative care and thus be less likely to need a trip to the emergency room.

Intuitively, reducing emergency room visits would be a good thing. One reason is that emergency room care is rather expensive and reducing it would save money—which is good for patients and also good for those who have to pay the bills for the uninsured. Another reason is that the emergency room should be for emergencies—reducing the number of visits can help free up resources and lower waiting times.

As such, extending insurance coverage to everyone should be a good thing: it would reduce emergency room visits and this is good. However, it turns out that extending insurance might actually increase emergency room visits. In what seems to be an excellent study, insurance coverage actually results in more emergency room visits.

One obvious explanation is that people who are insured would be more likely to use medical services for the same reason that insured motorists are likely to use the service of mechanics: they are more likely to be able to pay the bills for repairs.

On the face of it, this would not be so bad. After all, if people can afford to go to the emergency room and be treated because they have insurance, that is certainly better than having people suffer simply because they lack insurance or the money to pay for care. However, what is most interesting about the study is that the expansion of Medicaid coverage resulted in an increase in emergency room visits for treatments that would have been more suitable in a primary care environment. That is, people decided to go to the emergency room for non-emergencies. The increase in emergency use was significant—about 40%. The study was large enough that this is statistically significant.

Given that Obamacare aims to both expand Medicaid and ensure that everyone is insured, it is certainly worth being concerned about the impact of these changes on the emergency room situation. Especially since one key claim has been that these changes would reduce costs by reducing emergency room visits.

One possibility is that the results from the Medicaid study will hold true across the country and will also apply to the insurance expansion. If so, there would be a significant increase in emergency room visits and this would certainly not results in a reduction of health care costs—especially if people go to the expensive emergency room rather than the less costly primary care options. Given the size and nature of the study, this concern is certainly legitimate in regards to the Medicaid expansion.

The general insurance expansion might not result in significantly more non-necessary emergency room visits. The reason is that private insurance companies often try to deter emergency room visits by imposing higher payments for patients. In contrast, Medicaid does not impose this higher cost. Thus, those with private insurance will tend to have a financial incentive to avoid the emergency room while those on Medicaid will not. While it would be wrong to impose a draconian penalty for going to the emergency room, one obvious solution is to impose a financial penalty for emergency room visits—preferably tied to using the emergency room for services that can be provided by primary care facilities. This can be quite reasonable, given that emergency room treatment is more expensive than comparable primary care treatment.  In my own case, I know that the emergency room costs me more than visiting my primary care doctor—which gives me yet another good reason to avoid the emergency room.

There is also some reason to think that people use emergency rooms rather than primary care because they do not know their options. That is, if more people were better educated about their medical options, they would chose primary care options over the emergency room when they did not need the emergency room services. Given that going to the emergency room is generally stressful and typically involves a long wait (especially for non-emergencies) people are likely to elect for primary care when they know they have that option.  This is not to say education will be a cure-all, but it is likely to help reduce unnecessary emergency room visits. Which is certainly a worthwhile objective.

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Is the Emergency Room a Viable Alternative?

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Typical scene at a local emergency room
 (Photo credit: Wikipedia)

As Obamacare marches onward, its opponents are still endeavoring to stop its advance and send it packing. Of course, the opponents need to provide an alternative system. Interestingly, certain Republicans such as Rick Perry and Jim DeMint have claimed that uninsured Americans are better off relying on the emergency room for treatment. While the battle over Obamacare is largely ideological, the viability of using the emergency room would seem to be an objective matter.

On the positive side, anyone can go to the emergency room and hospitals cannot refuse to treat people with legitimate medical needs—even people who lack insurance or cannot pay.

However, there are numerous problems with the uninsured (or even the insured) relying on the emergency room. The first is the matter of cost. The emergency room is generally more expensive than the non-emergency options. It is certainly more expensive that routine preventative care that can keep a person out of the emergency room. The high costs are problematic because of the burden on the uninsured (medical bills is a leading cause of bankruptcy in America) and also because when the uninsured cannot pay, the cost is passed on to the rest of us (most often in the form of higher health insurance premiums). Thus, relying on the emergency room to treat the uninsured places a heavy burden on everyone and is actually a form of highly inefficient socialism in which those with insurance pay for needlessly expensive treatment for the uninsured. From a purely economic standpoint, if we are going to have medical socialism, we should at least go with the more economically efficient version.

The second is the matter of preventative medicine and ongoing treatments, such as routine checkups and dialysis. The emergency room hardly seems to be set for these medical matters, although people who are unable to avail themselves of them stand a significant chance of ending up in the emergency room, thus taking us back to the first problem. As such, the emergency room option does not seem to be a viable alternative to Obamacare. This is not to say that Obamacare is the only option or even a good option—just that it is better than the emergency-room-for-the-uninsured option.

The third is the matter of compassion. While hospitals cannot deny people necessary medical care, such care is certainly not charity: either the patient must pay or the cost is passed on to the rest of us. As such, relying on the emergency room as a matter of social policy is essentially saying to people that they can get treatment, provided that it is an emergency and that either the patient can pay or the cost can be passed on to everyone else. It is generally agreed that we should collectively protect each other from terrorism, foreign enemies, and our own criminals. This same concern should also extend to protecting each other from disease and injury. After all, whether Sally is dead because of cancer, a criminal’s bullet or a terrorist’s bomb, she is still dead. So, if we can have a huge collective defense against these other threats, we surely can have a developed collective defense against medical threats—one that is better than the emergency room.

 

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Adjuncts & the Affordable Care Act

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English: President Barack Obama's signature on...
 (Photo credit: Wikipedia)

The Affordable Care Act imposes fines on large employers (defined as those employing 51+ people full time) that fail to offer affordable insurance coverage to their full-time employees. As might be imagined, this has created some concerns for such employers and their employees.

While I do believe that the act has some positive aspects, I tend to agree with those who think that health insurance should be split from employment. That is, it should be something people can select from a competitive market regardless of who they are working for. Properly done, this would be a considerable benefit to businesses and individuals.  However, my main concern here is with the likely impact of the Act on adjuncts and others in a similar plight.

Adjuncts are, in many ways, the temp workers of academics. They are typically hired from semester to semester to teach a few classes at relatively low pay ($1,500-3,000 per class being typical) and generally have no benefits or job security.  Adjuncts are usually classified as part-time employees, primarily because they often teach less than what is considered a full class load and typically do not have the other duties (such as committee work or advising) of full-time faculty. They are also typically classified as part-time so as to avoid the need to provide them with the benefits of full-time employees.

The Affordable Care Act defines a full-time employee as one who is employed an average of thirty hours a week.  Currently, there is not a clear definition of how the part-time status of adjuncts should be determined, since adjuncts typically work in terms of credit hours taught rather than in terms of hours on the clock.

As might be suspected, colleges, universities and businesses have varied definitions of what counts as being part-time and not all of these match the Affordable Care Act definition. In response, some colleges and universities are already taking steps to address this matter. A common responses has been to cut the hours of adjuncts and other part-time workers to 29 hours or less to avoid having to provide affordable insurance or paying the fine.  In the case of adjuncts, some schools have cut the number of courses and adjunct can teach, despite the fact that the matter of what counts as full time faculty under the act has not been sorted out.

As might be guessed, the reduction in hours is an unintended consequence of the act. However, it is obviously not good for the adjuncts and other part-time employees who are typically struggling to get as much work as they can. As it stands, adjuncts often have to teach classes at multiple colleges in order to get by and other part-time workers often have to hold multiple jobs. If employers start reducing the hours of part-time workers, they will need to find additional jobs to make up for the lost income, which will be at least inconvenient.

On the one hand, it is easy to blame the Affordable Care Act (or, to avoid the fallacy of reification, the people who passed the act). After all, the “big” employers are being forced into a trilemma: provide affordable health care or pay fines or cut employee hours down to 29 hours a week or less. Since the first two options cost money, the obvious choice is the third one. No doubt employers would prefer to keep things as they are, but the act forces them to make the employees pay the price for the act.

On the other hand, it could be argued that the employers deserve some of the blame, especially in the case of colleges and universities. After all, adjuncts are exploited by universities and do not even get the insurance coverage that is offered to students (I had better benefits as a grad student than as an adjunct). Adjuncts could be provided with affordable health care (as students are) it is just the case that employers are choosing not to do so in order to save some money. That is, it is just another case of the working people being screwed over by those with vastly larger salaries and plenty of benefits. It is not surprising that many of the same folks who weep over the rich being forced to pay marginally more taxes are also outraged that businesses would have to provide affordable health insurance to employees. There is also a certain meanness in the attitude that is essentially this: “What, we have to provide full-time employees with affordable health insurance or pay fines!? In that case, we’ll just fire people or cut their hours!”

My own view is that this illustrates the important of separating health insurance from employment. This would allow employers to hire people without worrying about the costs of providing insurance (or paying fines) and would allow individuals to get insurance apart from being employed. Of course, this would require serious revisions to the health insurance industry to make health care actually affordable for individuals, especially those working low-paying part time jobs. Naturally, employers could continue to offer health insurance, but this would not be mandatory. However, no matter what is done, someone obviously has to pay the bills.

 

 

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Weather Defense Initiative

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Temperature difference in Europe from the aver...
 (Photo credit: Wikipedia)

Humans have always faced off against the impersonal power of the weather, sometimes winning and sometimes not. In many ways, humans are at war with the weather of our world and the damage inflicted by weather can be comparable to that which we inflict on each other. But, while some might attribute an intelligent design behind the ravages of the weather, it seems most reasonable to hold that the climate does not wage intentional war against us. Rather, the world simply does as it does and sometimes this kills us and destroys our cities. However, destructive weather, as it has historically done, does raise questions about the alleged benevolence of our alleged creator.

Sticking with the war metaphor, there are clearly times in which the conflict is more damaging than others. In recent years, the damage has stepped up considerably. The September 2012 edition of National Geographic featured “Extreme Weather” by Peter Miller discussed, as might be imagined, the recent extreme weather that has impacted the world. The article was, obviously, written before Sandy hit the United States. However, Sandy was, in some ways, just another example of extreme weather.

While there are some who are skeptical about climate change, it is possible to discuss the matter by ignoring the alleged causes of the extreme weather and focusing on the damage done by weather incidents.

Weather disasters have been rather costly financially in the United States and the damage done has increased significantly. From 1980-1995 there were 46 disasters causing $1 billion or more damage. In 1996-2011 there were 87 disasters causing that amount of damage. Insurance companies reported insured losses of $36 billion in 2011, which is 50% greater than the average for the past decade.

Part of this can be attributed to the fact that Americans increasingly live in areas that are subject to destructive weather, such as the coastal regions of the United States. Part of this can also be attributed to the greater value of the structures being built, especially in risky areas. After all, the destruction of a beach mansion costs more than the sweeping away of a beach cabin. However, even taking into account such factors (and the obvious factor of inflation) the damage being done has increased.

There is also the cost human life.  The 2003 heat wave in Europe killed about 35,000. In 1970 Tropical storms killed 500,000 in Bangladesh. There are, of course, many other sad examples of humans being killed in large numbers by weather events.

While the exact costs in deaths, suffering, property loss and economic damage can be debated, it is clear that weather events cost us dearly. If the damage inflicted by the weather was done by a human attacker, there would be screams for war, defense and retaliation. Look, for example, how the United States responded to 9/11.

Naturally, retaliation against the weather would be absurd—there is no intelligent agent to seek vengeance against (except, perhaps, God) or deter. However, it does make sense to establish a developed defense against the damage of weather.

People are, of course, establishing defenses against weather events. For example, France took steps, such as building air conditioned shelters, and cut the heat deaths in 2006 by two thirds. While storms still tear through Bangladesh, the construction of shelters and warning systems has reduced the death toll from hundreds of thousands to thousands. These are still heavy losses for humanity, but an improvement over the old system.

While these defenses have shown some effectiveness, our response has been largely reactive (we tend to slap together a response to the last disaster rather than preparing for the next one properly) and piecemeal.

So what I propose is a worldwide weather defense initiative (WDI—yes, this is blatantly stolen from SDI) to address the damagers presented by our planet. Many steps, such as large scale tsunami warning systems, are in place. However, most of our cities are woefully underprepared and our defenses are very limited. Meanwhile, we waste and squander resources making war on each other. I contend that at least some of these resources would be better spent (morally and practically) on defense against the weather rather than against each other. Such spending would, of course, allow for the profits and political dealings that defense spending now involves. However, at least the results would probably be more positive in terms of lives saved. I am not, of course, proposing that military defense be neglected—after all, I know us and I know that we are obviously not to be trusted unless guns are pointing at us. Even then we should probably not be trusted.

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