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NRL News
IN FIGHT
AGAINST HEALTH CARE RATIONING, During its 2007 annual convention held last June, the National Right to Life Committee announced a proposal for state-based health care reform that can cover those now without health insurance without imposing rationing. How Euthanasia Relates to Health Care Reform Since its inception, the pro-life movement has been as concerned with protecting older people and people with disabilities from euthanasia as with protecting unborn children from abortion. It has recognized that denial of lifesaving medical treatment, food, and fluids against the will of a patient is a form of involuntary euthanasia. When the government prohibits Americans from obtaining health care necessary to preserve their lives, or limits their ability to obtain it, this health care rationing is a form of such involuntary euthanasia. For this reason, NRLC opposed the Clinton Health Care Rationing Plan of 1993–94, and has fought rationing in Medicare. Although it is a single-issue organization that focuses solely on protecting innocent human life from abortion, infanticide, and euthanasia, NRLC has recognized that it is sometimes desirable to endorse and promote positive alternatives in order effectively to blunt the real threat of abortion and euthanasia—such as support for adoption as an alternative to abortion, or the promotion of pain relief as an alternative to legalizing assisting suicide. Today, the calls for restructuring America’s health care system are primarily based on two factors: the number of uninsured and health care costs. Many commentators and politicians—and, of particular importance, some leading Democratic candidates for President in the 2008 election (see story, page one)—advocate what amounts to a tradeoff: with variations in detail that differ among themselves, they propose to institute a U.S. system of government health care with similarities to those in effect in Canada, Cuba, and Europe. Such a system would provide for universal access to health care, but health care that is severely limited by government regulation in the name of controlling costs. NRLC has long argued that the cost of health care does not require rationing lifesaving medical treatment and sought to defeat any health care “reform” proposal that would do so. However, expanding access to health insurance to those in America who are uninsured in a way that does not require rationing of health care is consistent in principle with NRLC’s position that people should not be denied lifesaving medical treatment. With so much momentum building for enactment of some sort of measure to provide coverage for the uninsured, it is not enough for NRLC simply to oppose ways of doing so that entail health care rationing. It is necessary to demonstrate that it is in fact possible to achieve this goal without having to accept rationing as a tradeoff. Health Care Cost Problems False and Real For well over a decade, the National Right to Life Committee has been striving to educate grassroots pro-lifers, politicians, and, to the extent possible, the general public that well-informed economists have demonstrated the inaccuracy of the conventional wisdom that America, as a whole, cannot afford the rising proportion of resources we annually devote to health care. The fact is that continually rising productivity in other sectors of the economy, such as agriculture, frees up resources that can be and are used to extend our lives and improve our health. (See NRL News, March 2007, “Why America Can Afford Unrationed Health Care,” page 16.) There are, however, two real cost problems associated with health care. The first is that while the benefits of rising productivity are seen in rising real incomes for Americans, those income increases are not distributed equally. Those whose incomes have not increased when adjusted for inflation may have truly faced difficulties because of the rising (nominal) cost of health insurance. This accounts for many of the uninsured. Second, while the American economy as a whole can continually afford more and better health care because of rising productivity that frees up more and more resources for health care, the same is not true of government’s share of health care costs. Especially through Medicare (primarily for older people) and Medicaid (for poor people), the government has taken on a large proportion of the responsibility of paying for Americans’ health care, financed largely by payroll and income taxes. These tax collections do rise with the growing economy as productivity increases—but not as much as health care costs rise. Moreover, government expenditures in areas other than health care do not gradually shrink, freeing up more resources for health care, as they do in the general economy. As the accompanying chart of the federal budget outlays in Fiscal Year 2007 shows, setting aside the 23% devoted to Medicare and other health expenditures, a fifth is devoted to Social Security (which will increase, not decrease, with the impending retirement of the baby boomers), and the bulk of the rest is devoted to such things as income security, transportation, defense, education, veterans’ benefits, justice administration, and interest on the national debt. Few, if any, of these expenditures are likely to be able to decline because of increases in productivity in the way the typical American family’s food costs have. What is the result? Tax revenues will rise a little. But health care costs will rise more. Other government costs will not decline. The shortfall will put a squeeze on government payments for health care, which, unlike those in the private sector, will not be able to keep up with the rising cost. Consequently, there will be an increasing gap between the value of the health insurance, and thus the health care privately insured families will be able to obtain, on the one hand, and the value of the health insurance and health care governmentally insured families will be able to receive, on the other. This last point is crucial to understanding why any “solution” to the problem of the uninsured that involves government expenditures based on payroll or income taxes will necessarily result in rationing over the long term. The governmental subsidy, whether narrowly targeted to those now uninsured, or given more broadly to provide universal coverage to replace current means of private insurance, will have to be curtailed so as not to exceed available tax revenues, requiring limits on insurance premiums that will necessitate ever-increasing rationing. Designing an Alternative: Understanding Private Cost-Shifting Considerable amounts of money are presently spent on providing health care for those who are now uninsured. That is because under federal law (the Emergency Medical Transfer and Active Labor Act, better known by its acronym as EMTALA), any emergency room at a hospital that receives Medicare or Medicaid funding must provide essential health care services to those who show up, regardless of their ability to pay. In practice, this means that some of the money taken in from privately insured patients is used to cover the costs of those who are uninsured. This “private-sector cost shifting” has two main problems, however. First, it is geographically uneven. Most hospitals do not have an equally distributed proportion of uninsured and privately insured patients living in their area; for example, an inner city hospital may have a disproportionate share of uninsured people. Second, this situation results in uninsured individuals tending not to seek preventive care, which they cannot afford; seeking treatment only when an illness or injury is advanced; and using emergency rooms for all sorts of health care, not just the traumas for which they were originally designed. This results both in poorer health care and less efficient allocation of health care resources.
The NRLC
Proposal: What NRLC proposes (see details in sidebar) is that instead of this cost-shifting occurring unevenly and inefficiently in hospitals, it be done more fairly and efficiently through insurance. We propose that states adopt legislation ensuring that all within their borders obtain at least a defined level of basic health insurance, while requiring insurers to provide their fair share of basic health insurance policies to those the state determines will otherwise be unable to afford it at sliding-scale discounts varying with income and assets. Insurance companies would take into account the need to finance these required discounts when setting their premium prices, just as hospitals now have to take into account the need to finance undercompensated and uncompensated care in their emergency rooms when setting the prices for their services. Costs could also be covered by pooling a percentage of claims paid to be used to reimburse insurers for their proportion of discounted premiums or by a combination of these methods. This would mean that the level of health care for all would effectively be set, not by legislative votes establishing varying levels of taxes, but by the collective decisions of many citizens (and employers) deciding what premiums they were willing and able to pay for health insurance, with the cost of covering the uninsured taken into account in those decisions. The level of health care provided would never exceed what the economy as a whole could afford, but neither would it be held, by government constraint, below what Americans would freely choose. Yet as the level of available health care changed, the health care available to those otherwise unable to afford it would change with it. A rising tide really would lift all boats. The proposal essentially involves the more rational and efficient allocation of what is now being spent to cover health care for those who are uninsured, not the raising and spending of substantial new resources. Private-sector cost-shifting is going on now at the provider level, and it is effectively being paid for now, indirectly, by insurance premiums. Under the NRLC proposal, this cost-shifting would be moved directly to the level of the insurer, and would continue to be paid for by insurance premiums. Exceptions to requiring universal health insurance could be established for those with conscientious objections to traditional medical treatment (such as Christian Scientists). It is important to recognize, however, that when those who can afford to purchase health insurance choose not to do so and then, having sustained a severe illness or injury, obtain treatment under EMTALA, they effectively become “free riders.” They receive benefits without having paid their fair share toward the cost of those benefits, even though able to do so. A good analogy may be found in the requirement imposed when one registers a motor vehicle; one is generally required to show proof of automobile liability insurance policy in at least statutory minimum amounts. The reason is that there is the possibility of an accident resulting in injury or damage, and, without such insurance, there is no guarantee that the injury or damage could be adequately compensated. The pro-life movement believes that every human being has the right to life from inception to natural death, including the right not to be denied lifesaving medical treatment through health care rationing. The approach here proposed would provide universal access to health insurance without rationing, in an economically realistic and politically feasible manner. |