Reforming the Reform

by Kevin D. Williamson
After the Hobby Lobby case, do liberals still want to put government in charge of everything?

So, liberal friends and neighbors, how’s everybody liking their one-size-fits-all, federally dominated model of health care this week? A wee bit less than you were liking it Monday morning, I’d wager. I understand, completely: Most of my problems are of my own making, too, so no judgment, no gloating, no schadenfreude (okay, maybe just a taste — dang, that felt good!), because I understand how these mistakes get made. You’re naturally inclined to want to put government in charge of everything because you forget — wishful thinking, maybe? — that there are a whole lot of us knuckle-dragging right-wingers in the world, and, every now and then, we’re going to win one.

I’m trying to be charitable, here, but I really can’t see how you keep failing to learn that lesson. I remember the presidency of George W. Bush, which wasn’t that long ago, and you people went macadamias-and-almonds over a few signing statements. But then — poof! — you decided that the president could unilaterally amend federal legislation on the fly, set aside great swaths of it, and effectively have Congress deputize him to fill in the blanks on a half-finished piece of legislation passed in a frenzy. Now that that precedent has been established, I invite you to think of a Republican president in 2017 named Rick; you can pick your own surname, but I guarantee that you will not think of one that’s going to make you happy.

In the wake of the Hobby Lobby case, suddenly liberals are wising up to the fact that it’s kind of stupid to have your health insurance tied to your employer who may — get this — have a whole different set of financial incentives and values than you yourself have. That’s not just obvious — it’s John McCain obvious. I myself like Sarah Palin, but I know how you guys feel about her, so sit down for a minute and quietly chew over the fact that the guy who put Sarah Palin on the 2008 Republican ticket figured out that employer-based health insurance was a bad idea a long time before it started dawning on you guys.

And even though it’s slightly salt-in-the-wound for me to point it out, we have employer-based health insurance because of you geniuses. Like a great deal of what’s wrong with American public policy, this largely goes back to the 1930s, the New Deal, and FDR’s update of Wilson’s “war socialism.” Short version: The federal government enacted wage controls, but employers still had to compete over the best employees, so they figured out ways to pay them that would get around the wage controls, and what they came up with was what used to be known as the “fringe benefit,” which today mainly takes the form of health insurance. You guys kind of liked this; “corporation” had not yet become a synonym for “villain” in the progressive vocabulary, and Italian-style corporatism was very much in fashion among progressives, even after Benito Mussolini had gone out of style. Using the private sector to implement public policy must have seemed like a stroke of genius — the welfare state was still a pretty hard sell in 1935. Social Security, with its “teeny-weeny bit of socialism,” was disguised as an insurance program, and that worked spectacularly: It passed the House with 372 yeas, 33 nays, and two present votes.

When businesses started making health insurance available to full-time employees and their families, progressives saw this as a chance to achieve de facto the national health-care program that they could not pass de jure. A combination of incentives, union contracts, and regulations made employer plans nearly universal: By 1979, 97 percent of full-time workers were offered health insurance by their employers, according to the Bureau of Labor Statistics. But the realities of supply and demand, along with a great deal of (not pointing any fingers!) stupid regulation, sent prices up. Employers passed on some of those higher costs to employees, and participation went down — down to 83 percent by 1991. That, despite the creation of the HMO — another beloved, beloved progressive health-care reform — under the leadership of Teddy Kennedy in 1973.  

So, naturally, if a lot of mostly voluntary participation is a good thing, then universal and mandatory participation is an excellent thing, thus the Affordable Care Act’s employer mandate. But progressives are so used to getting their way in court that they sometimes forget that there are other laws, and that some of them, such as the Religious Freedom Restoration Act, passed by a near-unanimous Congress and signed into law by Bill Clinton, are pretty plain. It’s hard to see how anybody familiar with both the English language and the text of the RFRA could have been surprised by the Hobby Lobby decision, but the Left was deliciously unhinged to such an extent that conservatives could very well have whiled away the afternoon mixing martinis out of their tears. (If that were the sort of people we were.) (Come to think of it . . . )

Now most of you progressives, being intellectually primitive, have embraced a might-makes-right response: Get one more seat on the Supreme Court and that’ll be that. But it won’t. The Supreme Court has unanimously slapped down President Obama’s executive arrogations twenty times since he was elected, and all the howling in the world about the Koch brothers’ fortune isn’t going to stop the First Amendment from saying what it says — and Harry Reid is not going to be successful in his attempt to repeal item No. 1 on the Bill of Rights. That being the case, you might want to rethink things. Tri-Sprintec birth-control pills run about $12 a month — cash, no insurance. More expensive pills such as Ocella start around $40 — or about half the typical cable bill, and, so far, we haven’t needed a national mandate or a trillion-dollar subsidy for people to see Duck Dynasty and The Biggest Loser. Progressives mad about Hobby Lobby started a campaign under the motto: “Not my boss’s business.” But Obamacare makes it — pardon me for noticing — literally your boss’s business. And I don’t mean “literally” the way Joe Biden uses it; I mean “literally” the way literally literate people use it. The alternative is this: Your money, your pills, your call. If what you care about is access to contraception, then that’s a pretty good model. If what you care about is using the levers of the state to force moral uniformity on the entire country so that atavistic Evangelical types have to knuckle under to your demands — well, you lost.

Which brings us to another point that you recently humbled ACA partisans ought to be giving some thought to: We have not yet perfected time travel. Insurance, as understood by people who speak English better than the vice president does, is a future-oriented proposition. It is a financial instrument used to hedge against risks of certain negative events that may happen in the future, e.g., your car getting hit by an uninsured motorist, or your house burning down. Those events are impossible to predict for the individuals but occur at relatively predictable rates in a sufficiently large population. It is — literally — impossible to insure against something that already has happened (“preexisting conditions”) and it is — literally — impossible to insure against an event that is sure to happen within a given time frame. (The variable in life insurance isn’t whether you die but when.) You cannot insure against a birth-control prescription that you pick up on the 22nd day of every month; the prescription is not a surprise, and neither is the circumstance that necessitates it. (Which is not the case for so-called emergency contraception, but even that is less than 50 bucks, and therefore hardly worth insuring against.) Likewise, routine care is not an insurable risk. You can fold that stuff into an insurance plan, and sometimes that might make sense: The people who are insuring you against the expensive proposition of breast cancer have a good incentive to throw breast exams into the “free” column — but surely, surely you sophisticated, self-actualized, read-my-Kristeva ladies don’t think that it’s actually free? The facts are: (1) Mammograms cost money; (2) somebody has to pay for them; (3) your insurance company is not run by people who love you. So, do the math.

Some things are less expensive when they are prepaid group buys — package vacations, for instance. (E.g.) Most medical procedures and services are not, because there is no such thing — apologies to Christina Hendricks — as a bulk mammogram, no significant economics of scale in services in which the main expense is the time of a specialist. Which is to say: You’re going to pay for your contraception whether it is covered by your insurance or you pay out of pocket — and you’re probably going to pay more if it’s “free.”

If you’ll allow me an anecdote: My main physician operates on a no-insurance basis. Medicare? Nope — he won’t even touch one of those so-called Cadillac plans that the president wants to pillage. You go in, you hand over your American Express, and you go to your appointment. As a consumer experience, it’s an amazing improvement over the usual doctor’s office — and it’s rare that my costs in any given month ever run as high as my insurance premiums. I carry insurance because I might get hit by a bus or come down with cancer. And, sure, I use it for prescriptions and other things that it will pay for, though those very rarely are expensive. (That isn’t always the case — if you’ve had a lung transplant and need a four-month course of Valganciclovir, expect to lay out $8,500. Hence the distinction between insurable and non-insurable risks.) And if I should happen to ask for something to enable me to engage in some sort of activity that my bosses at National Review might not want to subsidize (I don’t know — hair transplant?), it never comes up — because they don’t.

You guys had your shot at this, and you passed the law — but you still managed to blow it. But there are more intelligent, market-based, consumer-driven alternatives, and they are ultimately what’s going to end up getting enacted. We’re here to help — whether you like it or not.

— Kevin D. Williamson is roving correspondent for National Review.

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