Hildegarde

As I write, it is very early Sunday morning.  Too early, really.  Sundays are usually good days for me, but last night I just couldn’t sleep, and now I’m sort of hammering along in the way I do when I can’t stop myself from thinking nonstop.

One of the things that occurred to me is an old theme here, but not one I think I’ve spent any time to work out in detail, so I thought I’d try it.

When I first brought up the moral argument that underlies the American health care debate–the principle that we have a moral obligation to care for the sick, that if we see somebody who is suffering or dying and know how to alleiviate those things, we are morally wrong not to do it–Robert wanted to know what that principle had to do with me.  It had to do with him, as a Christian, because he is a Christian.  But it could have nothing to do with me, because I am an atheist.

I find this entire idea–that moral principles are dependent on religion, and that without religion no objective moral principles can be discovered–odd in ways other than that I just don’t agree with it.

For one thing, any resident of the West, either in the Classical world or in the Europe of the Middle Ages, would have found such an idea nearly inexplicable.  The most important thing Aristotle and Aquinas had in common was that they understood morality to be something true about human beings that was available to all men to discover. 

It’s interesting, to me, that these two thinkers–and these two eras of Western civilization–both conceived of morality on the virtue side of MacIntyre’s virtua/rules divide.  That is, for both the Classical Greeks and the Medieval Church, talking about morality meant to ask what kind of person we should be, not what kinds of rules we should follow.

Aquinas was able to effect a synthesis of “Greek learning” and Christianity precisely because he shared Aristotle’s conviction that we could discover what virtue was and what we must do to acquire it “by reason alone,” as the Middle Ages put it–that is, without the help of revelation. 

For the Medieval Church, the truths of revelation were few and particular:  the Trinity; the Virgin Birth; the salvation of the world through Jesus Christ.

The law of God is written on the heart of every man, Aquinas said, and any man who wanted to could read it there.

It’s a long way from that understanding of the place of morality in human life to the one we have now, which assumes that, without revelation, no such moral law is available to be discerned at all.

We can trace the history of that idea–that morality is entirely dependent on religion, and that without religion there would be no moraliy–to the Renaissance, although a stray thinker or two had come up with it (and being doctrinally condemned for it) in other times and places.

It was the Thomist/Aristotlean conception of virtue and morality that gave birth to what was then called “Christian Humanism,” and what we now call the Renaissance, and it was the Renaissance that gave birth to Humanism as it came to be understood until ery recently. 

Humanism was first and foremost a commitment to the infinite moral worth of every human being.  What followed from that was a series of obligations both to ourselves and to other people, and among those was our obligation to care for the sick and the poor.

What interests me is the fact that this understanding of the moral life–as something objective, and outside our wishes and whims, and discoverable through reason–ended on both sides of the religious divide at the same time.

For that, we have to thank (or not) Martin Luther. 

Okay, maybe I’m being unfair here.  I’ve read only limited work by Luther himself.  What I really mean is that we have to thank (or not) the Protestant Reformation.

That Luther himself was not a fan of Christian Humanism is well documented, but what I think is much more important about Protestantism as an historical phenomenon is its narrative of sin and grace.

For Aristotle and Aquinas, for most of the philosophers and theologians of Classical antiquity and early to Medieval Christianity, man was a being who naturally longed for the good, and longed to be good.  Being good was hard, so he wasn’t always successful, but most men wanted to be successful, and therefore strove to understand what it meant to be virtuous and what it meant to live a virtuous life.

For a good chunk of the Protestant reformers, man was a being so utterly depraved by the fall that he was incapable of even willing what was good without the grace of God.  In fact, he was incapable of even conceiving the good.  Left to his own devices, without revelation or grace, he would choose to do evil as a matter of course.  His only hope was grace and revelation, and without them there could be nothing but chaos.

Maybe the idea was in the air.  Maybe it was just the idea of morality as a set of rules everybody was supposed to follow that was in the air.

Whatever it was, the Protestant Reformantion’s understanding of the moral law had a lot more in common with Macchiavelli than it did with the history of the Christian Church. 

It was, in fact, a complete break with the entire intellectual history of Western Civilization. 

I am not, I will admit, a big fan of the Protestant Reformation on almost any level, but on this level I think its influence was largely disastrous.

The idea that we could not know what was good unless God told us, that there were no rules to the game of being human that could be discovered by investigation, quickly led to the conviction that there were no rules except success–that all that mattered was whether you won or lost. 

Or, as Mr. Lombardi is supposed to have put it:  winning isn’t the most important thing, it’s the only thing.

And no, I’m not saying that the Protestant churches held this particular precept.  It was more that they held onto a rules-based moral universe for those people who chose to remain within their communities, and gave carte blanche to the men outside those communities to concentrate on the…practical.

I’m doing that thing again where I’m not sure I’m making any sense at all, so I might not be.

For better or worse, the cultural assumptions of the Protestant Reformation have become the cultural assumptions of most of the globe. 

It isn’t that we’ve all become Calvinists, or even that most of us have.  But the countries of the Protestant Reformation were also the countries of the Enlightenment, and the Enlightenment was a period that broke decisively with Christianity on all matters of revelation while retaining the Protestant framework for thinking about morality and ethics–as rules-based, and largely arbitrary, once the truth of revelation was rejected.

One of the things I’ve always wanted to learn more about is just how necessary the one thing (the idea of morality as rules-based and impossible without religion) was to a lot of other things that arose only in Protestant cultures (science as we know it, the democratic project).

For right now, I’d only like to point out that the assumptions necessary to believe that morality must either be based on God or be something entirely arbitrary that we make up ourselves are irrational–and unscientific–in the extreme.  They require that we assume that human beings, unlike any other animal on the planet, have no discernable and discoverable nature.

And that’s just to start. 

I understand the attraction, for both the religious and the nonreligious, in such a view of human life and human morality.  It gives the religious an automatic basis for feeling superior to their brethren–only we know the rules to make us good–and the unreligious both a blank check to do what they want in the world, and an excuse not to work very hard to be better people than they feel like being.

As a principle, however, I think it’s demonstrably untrue, and largely dysfunctional. 

And it leaves us in situations like this one.  A great majority of the US does in fact hold to the moral principle I started with–that we are obligated to relieve the sickness and suffering of our fellow human beings if we are able–without knowing why they think that, or even that they think it.

It therefore becomes damned near impossible to untangle the principle from its practical applications. 

Instead, we have discussions like the one we’ve been having on the health care proposals now before the US conference:  one side talks about doing something, the other side talks about why doing that particular something is going to be bad–but nobody comes out and directly addresses the problem:

Assuming that we have a moral obligation to relieve the sickness and suffering of our fellow human beings if we are able, what exactly are we in fact able to do? 

It’s not enough to say that THEIR plan in fiscally irresponsible.  You have to say what YOUR plan is to solve the fundamental problem, and to be specific about what ways it will solve the problem. 

Because, for all the yelling and screaming that’s been going on in the public square these last few months, the ordinary run of human being in the United States is concerned first and foremost with the moral problem. 

And he–or she–doesn’t even know it.

The  Senate is likely to pass a bill I don’t like today, that I do not think will solve the problem–

But it’s the only actual attempt to solve the problem on the table, and they’re getting away with a lot because of that.

Considering my track record on Saturdays lately, I think it’s going to be interesting to see if I can get this thing written and posted without blowing it up at least twice.

So, anyway, let’s see what I can do here.

Robert says he saw the ethical question as peripheral.

I see it as absolutely central, and it was the ethical question–not the present health care proposals–that I was talking about in yesterday’s post.

Robert also says that the ethical principle applies to him as a Christian, but he doesn’t see what it has to do with me.

That implies that such a principle is valid for  Christianity and for no other moral system, and with that I absolutely disagree.

The idea that every human being is of infinite moral value and, simply by existing, imposes on each of us an obligation to be concerned with his well being is just as central to humanism (in its original forms) as it ever was to Christianity.

A number of interesting questions come out of that fact–and it is a fact.  One of those questions is why contemporary humanism has abandoned not only the principle, but the understanding of what it means to be “human” that it was founded on.

James Schall, one of the people I’ve referenced here a few times in talking about the idea of the university and the place of the liberal arts, says that the “problem with atheistic humanism isn’t that it’s atheistic, but that it’s not a humanism.”

And he’s got a point.  Whatever is going on with the Council for Secular Humanism and most of the other humanist groups these days, it isn’t humanism as historically understood. 

And that brings on the question of whether humanism as historically understood not only began as a Christian movement as a matter of historical fact, but could only have begun as a Christian movement.

That’s where it gets a little tricky.  It’s certainly true that the principle has not arisen in any society except those that are Christian, but it’s also true that the principle did not arise in Christendom until Thomas Aquinas “Christianized” Aristotle.

Aristotle was not enough.  Averroes–the Islamic scholar Ibn Rshd, who wrote in the Iberian peninsula in the early Middle Ages–came to the conclusion that there was the truth of philosophy and the mythology of scripture (in his case, the Koran) and never the twain could meet, since scripture was written for the ignorant and stupid, and only the wise and educated could understand the real truth that was Aristotle. 

And the last thing Averroes came up with–or could have come up with–was the idea of the infinite worth of every man.

So, in the absence of trying to untangle these strands that make up what is properly humanism–Christian humanism and non-Christian humanism–I’ll leave that particular question until later.

I’ll just say that not only do I consider such a principle to have something to do with me, it was the principle on which I was raised and the foundation of the humanism I learned from people who did not believe in God, never mind in Christ, and couldn’t have.

My interest in that principle at the moment is of another kind altogether.

No matter where it came from, I think a solid majority of Americans accept it.  I think they accept it without ever thinking about it, or having thought about it.  They’re convinced that this is right and true.  They don’t think about why they’re convinced that this is right or true.

Does holding such a principle mean that you have to be in favor of a government-run health care system?

No.

In fact, it MIGHT mean that you have to be against it.  That’s a matter of the practical reality of running such a system, and not the subject of this post.

But what holding such a principle does do is to make some forms of arguing about such a health care plan look better or worse than others.

The uninsured patient who’s losing his house because of the medical bills, or who’s losing his life because he didn’t go in to get a colonoscopy, or whose life is being shredded because his child is dying of leukemia is the seven hundred pound gorilla in the middle of the room.

His situation has to be addressed.

You don’t want a government run health care system?  Fine.  Tell me what you do want that will fix this problem.

The Obama initiative is coming closer to success than the Clinton proposal did because the Obama people have kept the focus directly on the seven hundred pound gorilla–

And the opponents have been talking about everything from fiscal responsibility to fascism (sorry, but most people watch television, and Obama’s face on a poster with a Hitler mustache over a swastika is what they’re seeing a lot of these days)–

But they haven’t been talking about the seven hundred pound gorilla. 

No, I don’t think Nancy Pelosi gives a damn about the ethical question.

But the majority of Americans do, and at the moment, only the Democrats are making even any pretense of addressing it. 

The opposition is off on a different subject entirely, and no matter how important that subject may be, it cannot substitute for addressing the moral question first.

I wish somebody would try.

It’s Friday, which is always bad news on the sensibleness front–if sensibleness is a word.  Yesterday, I had nothing much to do and so ended up doing nothing.  But one of the things I did do was to watch Countdown with Keith Olbermann, which is an opinion show on MSNBC, and which I normally watch regularly.  Or semi-regularly.

I’m stumbling over myself here, but bear with me.  This is kind of hard to untangle.

Keith Olbermann is a liberal commentator, sort of like the mirror image of Bill O’Reilly over on FoxNews.  My younger son and I started watching both shows back during the last Presidential campaign.  Olbermann is on at eight o’clock, and so is O’Reilly, but O’Reilly reprises first thing in the morning, so we tended to watch Olbermann in the evenings right after dinner.

And I like Olbermann.  He does a version of political stand up comedy that can be very entertaining, even when I don’t agree with it.  He’s often unfair, but I don’t mind that either.  So is O’Reilly, and they’re both running opinion shows.

Just before Christmas–back in October, actually, I think–Olbermann’s elderly father fell out of bed and landed in the hospital with what looked like serious and unfixable problems.  At around that time, Olbermann devoted an entire show to a single “special comment” on the health care/health insurance reform system, a ringing endorsement of the public option and denunciation of the individual mandate.

It was, as far as I’ve seen, the best program Olbermann ever did.  And I think I’d still believe that if the comment hadn’t mirrored my own feelings about health insurance reform exactly.  The talk was well written, cogently argued, passionately delivered, and emotionally and intellectually compelling.

One of the reasons it was all those things is that is was an appeal to a shared moral principle–that is, that Olbermann assumed, wholeheartedly and without embarrassment, that all the people who were listening to him believed that caring for the sick was something each of us owed our fellow human beings because they are our fellow human beings.

Or, to be more specific, I suppose, that it is morally wrong for any one of us to allow other people to die, or to suffer, when it is p;ossible for us to relieve that death or suffering.

This is a principle that, I think, most people would agree with in theory, if not in practice.  And the principle itself does not tell us how to go about making sure we alleviate the suffering and spare the deaths that we can.  I think there is a good case to be made that the only way to do so adequately and equably is to institute some sort of public program, or at least a not-market one.

I’m convoluting that last thing a little.  Let me put it this way:  I think that there is something in the nature of medical care that makes it illsuited to a market approach.  I could go on for some length as to why, but that’s not the subject of this post, so I’ll leave it to later.

What concerns me now is this:  in the time since that comment originally aired,Olbermann went off the rails and completely nuts in terms of any of his segments on opposition to the health care bill, so much so that even Jon Stewart of The Daily Show started mentioning it.

Instead of ripping up people’s arguments, Olbermann began to run segments on how there weren’t any black people at the last tea party rally, for instance, or how all the signs at an anti-health-reform rally were talking points put out by Republican operatives or insurance company lobbyists.

This is the essence of an ad hominem attack–it doesn’t matter if the people at the tea party were all Martian space aliens here to take over the world, the arguments are the arguments.  They’re true or false on their merits.  If Hitler had discovered that the world was round and every decent person on the planet had insisted itwas flat, the world would still be round.

I don’t want to beat the guy up too much here.  His father was dying.  I think it’s probably normal that he wasn’t staying screwed on too tight, if that makes sense.

But that kind of approach to the argument is not only not helpful, it’s positively desstructive.  And, yes, I’ve seen some of the wilder nuts, and I know they’re both infuriating and something worse–but there really are issues, real ones, and they need to be dealt with. 

Because this issue is not going to go away.  Not even a little.  It won’t go away if the bill fails, and it won’t go away if it passes. 

Countdown reran that comment last night, along with anotice that Olbermann’s father had died.

It’s worth listening to if you can get it online at MSNBC or anywhere else.

It is, in fact, the best single speech on the health care issue I’ve heard yet.

It’s Wednesday, which is a day I’ve been thinking would be without blog posts for a while.  I’ve got one of those scheduling conflicts that I look back on and wonder how I got myself into–I teach a night class that goes until nine on Tuesday, then a day class that meets at eight on Wednesday, and with the drive that means I go to be around midnight and get up at four and feel like I’m walking into walls.

But it occurs to me that a lot of the discussion of the health care bill is going past each other.  I’ve been making general statements about the national stats, while the concerns of a lot of you here are for individual cases.

It seems to me that JEM, for instance, is supporting the health care bill because she thinks it will result in her daughter getting health insurance coverage–she expects that if the bill passes, her daughter, who works part time, will have health insurance while she now has none.

I think that that won’t happen. 

Rather, I think that what will happen if this health care bill passes is this:

The advantage for hiring people part time will disappear–now, an employer can hire part time and not have to pay for health care coverage.  After the bill, he’ll have to pay for coverage whether the employee works part or full time.

The sensible thing for him to do, then, is not to hire any more part time employees, and to fire the ones he has in favor of hiring more full time employees.  In most part time arrangements, a single full time employee can do the work of at least two part time employees, and in many jobs the ratio is even higher.  So if I now have 10 full time and 90 part time employees, I fire 45 part time employees and make the other 45 full time, and I save the cost of insurance for 45 people. 

But the bad new may be even worse than that.

The prices for health insurance being quoted are very low.  You couldn’t insure a single healthy adult at $400 a month in CT, and the reason is not that CT is naturall more expensive in that way.

Rather, CT mandates lots of coverage that all insurance policies in the state must carry.  FL  does not mandate so much coverage, so health insurance is cheaper precisely because it covers fewer things.

But the present health care bill will mandate coverage in a whole list of areas that are not mandated by the state of FL at the moment–for diagnostic tests, for mental health services, for rehab–

That will drive the cost of insurance up.

And the bill requires insurance companies to cover people with previously existing conditions, which will also drive the cost of insurance up.

Some of the original versions of this bill had provisions which would be helpful–all those provisions are now gone.

The health insurance companies are exempt from antitrust laws–they still are, under this bill.

Their premium prices are entirely unregulated–they still are, under this bill.

Mandated coverage is actually increased, making premiums higher.

And there is no alternative to dealing with the insurance companies.  A public option would have meant that if I didn’t like the way Aetna or Blue Cross was treating me, I had someplace else to go. 

With this bill, I have nowhere.

If you think this bill will insure people who are not insured–by all means, support it.

I think it will render even more people uninsured, and lead to a significantly more people unemployed at the same time.

I don’t see why I should support something I am sure will only make things worse.

And now, I’m going to go support some caffeine.

Well, let me see what I can do here.

First, I have never had to beg for medical care.  Not once.  Not with insurance, and not without it.  Every single doctor and hospital (but one) we worked with when Bill was dying, and every one my sister in law worked with in the same circumstances twelve years later, assumed that when medical care was necessary it was necessary and it was freely given.

And we were told–we’ll talk about the money later, when the crisis is over.  Even the providers didn’t want to talk about the money up front.

Second, all medical care in catastrophic cases is charity, and has to be.  Unless Canada’s system is unlike any other in the world, it has to supplement “what you put in” with tax funds outside the system to keep the system going. 

All catastrophic patients and patients with chronic illnesses take out more than they put in, and more than anybody else could be asked to put in, too.  That’s true of our Medicare system for seniors (a government program), and it’s true of our Social Security system.

An actual insurance program does not have this problem, but nobody in any of these cases wants an actual insurance program–it would leave you paying out of pocket for virtually everything, with the only things covered being the very costly and very unusual high-end major care that almost nobody ever uses.

Socialized systems are charity.  That’s what they are.  That they give people a reason to hide that reality from themselves–by having them pay in basically nominally amounts so that they can feel like they’re “entitled” to the benefits they eventually receive–doesn’t change their fundamental nature. 

I’ve got nothing against that–I’m the one here plumping for single payer–but I’m not deluded as to what’s going on when we institute such a system.

Third, the only way you can know that you can “never afford to pay” something is if you know what the price of it is.

But the only way to know what the price of any medical care in the US is, outside a few testing areas and entirely-out-of-pocket stuff like tummy tucks and liposuction, is by negotiating it.

There are no “prices” on these procedures.  No hospital knows what it actually costs to treat people in serious cases.  At best, they know what it costs them to hire their staff and keep their building running.

If the hospital accepts insurance from five different companies, each of those companies will pay a DIFFERENT price for the procedures in question.  If a doctor accepts five different kinds of insurance, each of those kinds of insurance will pay a DIFFERENT price for the same office visits and the same care.

And those same hospitals and doctors will paid yet two MORE different prices for treating patients on the Medicare (elderly) and Medicaid (poor) programs.  Government reimbursements for Medicare and Medicaid are so low that many doctors simply refuse to treat patients with that kind of insurance.

Fourth, Lymaree has it exactly right.

Patients with insurance are not being charged extra to cover uninsured patients in American hospitals.  Rather, the prices quoted to uninsured patients are far higher because insurance company payments are so low.

American insurance companies are enormous entities that span state lines and control reimbursements for thousands of patients.  Hospitals are local, small, and generally non-profit.   They don’t have “profit margins.”  Mostly, they operate at a loss–no matter what anybody is paying–with the shortfall being made up by their endowments or their local fundraising.

A local hospital that didn’t bite the bullet and accept pretty much anything the insurance companies wanted to pay it, no matter how inadequate, would soon find itself out of business as the insurance company sent its members over to the next county where the hospital was willing to play ball. 

It’s been decades since insured patients subsidized uninsured patients.  These days, it’s largely the other way around. 

Fifth, insurance is affordable to the extent that you can buy it as insurane.  This present health care bill will make plans like the one Lymaree and her husband have illegal, by requiring all plans to “cover” a laundry list of health care procedures–in other words, no more catastrophic-only policies.

And even what looks like some kind of actual reform–such as allowing patients to buy insurance policies from any state they want–isn’t really.

The reason buy-from-any-state brings down the cost of health insurance is that, if I can do that, I can choose to buy from a state that does NOT mandate coverage I don’t want.  So, if I don’t want to be insured for “mental health services,” I can go to a state that won’t require my policy to insure me for that.

But the bill mandates dozens of such forms of coverage on a federal level.  It won’t matter what state I’m in.  I’ll still have to have the mental health coverage.

There are people here saying that the point of this bill is to push through partial “reform” and then let it collapse, thereby “proving” the need for a single payer system–that is, that the people advocating for this bill know it’s going to make things worse and think that they can use that to get them where we’re going.

I think it’s a risky proposition.  Once things are worse, the electorate might decide that we need a single payer–or it might decide that they gave the government a shot and it was so bad, they’d better get it out of health care entirely.

So, Jem asks:

>>>>Are you saying that: a)we would be better off with the health care and insurance costs we now have b) that any health care reform that doesn’t include a public option does not serve the nation as a whole or c) that making health care insurance mandatory will result in unemployment for more people?>>>

And Cheryl is worried about the negotiating aspect.  So let me try to take everything in order.

First, do I think we would be better off with the health care and health insurance costs we now have?

Well–better off than what?  I think the bill as now written would make the cost of health care and health insurance worse, in the long run.  I think it will end up making health care more expensive and leaving even more people uninsured. 

But I don’t much like the system we have now.  In a way, it’s the worst of both worlds–all the drawbacks of a public system and none of the advantages. 

Second, do I think that any health care reform that doesn’t include a public option doesn’t serve the nation as a whole?

No.  There are forms of health care reform without a public option that would make things better–something like that insurance for catastrophic care only, everything else paid for by tax-exempt (or credited) MSAs (medicaal savings accounts) would probably make things better, because that would be an actual free market in basic health care services.

But this bill will only make things worse if there is no public option in it, because it forces us to deal with insurance companies that rip us off at every turn, thereby letting them go on ripping us off with impunity.  After all, what could happen?  If there’s a mandate, it’s not like we can refuse to deal with them and punish them in the pocketbook for their behavior.

Third, do I think that making health insurance mandatory will result in unemployment for more people?

Yes.

Absolutely.

Do the math.  If I’m a small business with $300,000 a year to spend on my workforce, and I employ 10 people at $30,000 a year, but do  no provide health insurance coverage–then when the government demands that I do provide that coverage, I must spend $10,000 a year EXTRA on each employee I hire.

But I still have only $300,000 to spend on employees.  That’s all the business can afford.

What do Ido? 

I fire as many employees as I need to to make up for the fact that each of the employees I have left now costs me an extra $10,000 he didn’t before.  Instead of employing 10 people, I employ only 7.

And, what’s more, I make sure to limit or eliminate, as far as possible, unskilled employees–I cut back on receptionists and put an automated system for most calls, for instance–because they’re the people I can most easily do without. Meaning there’s not just more unemployment, but the rise in unemployment hits the poorest people first, and disproportionately affects minorities. 

Most of the companies in the US that provide employment are small businesses–and a mandate for them to provide health insurance for their employees willresult in lots, and lots, and lots of firing.  It has to.

Fourth, do I think a public option would have to cover illegal immigrants?

Yes.

And I think that means that if we have one, we will have to restrict immigration generally and come down hard on illegals. If we don’t, we’ll see a lot of immigration specifically targetted at taking advantage of the welfare systems, and that will bankrupt those systems in no time at all.  That’s a drawback to any significant welfare system. 

I do know that it’s expensive to pay for health care on  your own–I suppose my basic response to that is:  so what?  It’s expensive.  A  lot of things are expensive.  I don’t see anything wrong with people paying out of pocket for health care, any more than I see anything wrong with people paying out of pocket for food.  Both are necessities.  We usually do expect to pay for the things we use.

As for the situation in Florida for hospitals–there is only one public hospital in CT.  All the rest–every single one of them–are private.  The vast majority are also not for profit.  And they make arrangements.  So do doctors.  For profit hospitals are a different animal, but I haven’t dealt with one. 

As for Cheryl’s problem with negotiating–you don’t negotiate when you’re sick, but after you’re well, and the reason for that is that health care is not like buying a car.  There’s a reason why I called these posts “Acts of Corporal Charity.”  Tending to the sick is always an act of charity, even when we fund it through a government program.  It is always the case that tending to the sick means helping people who do not have the resources to help themselves. Sick people don’t work. They spend down their assets.  They can’t give us much in exchange for caring for them. 

The hospitals I deal with are private not-for-profits that get tax breaks–in fact, are free of taxation–on the assumption that they provide a charity for the area in which they exist.  They’re not businesses whose purpose is to make a profit. 

Even if you’re insured, the chances are that the fees your insurance company pays for the procedures you get vary wildly from what other companies pay that same hospital for those same procedures.  All fees in US health care services are negotiated.  None of them is a standard price charged to all comers–and the stated price for people not insured is often far higher than what insurance companies pay.

If the insurance companies can negotiate down those fees, I don’t see why it’s dishonest for me to do it.

I once wrote a short story by this name.  It appears in an anthology called  Like A Charm that Karin Slaughter edited.  If you’re used to my novels, it may not be your kind of thing.  I’m a lot darker in my short stories than I am in my books.

But the reason the phrase occurred to me today is that I’m still thinking about that health care bill, and I’ve come to the conclusion that if there’s a single good reason to reject not only it, by any move to a public system in the US, it’s this:  the people who want to make absolutely sure that the public system does not cover illegal immigrants are right.

This is going to take a little explaining, so let me get to it.

To the extent that we operate health care as a public utility–which is largely what public systems do–the problem of free riders becomes acute.  We need everybody who is capable of paying into the system to pay into the system, because otherwise the system will go broke or be forced into rationing of a kind most Americans would not, and should not, accept.

Depending on the country involved, this may or may not necessitate taking a hard line against illegal immigrants.  Some countries don’t have very many, so that accommodating the few there are puts no strain on the system and can be done without large scale cost to the population at large.

The United States, however, has something like one and a half million illegal immigrants a year–okay, a guess, but you see what I mean.  We have lots of them.  I’m told that in some of the border towns of the southwest, the flood of such immigrants from Mexico overwhelms existing hospital facilites and sometimes public school systems as well.

And that’s without a public system.

Some of this problem could of course be addressed by stricter enforcement of existing immigration laws, and by accepting the need in such enforcement for an unflinching resort to deportation–but that particular policy tack makes lots of people very squeamish, and I think there’s good reason for that.

The country at large seems to have no trouble with the idea that we should deport people who have come here illegally–except, say, in cases where they brought their children when their children were four years old or so and now the kid is getting ready to graduate from high school and never even knew that he was here illegally and…

I didn’t make that up.  That’s a real case–in fact, more than one.  It doesn’t represent a huge number of cases, but I’d be willing to bet that if you went out into the country you could find dozens of such children and teen-agers, brought here by their parents so long ago they weren’t of an age to remember, who not only consider themselves Americans but who are Americans to the bone in every way but the official.

There are other kinds of cases, too:  the families of soldiers who have been in Iraq and Afghanistan; the families who have been here for decades and built businesses that emply “real” Americans and paid their taxes and all the rest and still do.

Americans tend to dislike the idea of illegal immigration a lot more than they dislike illegal immigrants, especially the ones they know in their own communities.  When it turns out that Carlos who does our lawn is illegal and the latest incarnation of the INS wants to deport him and his wife and children, we tend not to cheer on the deportation but to take up a collection to get him a good lawyer to fight it.

Immigration has done the United States more good than harm over time, and we tend to be very good at turning immigrants into Americans.  We do it through the public schools, yes, but also through our popular culture.  For all the yelling and screaming about large scale Hispanic immigration at the moment, the fact is that the Latinos show every sign of behaving like all other waves of immigration–the second generation speak both Spanish and English badly, the third generation speaks enough Spanish to swear effectively and figure out where the Christmas presents are hidden, and the fourth generation doesn’t speak Spanish at all.

In the bilingual education wars in California, for instance, the vast majority of the state’s Latinos were on the side of abolishing it and going for English immersion instead. 

Large, comprehensive welfare states tend to make it more difficult for countries to accommodate immigration and to assimilate immigrants.  There are a number of reasons for that.

One of them is that the success of such welfare states depends on a tacit acknowledgement of a tacit contract between all the members of a society–that is, on our all accepting certain base rules of conduct.  Sweden, for instance, did quite well with the most comprehensive welfare state on the planet as long as immigration was nonexistent to low, because all native born Swedes shared certain assumptions (state aid should never be asked for except in the last resort, for instance, and working hard and saving and keeping personal expenditures low was the only decent way to conduct a life, and government was good and not usually corrupt and therefore to be trusted and respected). 

Once Sweden started to take in large numbers of mostly Muslim immigrants from the Middle East, who saw government as essentially corrupt and in existence only to rip off the people, and therefore fair game to milk benefits from, the welfare state started to have significant problems, and the projection is that the problems are only going to get worse.

This is not to say that the Muslim immigrants were somehow immoral while the Swedes were moral.  Most of them came from countries where the governments were in fact corrupt, and not usually democratic to boot.  Their understanding of a citizen’s relationship to his government is the result of very real experience.  They have no reason to think that the government of Sweden will be any different from what they’re used to, except that it will be richer, and more willing to hand out stuff.

But you don’t need something as deeply significant as this to cause friction in a welfare state with a diverse population.  Think of the kinds of things that go on in families.  Bob and Sally are indignant that Johnny went out and bought those books today–he’s declaring bankruptcy!  Books are a luxury!  But Johnny, of course, doesn’t think books are a luxury.

The more real diversity a society has, the more difficult it will find trying to operate an extensive welfare state, and the more extensive a welfare state a society has, the more difficulty it will have in accommodating diversity.

I’m talking about real diversity now, not the rainbow sprinkles kind.  Some people think of “diversity” as black and brown and white and yellow people who all run around wearing  pretty colorful costumes and eating exotic food but all think the same way.

Real diversity means living side by side with people who think everything you believe is absolutely wrong, and yet finding a way to be all Americans together.

So there’s the argument from diversity against expanding into a public health care system.  Americans actually like diversity, even if they get exasperated with it sometimes, and most of them are not willing to give it up.

But I think what bothers me most about the need to restrict such a public system in such a way that it will not “cover” illegal immigrants is that it’s simply wrong to deny medical care to people who need it.

I don’t think I’ve ever seen it stated that baldly, but I think it’s at the core of what a lot of our present US health care debate is about, and a lot of why so many people are furious at the insurance companies.

In spite of all of the professional policy rhetoric we all talk in these days, health care remains, in the minds and hearts of most Americans, not a public utility or a business opportunity, but an act of corporal charity.

It is a moral obligation we owe to our fellow human beings for no other reason than that they are human beings and we are too. 

Hell, most of us now feel that way about cats and dogs. 

Still, I’d guess that almost all of us feel that way about human beings, and almost all of us find it deeply repugnant to envision a situation where a woman comes staggering into the ER about to have a baby, or cut up by her boyfriend so that she’s nearly bleeding to death, or collapsing from undiagnosed and untreated cancer, and we run her through a data base and go:  nope, no treatment, you’re illegal.

And yes, I know, that isn’t what would happen even under strict rules about illegal immigrants.  But it’s the possibility of that happening that makes so many people ambivalent about such rules, and some people completely hysterical on the subject.

I could go on for some time here about the roots of this conviction, that it is a moral imperative that we treat the sick.  It’s most certainly a Christian imperative and its strength comes from a Christian understanding of the relationship of human beings to their fellow human beings.

But for the moment, it’s mostly important to me that the unstated, unelaborated moral conviction exists, because as long as it exists it forms a part of the health care debate that cannot be ignored, even though we all spend so much time trying to ignore it.

And since it’s one of those Christian principles I don’t want to see disappear,  I’d rather we didn’t ignore it.

It may, however, provide the death blow to any public system, and we’ll have to wait until this system to collapse–which it will–before we can formulate something saner.

Every once in a while, I wonder if the universe is trying to tell me something.

Today, I wrote a post for this blog, which died when the computer froze up.

Then I wrote a second post of this blog, on the same subject, and accidentally deleted the entire thing when I was trying to copy it onto the post form.

I was writing about a book by Theodore Dalrymple called The New Vichy Syndrome:  Why European Intellectuals Surrender to Barbarism, and my general thrust was that somebody had foisted the title on him.

This is a man who is passionately committed to the principle that there are objective standards in art, that high art is among the greatest achievements of civilization, and that any educated person who prefers murder mysteries to Shakespeare and Kellie Pickler to Mozart is not just wrong, but doing something that is positively shameful.

It’s an interesting book on a number of levels, not the least of which is his feeling that the assault on art comes from three sources:  the aggressiveness of modern popular culture; the modern phenomenon of Islamic radicalism; and the people who now call themselves “artists” and “novelists” who produce things like Piss Christ and atonal “symphonies” and all the rest of the mindnumbing crap that makes up the contemporary “elite” art world.

But he’s also got no use for the endless bashing of “elitism” by contemporary conservative political movements, either.

Maybe I am just drawn to this thing by the fact that he is one of the very few other people who seems to be like me–neither on the left or the right of modern political thought, and definitely in favor of the life of the mind in general and the high art tradition in particular while not being in any way the American version of “liberal.”

Or, worse, “progressive.”  Have the people who call themselves “progressives” actually looked into the Progressive Movement?

Never mind.  This is try three, and I’m going at it mostly because it’s begun to feel personal, this thing with the disappearing posts.

If there’s a drawback to Dalrymple’s book, it’s that he never actually reaches any conclusions about why Europe is doing what it’s doing.  He certainly has no solutions he’s even interested in offering.

I don’t know why I think he should have them.

I’m going to give this another shot now.  I’ve replaced the Mozart with Telemann.  I have tea.

Keep your fingers crossed.

When I started thinking about responding to the comments on the last post, my original impulse was to strike at the argument about principles.

For instance–“our government” does indeed demand a lot of things from us, but the Constitution deliberately limits what those things can be, at least as far as the federal government is concerned.  State governments demand that people who want to drive have car insurance–actually, that people who own a car and want to drive it on the public roadways do, since you can have a license and no car, and then you can’t buy auto insurance even if you want to–but state governments are not the federal government. 

It took a Constitutional amendment to allow the federal government to impose an income tax on individuals, and another for it to institute a peacetime draft.  I could make a good case that there is nowhere in the Constitution where the federal government is authorized to impose such a mandate–and the lawsuits that will inevitably result from this bill are going to make exactly that case.

I could also go on at some length about the virtues of strictly limiting what actions a government is allowed to take, and at even more length about the incompatibility of a significant welfare state with large scale immigration.

And I may do all that at some point.

But the fact is this–even if we had a Constitutional amendment allowing it, I’d oppose this particular health insurance mandate, because it is what it is.

Why?  Well–

1) Because it’s not insurance.  Insurance is pool to spread the risk for things that are both relatively random and rare.  The “rare” part is important.  Most people who have car insurance will never have a major accident.  Most people who have house insurance will never have a house fire.  Even so, car accidents and house fires can happen for reasons almost entirely outside our control, and can happen to anybody at any time.  Therefore it makes sense to band together to pool our resources so that if that random chance happens to us, we have something to fall back on. 

If most people had car accidents, any car insurance scheme would bankrupt itself in no time.  The same for any house insurance scheme in a world where most people had house fires.

What insurance does not pay for is the routine cost of keeping up the car or the house.  Think of how expensive your car insurance would be if it was expected to pay for replacing your shock absorbers and fixing your flat tires, for your routine 3000 mile maintenance check-ups,  and for trips to the car wash.  Think of how expensive your house insurance would be if it was expected to replace your water heater when it got old and to pay for repainting the place every three years, never mind things like cleaning your gutters or getting the kitchen retiled when the tile got old and started to crack.

Health insurance is what we all had back in the Fifites–it covered things like hospitals stays and surgical procedures.  You paid for your yearly physicals, your routine check-ups. uyour vaccinations, and your routine medical problems (colds, flu, strip throat) yourself. 

What we call “health insurance” today is actually a comprehensive medical plan that covers every little thing we do and every visit we make to  a doctor.  It is not an insurance system, and couldn’t work as one–since it covers everything, everyone is drawing benefits from the system all the time.

That’s why “preexisting conditions” are so controversial.  Nobody expects your new car insurance, bought last week, to pay for fixing the damage caused in an accident you had a month before you signed onto the plan, and nobody expects your new house insurance to pay for damage that occurred to your house because you bought it, either. 

What we want from our health “insurance,” however, isn’t insurance, it’s a comprehensive payment system that will cover absolutely everything we need medically.

A government mandate to buy actual insurance would be relatively minor in terms of its impact–on an actual insurance model, as in the Fifties, it would be relatively cheap.

But a comprehensive payment system is going to be expensive.  Really expensive.

How expensive?

2) The costs are absolutely staggering.  In case you don’t know, the cost to buy comprehensive insurance–not a “cadillac plan,” but ordinary insurance–for a family where no one is over 50 is a little more than $900 a month.  The cost for a family where at least one member is over 50 is $1200 a month. 

And that’s assuming you can buy into a group plan at your place of work.  For self-employed people or people trying to buy insurance on the individual market, the prices are much higher, even in lightly regulated states.  (Regulations always drive up the costs of health insurance because they almost always mandate specific kinds of coverage.)

In a best case scenario, then, a family mandated to buy insurance under the new bill would be out between $10,800 and $14,400 a year–how many people do you know who can afford that? 

The bill is supposed to fix some of the problems with this–there’s a subsidy on a sliding scale, for instance, and individuals will be allowed to deduct the cost of their insurance on their income taxes.  At the moment, people with health insurance from their employers essentially receive an extra untaxed income in five figures, while people who must buy their own have to buy it with after-tax dollars or (if they’re self-employed) half with after-tax dollars, since the other half is deductible.

The mandate is just as bad for businesses–if my business is required to spend an extra 10 to 14 K a year on every employee, I’m going to hire fewer employees.  I’m going to have to.  The money available for salaries for staff is limited.  How do you figure the little Mom and Pop places are going to do under this kind of mandate?  On a business level, this damned thing is welfare for large corporations, effectively restricting the ability of their small competitors to grow and therefore challenge them.

3) The corporate practices of most US health insurance companies amount to legally sanctioned organized crime.  I’ve said this before, but I’ll say it again.  I had a cousin who worked in claims for one of the country’s largest health insurers.  She and her fellow workers were told to automatically deny certain claims even though these were explicitly covered under their health plans, because a good hunk of people wouldn’t dispute the denial, thereby saving the company millions of dollars by making it unnecessary for them to pay off on what they were contractually obligated to do.

This was not a single instance of bad management.  This is a fairly routine practice throughout the industry.  And it’s only one of a list of things these companies do to escape from paying off on what they have agreed to pay off on–and taken your money on your assumption that they would pay off on. 

If this was any other industry, these guys would be in jail.  The other side of the constant niggling interference of state regulation of insurance companies, however, has been both federal and state hands-off, look-the-other-way policies about corporate abuses and outright fraud.

I have nothing at all against people making lots and lots of money, as long as they earn it.  I figure Bill Gates deserves every cent he has, and Warren Buffet, too.  I don’t think there’s any such thing as “obscene” profits or “out of control” bonuses as long as companies aren’t using my tax money to pay them.

But this is not earned money.  The health insurance companies make most of their money these days by a form of bait and switch, by denying their customers what their customers are paying them for.

I’ll sit still for the mandate if there is a public option that allows me to refuse to deal with these people.

If there isn’t, what this thing amounts to is nothing better than government mandated rape.

I’m having one of those mornings where I feel sort of percolated–as if I’d swallowed a fleck of tea leaf and now I’m overcaffeinated.  This happens to me once in a while, and I don’t really know why.  Sometimes I do swallow a speck of tea leaf, and know it.  This morning, I was like this before I had my tea.

The problem with feeling like this is that I find I have a hard time concentrating on any one thing.  Part of my brain has been wandering around in the discussion about whether or not the people who want to know what Jon Venables did to land himself back in jail represent a “mob mentality.”

And I think I’ll stick to my original take–and, to an extent, the one from Spiked–that it seems to me that simply wanting to know, or even thinking that the government should be obliged to provide such information, isn’t the same thing as acting as part of a mob, or even of the kind of emotional irrationalism that a “mob mentality” implies.

One of the reasons I think I feel this way has to do with something that is not in any way part of the discussion about Jon Venables–the state of the public debate in the US at the moment on the subject of “healthcare reform.”

I’m not going to apologize for the scare quotes.  They belong there.  There is nothing about the present debate in the US that has the least to do with “healthcare reform.”  We’re not talking about issuing rules and regulation for, say, when doctors will be allowed to order CAT scans or when surgery will be required for breast cancer rather than a course of radiation.  We’re not even talking about new regulations to keep hospitals clean or to make sure imposters aren’t practicing medicine without a license.

What we’re talking about in the US is health insurance reform, which is something else altogether.

And I’ll say now, as I have several times in the past, that I personally would prefer to see some form of single payer system.  Those are the ones that seem to have worked best in most of the places I’ve lived, and that seems to be the only solution that will effect any kind of real change in the system we have now.

I am not, however, opposed to a free market in health care.  The problem is, we don’t have a free market in health care, or anything like it.  Not only are there endless mandates and regulations from both state and local governments–including federal provisions that make it illegal for the citizens of state A to buy their insurance from state B–but the health care companies themselves behave the way monopolies behave.  And monopolies are what we’re looking at here, both enabled by and protected by government (so that they’re exempt from antitrust law, for instance), and made stronger by the fact that it is becoming increasingly impossible for middle class people to refuse to have such insurance at all.

And yes, I did say refuse.  The one thing about the present bill that makes me absolutely wild–the one reason why I would be happy to see it defeated–is the individual mandate that would require all adults to purchase health insurance…from the health insurance companies.

Give me the public option, where I am allowed to refuse to give my money to these people at all, and I’ll consider it.  But the policies of most American insurers are outrageous, the exercise of power for the simple fact that it’s there to be exercised.  And I don’t see why my government should require me to hand my money over to them. 

I read an article a couple of months ago that pointed out that one of the problems Republicans and libertarians (small l) have is that they tend to be blind to the fact that large bureaucracies are large bureaucracies, whether they’re technicallay in the public or the private sector.  I’m not so worried about a “massive government bureaucracy” in health care because Aetna and Blue Cross/Blue Shield are already massive bureaucracies, and their operations are just as protected as that of any government department.

But in spite of my basic feelings about health care, the health care debate in this country has become very ugly, and the worst of it is definitely just that thing we were talking about in the Venables case–the tendency to see anybody on the other side as part of a “mob,” dangerous and out of control.

There are certainly some aspects of the present US opposition to “government run health care” that would fit this description, and individuals in the crowds who are almost certainly racists who would dislike anything Obama was in favor of simply because he is black.

But the fact is that there are cogent arguments to be made against the idea of socialized medicine in general and the present bill in particular, and most of the time the pro-“health reform” outlets like MSNBC don’t address them.  Instead, what we get is endless stories about how everybody in the crowd at the last tea party rally was white, or how one nutcase came with a sign saying we should shoot all the liberals, or whatever.

It’s like a national object lesson in ad hominem arguments.

I think there are good reasons to object to the attitude towards crime and criminals on display in the Melanie Phillips article, and, as far as I can tell, largely held by the present round of British authorities.  I think that protesting specific actions of those authorities–like not releasing the information on Venables–might be a reasonable expression of such objections.

Phillips’s article did not just present a position on the Venables case.  It presented a raft of assumptions and declarations on the nature of crime and not-punishment, an overarching understanding of the meaning of crime and what should be done about it.  I can see how people would object to that understanding.  I object to it, and that’s in spite of the fact that I think we lock up too many people in the US and think we’re far too quick to brand people for life. 

If Phillips is upset that too many people have dark and horrible ideas about human nature, the least she could do is address them, rather than simply dismiss anyone who wants a different policy on the Venables case as part of a mob out for blood.

And now I really need to go get something done.