208 Commission Rejects Free-Market Proposal
by Ari Armstrong, July 30, 2007
The 208 Commission, named after Colorado Senate Bill 2006-208 and more formally called the "Blue Ribbon Commission for Healthcare Reform," has rejected the only free-market proposal submitted to the Commission in favor of four plans that would dramatically increase political control of medicine in Colorado. To this set of four plans the Commission intends to add its own proposal for submission to the Colorado legislature next year.
In future articles, I intend to explore more fully the details of the four plans that the Commission selected. Here my purpose is to document the Commission's rejection of the only free-market proposal, "FAIR: Free-markets, Affordability, & Individual Rights," by Brian T. Schwartz, Ph.D. (archived).
In a letter (archived) dated February 22, 2007, Bill Lindsay, chairman of the Commission, announced a "Solicitation for Colorado Health Care Reform Proposals." Any person or group could submit a proposal. The deadline for submission was April 6. The Commission received 31 proposals, including Schwartz's free-market proposal. (While the Commission claims to have received 31 proposals, its list includes only 28 proposals. Perhaps the Commission received 31 notices of intent but only 28 proposals.)
I shared the results of some of my research with Schwartz for use in his proposal. In addition, Schwartz corresponded with Linda Gorman, who is so far as I can tell the only member of the Commission seriously interested in free markets in medicine.
Due in part to pressure by Gorman and other Commissioners who thought that the body should include a free-market proposal in the mix, Schwartz's proposal made the first round of selections. The Commission asked Schwartz to answer additional questions about his proposal, which he submitted (archived).
Overview of the FAIR Proposal
Before continuing with the chronology of the Commission's rejection of the FAIR proposal and selection of four proposals that expand political control of medicine, I'll offer a brief summary of Schwartz's proposal.
Schwartz gets to the root of the matter by explaining the causes of skyrocketing medical costs. Federal tax distortions have entrenched high-cost, non-portable, employer-paid health "insurance" that acts more like pre-paid medical care than true insurance. (I've made this point by contrasting health insurance with other sorts of insurance.) Next, massive federal welfare programs have further eroded the incentive of patients to seek the best value for their health-care dollar. In addition, federal and state governments have subjected health insurance to a host of controls, further increasing costs.
As John Stossel has summarized: "Government mandates, overregulation and a tax code that pushes employer-paid health insurance prevent the free market from performing its efficient miracles. Six out of seven health-care dollars are spent by third parties. That kills the market. Patients rarely shop around, and doctors rarely compete on price or service."
Schwartz opens his proposal with a quote by Milton Friedman:
Third-party payment has required the bureaucratization of medical care and, in the process, has changed the character of the relation between physicians (or other caregivers) and patients. A medical transaction is not simply between a caregiver and a patient; it has to be approved as "covered" by a bureaucrat and the appropriate payment authorized. The patient -- the recipient of the medical care -- has little or no incentive to be concerned about the cost since it's somebody else's money. The caregiver has become, in effect, an employee of the insurance company or, in the case of Medicare and Medicaid, of the government. The patient is no longer the one, and the only one, the caregiver has to serve. An inescapable result is that the interest of the patient is often in direct conflict with the interest of the caregiver's ultimate employer. That has been manifest in public dissatisfaction with the increasingly impersonal character of medical care.
(In an appendix on pages 47 to 54 of his report, Schwartz includes an essay by Friedman.)
Measured by access, survival rates, and mortality rates, people in the [United] States have access to the best health care in the world. Yet, costs of health care covered by third parties (e.g., insurance, Medicare, and Medicaid) are exploding. ... Health care costs have been increasing because federal tax policy and state-level mandated benefits encourage insurance policies to offer too much coverage, not too little. This escalates costs such that too few people [have] access to adequate health care.
Decades of misguided federal and state policies have trained many people to expect somebody else to pay all or most of their routine, expected health care expenses -- while they get stuck with outlandish insurance and tax costs. The problem is not "profit" or the "free market" -- there is no free market in modern American medicine. The problem is political interference in medicine.
Schwartz's proposal is the only one to suggest rolling back the political controls that have created existing problems. The four proposals selected by the Commission all call for more political controls.
The income-tax distortion, Medicaid, and Medicare are creations of the federal government. The state legislature can do nothing directly to alter those programs (even though federal rules grant significant leeway to the states for spending Medicaid dollars). Thus, the most important reforms must occur at the federal level. (The introduction of Health Savings Accounts, which equalize the tax exemption between individual and employer-paid health insurance, is a small step in the right direction.) Because the Commission was authorized by the Colorado legislature to make recommendations regarding state policy, Schwartz explained the problems at the federal level but specified reforms that the Colorado legislature can enact. Thus, Schwartz's proposal would not, if enacted, totally solve the problems in medical policy. It would, however, take significant steps in the right direction. And it does offer a general outline for needed federal reforms.
Schwartz first recommends that the Colorado legislature remove its mandates for health-insurance benefits. By law, much insurance in the state must offer benefits such as mental health for emotionally healthy people and maternity care for people who have neither the intention nor the physiological ability to have children. These mandates increase the cost of insurance premiums, price some people out of the market, and force some people to subsidize the health expenses of others.
Second, Schwartz recommends that the legislature phase out "guaranteed issue" requirements for health insurance for the self-employed. The problem is that, if people are guaranteed insurance even after they get sick, they have less incentive to purchase insurance while they're healthy. Schwartz's proposal is limited in scope because the federal government imposes "guaranteed issue" requirements for other small employers.
Third, Schwartz wants to scale back the dysfunctional Medicaid system and introduce more private competition. Schwartz writes: "Medicaid reform seeks to transfer more enrollees into the private insurance market... decrease over-consumption with cost-sharing... reduce asset sheltering for long-term care... and increase access to home-care.... This proposal also asks the Colorado legislature to allow Medicaid to compete for funding with voluntary charities on the private market."
In an appendix on pages 39 to 46, Schwartz discusses the various failures of Medicaid. The program does not meet the Commission's own requirements for reforms, Schwartz notes. Schwartz summarizes: "Medicaid is neither efficient nor sustainable. Further, it limits consumer choice and access to health care for both enrollees and taxpayers who fund it, and increases the health care costs for those not enrolled. It provides sub-par quality care for its enrollees, and disempowers them because its means-based eligibility discourages them from saving money and seeking higher-paying jobs."
Yet, rather than look at ways to scale back Medicaid in favor of health care that works, the Commission selected plans that would massively expand Medicaid.
The Commission Evaluates FAIR
On May 17, the Commission met to discuss the proposals. A summary of the meeting is provided in the Commission's document, "05/17/07 Commission Meeting-Draft Summary" (archived). I didn't attend the first part of the meeting, when the Commission discussed FAIR. However, I've read the notes published by the Commission, and I've also seen the notes of Lin Zinser, who heard the discussion.
The Commission's notes first deal with Medicaid reforms. Concerns center on the workability of the suggested reforms. The Commission's notes are more positive regarding the other two major reforms. (Names of Commissioners who offered particular comments are not included. In some cases, the notes are ambiguous, so I am giving them the most plausible reading.) Schwartz's reforms would potentially "minimize adverse selection," reduce the costs of insurance premiums, increase the number of people who purchase insurance, and reduce the problem of "free riders" in which "people who do not take personal responsibility (i.e. buy insurance)" then expect "free" care at the ER.
Next, unfortunately, the Commission's notes suggest that, without third-party intervention, low-income people are too stupid to seek needed preventative care. Here's the relevant line: "Cost-sharing for managing utilization -- for low-income individuals, that equation may result in under-utilization and drive up costs on the back end when people forego preventive care."
This line is frankly insulting to those with lower incomes, most of whom are quite capable of acting prudently even without "help" from the nannies on the Commission. I have already critiqued the claim that, absent third-party payment, people won't get needed preventative care that saves money in the long run. It just makes good sense to take care of your health in order to minimize the risks of expensive long-term problems. A paper from United Health Group reinforces this, as Schwartz points out. (Similarly, it makes sense to change the oil in your car, paint the house and fix the roof, and so on.) The only incentives to take foolish risks with one's health are created by political controls that mandate "free" high-cost care. Schwartz also points to a paper from The Journal of the American Medical Association showing that high-deductible insurance discourges abuse of ERs. Granted, some people don't change the oil, fix the roof, or take care of their health -- but this is not a problem that can or should be solved with greater nannyism.
That is not, unfortunately, the first time that the Commission has insulted the intelligence of Colorado citizens. When asking follow-up questions of Schwartz, the Commission claimed, "This proposal requires a much higher educational level regarding managing one's health care coverage than the vast majority of people possess." One Commissioner elaborated: "The proposal requires a great deal more understanding of personal health matters than is possessed by the general public. In order for the public to handle heath care coverage that requires more financial involvement and personal responsibility they will need a much higher degree of understanding. If the public was just thrown into the structure described in the proposal, there would be chaos." (It is possible that the Commissioner was to an extent playing devil's advocate.)
In addition to the general response that, no, most Coloradans are not too stupid to direct their own health care and seek out expert opinions, I have several additional replies. First, Schwartz's reforms would have limited impact on most Colorado residents, so the suggestion of impending "chaos" is hyperbolic nonsense. Second, as Schwartz suggests, every incentive to avoid responsibility for one's own health is created by political controls on medicine. Third, Schwartz's reforms would increase people's incentive to take care of their health. Schwartz's further comments are worth review:
[I]t is this personal responsibility, ability to choose, and self-determination gives each of us identity, values, and makes possible a meaningful life. In many cases government policies have the same effect on citizens that over-protective parents do on their children. ... Consumers already have choices in life insurance and car insurance, and there are on-line services that compare plans. To the extent that Coloradans are not informed health care consumers, their ignorance can be attributed to existing government policies. For example, the federal tax-exemption for employer-paid premiums limits consumer choice by providing a large incentive for consumers to be insured through their employer. ... The [Commissioner] writes that if 'the public was just thrown into the structure described in the proposal, there would be chaos.' This implies that my proposal suggests radical changes from the current system, whereas these changes are meant to be incremental and are modeled on existing policies.
The Commission's notes add: "Disconnect: people care about cost when they purchase insurance but not when they need care." This again is mostly nonsense. The large majority of visits concern health care for matters that aren't immediately life-threatening. In such cases, people (in a free market) have every incentive to spend a little extra time to find the best value for their money. With respect to life-threatening emergencies, it is true that people will, at the time of treatment, generally choose haste over cost, as is prudent in the circumstances. However, there are three mitigating factors to this tendency. First, people can research hospitals in advance. (Even today most people have some idea of which hospital they'd prefer, and on a free market independent parties would offer much more extensive information to prospective patients.) Second, most people would (in a free market) hasten to purchase insurance for unexpected, high-cost procedures, so insurance companies would also have an incentive to monitor costs. Third, after one's life is out of immediate danger, patients and their families can easily consider simple, common-sense cost evaluations. Of course, one major problem in modern American medicine is that Medicare and Medicaid underpay for health procedures, causing hospitals to try to pass along those costs to other patients.
The Commission's notes claim: "Many of the things the public has told us they want would be lost if we follow a mandate-free approach. Insurers won't cover high-cost services [without] mandates." This statement manifests a basic ignorance of the concept of "concentrated benefits, dispersed costs." "The public" does not speak in one voice. Instead, certain members of "the public" ask politicians to force other members of "the public" to fund their needs. Obviously, many members of "the public" would, if they were legally allowed, purchase lower-cost insurance lacking benefits that they don't need or use. As for the question of whether insurers would offer certain benefits absent mandates, that should be entirely between the insurers and their customers. (Note that insurers agree to provide life insurance with very high pay-outs, and people happily agree to buy it.)
The Commission's notes continue: "Community rating makes premiums so high that healthy people leave system -- that's what leads to need for individual mandates." In other words, political controls breed calls for more political controls. However, there is no "need" for individual mandates; there is a need to remove the political controls that created existing problems. Unfortunately, more political controls are precisely the "solution" at which the Commission is now looking.
The Commission in its notes concedes that FAIR is a "unique proposal." What's unique about it is that it's the only proposal that seeks to return to voluntary association and free markets rather than impose more political controls on medicine.
The Commission Promotes "Bold," "Refreshing" Health Socialism
The Commission's notes regarding "Better Health Care for Colorado," proposed by the Service Employees International Union (archived), state: "Overall: well-thought-out, some good concepts." This proposal would dramatically expand medical welfare.
With respect to the single-payer plan, the Commission's notes state, "Bold approach." Bold, indeed: the plan would socialize the financing of nearly all medical care in Colorado, place all doctors and patients under the control of a new health bureaucracy, and impose price controls, among other things. This "Colorado Health Services Program" was submitted by the Health Care for All Colorado Coalition (archived). (I've discussed the proposal elsewhere, and I'll evaluate it in greater detail in the future.)
The other two plans selected by the Commission are "Solutions for a Healthy Colorado," submitted by the Colorado State Association of Health Underwriters (archived), and "A Plan for Covering Coloradans," submitted by the Committee for Colorado Health Care Solutions (archived). In a statement (archived in parts one and two), the Commission lists and summarizes the four selected proposals.
I did attend the part of the meeting in which the Commission discussed the single-payer proposal. It became abundantly obvious that the Commission (on the whole) is strongly biased toward more government control of medicine and against free markets in medicine.
True, some of the Commissioners did raise concerns about the practicality of the plan and its accountability to taxpayers. But other Commissioners spoke glowingly of socialized medicine; two Commissioners described it as "bold" and "refreshing." And, after all, the Commission selected the single-payer plan and rejected the free-market proposal.
A snipet of the discussion in which three Commissioners praise the single-payer plan is available as an mp3 file. (Unfortunately, the sound quality is not very good, because during its early meetings the Commission didn't amplify its discussions for the benefit of the audience.)
For me, sitting through various Commission meetings has been a painful experience. You get the usual interminable and often-pointless discussion that typifies any large bureaucracy. And this Commission is absurdly large, with 27 members. (The original number was 24. SB-208 was passed in 2006, when Bill Owens was governor, so Owens appointed some of the members. However, the new governor, Bill Ritter, appointed three additional members.)
But the problem is not primarily one of numbers. Each of the members was selected by a leading Colorado politician. Yet each put him or herself in a position to be selected. Thus, to a large degree, the Commission is self-selected among those with a prior interest in expanding government control of medicine. The Commission is to a large degree an echo chamber. The members tell each other what most of them have long believed -- such that socialized medicine is "bold" and "refreshing" -- and they surround themselves with staff and speakers who reenforce the party line. The result is that the Commission is largely insulated from the views of most Coloradans, who see nothing bold or refreshing about putting their health in the hands of politicians and bureaucrats.
As just one illustration of the tendency of the Commission to devolve into a Theater of the Absurd, I'll include a comment from Commissioner David Downs, available also as an mp3 file. He is discussing whether a plan mandates insurance coverage: "The way that it's enforced is through default enrollment... But it proposes that anybody that doesn't sign up is automatically enrolled." At this point, another Commission member broke in: "That's even worse: no choice." To this, Downs replied, "No, you have choice. But if you make the choice not to be covered, the enforcement is, you're covered."
Commission Touts "Diverse" Plans to Expand Political Control of Medicine
On May 21, the Commission held a media conference at the State Capitol to discuss its selection of the four proposals. (Shown in the photo are Commissioners Linda Gorman, Christy Blakely, Bill Lindsay, Julia Greene, and R. Allan Jensen. The next photograph shows Edie Sonn, who works for Strategic Policy Communications and contracts with the Commission, and Lindsay, who chairs the Commission.)
A complete recording of the conference is available as an mp3 file.
Lindsay claimed that the Commission is a "very diverse group, both politically and ideologically." Yet, aside from Gorman, the token free-market member, the Commission endorses only a "diversity" of ways to impose government controls.
Blakely claimed that the Commission first pared down to eleven "very diverse" proposals, from which it selected four "very different" ones to model and submit to the legislature. She reiterated the point, claiming that "the Commission... decided to get a breadth of proposals" that are "very diverse." Yes, the Commission selected four "very diverse" ways to impose more political controls on medicine.
One reporter asked to what degree the plans would "cost a lot of money." Lindsay answered, "We recognize there may be a significant price tag. That is a concern. That is not something we took lightly." He said he'd rely on the modeling firm to quantify the costs. He added that "a lot, or a whole bunch, needs to be defined" with the plans to generate cost estimates.
Lindsay continued, "Each of the proposals includes specific provisions to attempt to reduce costs. There's a myriad of suggestions included in these proposals. But we've got to recognize that if you suddenly, on January 1 of some year, dropped a curtain and allowed all Coloradans to have access to insurance, at the same time implementing cost-containment provisions, the access to insurance will start to drive costs immediately, those cost-containment provisions will take time in terms of their savings capability."
Lindsay's comment here is stunning. He recognizes, as I (and many others) have argued, that "allowing" -- i.e., either directly forcing or subsidizing through force -- "universal" health insurance, insurance that covers all or most routine health visits (and that is thus more pre-paid medicine than real insurance), will artificially and dramatically drive demand for health care. Other things equal, this must increase costs. Ah, but then the "myriad" of "cost-containment provisions" will magically offset this artificial demand. What does this mean? Among other things, it means that bureaucrats will decide which medical procedures will be provided.
I asked, "How can the Commission justify throwing out the only free-market proposal in favor of four 'very diverse' proposals that all increase the power of bureaucrats over the lives of Colorado citizens?"
Lindsay answered, "The FAIR proposal, as it was referred to, supposedly free-market proposal, we did not feel was as thoroughly thought-out, fleshed out, as were the other proposals, frankly. That doesn't mean it was a bad proposal. It doesn't mean it maybe didn't have a lot of merit. We just felt the other four proposals were more specific, were more focused, and more detailed. I would also argue that the first proposal in the list that Christy [Blakely] identified, which is the Better Health Care for Colorado Proposal [the union plan], has a lot of... aspects of the current system in it, and I think comes close to being what you would consider to be a current market-based proposal. [It] didn't go as far as the FAIR proposal, but I think it has those attributes in it."
Lindsay's comments are misleading on several levels.
The union proposal is not remotely similar to a free-market proposal. Instead, it calls for the massive expansion of Medicaid, the coercively funded, government-run welfare program. It represents a move further away from free markets.
I asked a follow-up question, "So by 'market-based' you mean an expansion of bureaucracy over citizens' lives. That's what you mean by 'market-based'."
Lindsay replied, "We can debate that issue, but if that's your determination I guess the answer would be yes."
What about Lindsay's other characterizations of the FAIR proposal? He claimed that FAIR is not "as thoroughly thought-out." Yet Schwartz's proposal uniquely explains the actual, root causes of existing problems in medicine, and it offers specific steps to begin to reverse those problems. Not only is the FAIR proposal well thought-out, but it is the only proposal that the Commission examined that is "thoroughly thought-out."
Lindsay's claim that the FAIR proposal is not "thought-out" amounts to an ad hominem attack. Rather than offer specific criticisms of the plan, Lindsay merely dismissed it out of hand with a sweeping indictment of Schwartz's intelligence (at least as applied to the FAIR plan). Meanwhile, Lindsay's Commission selected the proposal of Rocky White, whose arguments are demonstrably ridiculous.
Lindsay's claim that the FAIR proposal is not as "specific" is similarly laughable. Granted, any reform of Medicaid will be plagued with problems, precisely because it is a federally funded, chaotic, government-run welfare program. On that score, Schwartz's proposal is at least as "specific" as any other plan. But Schwartz's two other proposals, regarding benefits mandates and guaranteed issue, are quite specific, in that they indicate specific state statutes that should be revised.
I sat through the Commission's meeting on July 17, during which the Commission reviewed the first results of the modeling. What was abundantly obvious throughout the meeting is that the other plans were anything but "specific." Not only were the plans' authors allowed to modify their plans during the modeling process, but the hearing was punctuated by claims that the plans could be further modified, apparently indefinitely, in order to address continuing problems. (I'll include more information about that meeting at a later date.) Yet, according to Lindsay, it is the FAIR proposal that is not sufficiently "specific."
Lindsay's suggestion that the single-payer plan, which would massively expand political control over medicine, is somehow more "focused" than the FAIR proposal is equally absurd.
Commission Claims Government-Controlled Medicine is "Free Market"
On May 28, Dr. Paul Hsieh sent the following letter to the 208 Commission via e-mail:
Dear 208 Commission:
On May 30, the Commission responded:
Note here the inconsistency in the Commission's replies. First Lindsay claimed that the union proposal is a "market-based" alternative to the FAIR Proposal. In its May 30 communication, the Commission admits that none of the four selected proposals is "free-market." But what is this alleged second "free-market proposal?" I asked Edie Sonn, who (as noted) works for the Commission:
Here's the reply I received:
Subject: RE: "free-market proposal"
Perhaps Sonn would like to share with Lindsay her opinion that the FAIR proposal is "comprehensive." But is the Simple proposal (archived) actually a "free-market proposal," as Sonn (writing for the Commission) claims? Following are the five provisions of that plan:
First, the Simple plan would "make it illegal to sue a doctor, physician's assistant, nurse practitioner or hospital in Colorado." This provision is not "free-market," it's just silly. I quite agree that frivolous suits should be limited. But a free market entails and requires the legal enforcement of contract, and this involves torts under objective law. So the Simple plan is in this case in violation of free-market principles.
On this first point, the Simple plan continues:
Making it illegal to sue a healthcare provider sets off a chain of events that combined with a few simple changes can revolutionize healthcare. People can file complaints to the Board of Medical Examiners who would become more active in policing physicians and ridding the state of incompetent doctors. The Board of Medical Examiners would also have the luxury and responsibility to pick and choose from the best of the best physicians who will flock to Colorado to practice, leaving no physician shortage areas. The state should develop a strategy of recruiting an army of primary care physicians with a broad scope of practice who are intent on meeting the needs of their patients, not intent on excessive wealth and offer these physicians esteem and moderate financial security, and the ability to spend the majority of their time taking care of patients unencumbered by administrative red tape.
For Sonn to suggest, in a letter that she wrote for the 208 Commission, that a "free-market" entails allowing a bureaucratic "Board of Medical Examiners" to "pick and choose" Colorado's doctors is grotesque. Obviously, neither Sonn nor the Commissioners who empower her to write letters in the Commission's name have even the remotest idea of what is a free market.
But the Simple plan gets more ridiculous: "Second, in exchange for this absolute tort reform, make it illegal for any physician in Colorado to refuse to see a patient because of their inability to pay." Okay. For the record, when politicians force doctors to see patients, that's not a "free market."
The Simple plan's third proposal involves state controls on insurance. Its fourth proposal involves state controls on medical pricing. Its fifth proposal calls for state subsidies for "preventative medicine."
In other words, not a single element of the Simple proposal is free-market in nature. Yet Sonn calls the ridiculous Simple plan a "free-market proposal" and thus tries to taint the FAIR proposal by association. The two proposals are not even remotely similar in content or quality.
Commissioners Attack Their Critics
In a June 29 Speakout for the Rocky Mountain News, 208 Commissioners Elisabeth Arenales and Steve ErkenBrack continue to subject their critics to ad hominem attacks.
The Commissioners claim that their critics are making claims about the Commission that are "wildly different" from the facts and are "generating some misperceptions." Yet the Commissioners do not offer even a single example of the alleged inaccuracies of their critics, nor do they bother to specify which critics they are discussing. Thus, their claims are nothing but personal attacks meant to taint the character of anyone who dares speak out against the Commission. (I, on the other hand, have cataloged my specific complaints against the Commission.)
Discussing the selection of proposals, the Commissioners write, "To develop that list, we looked for a range of the most well-thought-out proposals that we believe will give legislators the best information about the impact of various approaches to health-care reform."
The claim is again that the FAIR proposal is not as "well-thought-out" as is, say, Rocky White's single-payer plan. This is, again, nothing but an ad hominen attack.
Then the Commissioners have the gall to assert: "We selected four very different plans to analyze. ... One emphasizes choice and the enabling of market forces."
I sent Sonn another e-mail:
Sent: Friday, June 29, 2007 1:01 PM ...
Sonn wrote back with one acronym: "CSAHU," a reference to the plan by the Colorado State Association of Health Underwriters. That's odd, because on May 21 Lindsay claimed that the union plan is supposedly the "market-based proposal," because the other three plans impose universal mandates. However, on July 17, the lead author of the CSAHU plan did describe it as involving "private market competition." Yet the central feature of the plan is a massive expansion of political control over medicine and the further violation of free markets.
In fact, the FAIR proposal was the only free-market proposal submitted to the Commission. The Commission rejected the FAIR proposal because most Commissioners are committed to more political control of medicine. The fact that various Commissioners refer to politically-controlled medicine as "market-based" or a "free market" demonstrates only those Commissioners' overwhelming ignorance of what free markets are and why they are effective and just.