Massachusetts deception

RomneyCare, Gov. Mitt Romney's "revolutionary" healthcare initiative, was introduced earlier this year to applause from the mainstream media, Senators Hillary Clinton and Teddy Kennedy, and Families USA-all wild at the idea of universal healthcare in Massachusetts. Such endorsements were not the best of signs for conservatives, but they were certainly eye-catching, especially with the hunt for future presidential talent on. And many Republicans were wondering whether RomneyCare was the conservative solution to the problem of uninsured Americans that the party was looking for.

Almost immediately after the bill creating it was signed into law, the Wall Street Journal ran an op-ed, which claimed that, under RomneyCare, "the state is forcing people to buy insurance many will need subsidies to afford, which is a recipe for higher taxes and more government intervention down the road." Not so, said Romney. Despite the potential weight of RomneyCare on the public purse -likely to be exacerbated by the plan's focus on signing up the 20% of Massachusetts' population that is eligible for Medicaid, but not enrolled-Romney said he would not need to raise taxes to pay for the program.

Of course, he was right. RomneyCare has not even been fully implemented yet, and a cost overrun of $151 million in 2007 alone is already in the cards, perhaps because the RomneyCare financial model assumed the wrong number of uninsured in Massachusetts (the Census Bureau puts it at 748,000, but RomneyCare assumes only 500,000). But any needed hike in taxes won't be pushed through by Romney -he'll be out of office when the bill comes due, and when extra federal dollars will likely have to be allocated to Massachusetts to help cover the shortfall between RomneyCare's cost and its budget.

Yes, RomneyCare is reliant on federal funds. So imagine if, as Romney hopes, it is replicated in other states. Even if we do not have federally-mandated universal healthcare a la HillaryCare, we could easily end up with that option's badly behaved little brother-"state-specific" universal healthcare, funded in large part, and at greater than current levels, by the federal government.

That matters because it means more government intrusion into personal healthcare choices. Government will end up funding healthcare at a higher level, and in exchange, making mandates about the kind of coverage you must have, and who may treat you (RomneyCare mandates that individuals must purchase HMO coverage; PPO coverage, often better and more flexible, is not allowed). Moreover, government will end up dictating to businesses and requiring them to incur potentially great costs: RomneyCare mandates that employers with more than 10 workers must assume ultimate financial responsibility if employees or their immediate family members need expensive medical care, and that if such businesses do not insure their employees, they must pay a $295 per uninsured employee fee to subsidize healthcare costs. This threatens employment levels and discourages small businesses from growing.

Ultimately, the entire specter of government engagement in the realm of healthcare hits at a fundamental question. Is healthcare and health itself primarily an individual responsibility, the product of individual choices made in consideration of private matters, or is it a benefit to be assured by the government, without regard to the wishes of the individual?

Only an individual can know what their objectives are in terms of health and how best to ensure that they are met. For example, someone with a rare and difficult-to-treat illness may wish to carry PPO insurance, rather than HMO insurance. PPO insurance generally affords access to a wider range of physicians and treatments, yet RomneyCare bans taking it out. Alternatively, someone earning $30,000 a year-too much to be eligible for state-subsidized insurance under RomneyCare-might want to buy cheap, basic coverage, instead of insurance costing around $3,600 annually for an individual and $11,000 annually for a family, plus 10%-14% annual inflation on premiums. But buying cheaper, more basic insurance is not possible-RomneyCare didn't change Massachusetts' rules mandating coverage for chiropractic treatment and acupuncture, or allowing purchase on the day of diagnosis, which make insurance there so expensive, compared to less regulated states.

This is the big problem with RomneyCare. It represents an interventionist, big government approach toward what is a highly personal matter, and does virtually nothing to reform burdensome insurance regulation that is responsible for the problem of underinsurance.

Romney disagrees with this characterization. He claims that his plan (and make no mistake, he claims it as his), which is already costing more than intended, imposes criminal sanctions on individuals who do not buy what may be a totally unsuitable product, mandates significant costs and imposes obligations on businesses, and results in government guaranteeing healthcare as a virtual right, is a good, conservative initiative. He contends that there's nothing wrong with forcing people via government diktat to purchase health insurance, because states already force people to carry car insurance. But he ignores that it is not standard to require drivers to carry insurance for damage to themselves or their own cars-only for harm done to others. This may be stupid, but so is driving a Yugo, and yet we don't mandate that everyone drive a BMW, do we?

Romney also contends that, since hospitals are required to provide treatment for the uninsured irrespective of their ability to pay, underinsurance is a grave risk and government already is in the position of footing the bill for something that should be a matter of individual responsibility. Yet, as the Wall Street Journal's "RomneyCare" op-ed notes, the cost of covering the care of uninsured patients is low, and uses a very small proportion of governmental medical budgets. Plus, the uninsured that benefit from emergency-room treatment can always be pursued as debtors, just like people who default on loans.

It is a shame that Romney could identify no more market-friendly options to curb the problem of under-insurance. Surely, in a state where insurance must cover rather exotic treatments, un-mandating coverage for chiropractic treatment and acupuncture as well as in vitro fertilization, could and should have been pursued first. This would have enabled cheaper policies to be marketed in Massachusetts, the number of uninsured to be cut, and for Romney to have legitimately claimed responsibility for meaningful, market-friendly reforms in the realm of healthcare-something RomneyCare effectively prevents.

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BULL**** ABOUT BRITISH HOSPITAL ER CLOSURES

The closure of accident and emergency services at some hospitals is in the interests of patients, the Government said yesterday. Presenting them as part of a plan to create "super-A&Es" to deal with heart attacks, strokes, and aortic aneurysms, Patricia Hewitt, the Health Secretary, sought to halt a tide of opposition to the closures. They were not about saving money but about saving lives, she asserted.

If that were true, Andrew Lansley, her Conservative opposite number retorted, it could have been done before, not after, financial deficits in the NHS had come to light.

The Department of Health published two reports to support the claims by Ms Hewitt. They called for "reconfiguration" of A&E services, to allow specialist centres for the most serious conditions to be created, and enable more people to be treated in their homes. According to Professor Roger Boyle, the national director for heart disease and strokes, local A&E units are not the best places for providing good care for patients suffering from either of these conditions. Specialist centres might mean a longer journey for many people, but they would produce better results, saving the the lives of 500 people suffering heart attacks every year, preventing 1,000 further heart attacks and saving 1,000 more stroke victims from death and disability, he said.

Sir George Alberti, the national director for emergency access, said: "We have to be up front and tell the public that, in terms of modern medicine, some of the A&E departments that they cherish are not able to provide this type of care and cannot and will not be able to provide the degree of specialisation and specialist cover that modern medicine dictates the public deserves." It would be better, he said, for many patients to bypass the local hospital and be taken by highly trained paramedics to specialist centres. " `But won't I die on the way?' many people ask," he said. "No, you won't. Long ambulance journeys do not lead to more deaths."

Ms Hewitt said: "Whenever the A&E starts to talk about reorganising, people think it's all about money and it isn't. It's about saving more people's lives, it's about making care more convenient, it's about getting the money into the right place so that people get the best care from the right person at the right time."

The Government fears that it is losing the argument over NHS reconfigurations, which involve A&E and maternity services, among others. The reports, published yesterday, are designed to present the issue more positively, by showing that change might not mean worse care. But the argument assumes that the money saved by closing some A&Es is devoted to building others into specialised centres. That is not guaranteed. Karen Jennings, the head of health at the public sector union Unison, said: "The climate of debt in the NHS puts the development of new policy under suspicion. We are extremely concerned that these policies may be being driven by deficits, not what is best for patient care. "If we move towards more specialist units we still need to ensure that patients have access to really good local A&E departments."

Geoff Martin, of the campaign group Health Emergency, said: "Claiming that closing local A&E departments, trauma units and intensive-care facilities will improve services turns all logic on its head. People are fighting these closures in their tens of thousands up and down the country because they know that closing local services and increasing journey times puts lives at risk."

Mr Lansley did not dissent from the idea of specialist units, which he has championed for some years. But he said that the patients who would be sent to them represented, at most, 5 per cent of all A&E attenders. "I accept the need for specialisation, but this should not be used to justify taking accessible A&E departments away from district general hospitals," he said.

Ms Hewitt said that casualty services in future would divide into three kinds, with "super- A&Es" for people with the most serious conditions, local A&Es for most treatment and the A&E that "will come to you" for less serious injuries. "Financial problems are forcing people to look at changes they ought to be doing anyway, and in a few cases financial problems are driving people to make changes they should have done years ago," she said.

The report by Sir George Alberti arrives at a similar conclusion. "Finances may have been the issue that drew the media's attention, but they are not the reason for reform," it said. "Reforming emergency care is about responding to medical advances and providing new and better services in ways that allow the NHS to save more lives."

Beverly Malone, the general secretary of the Royal College of Nursing, said: "Any changes must be subject to full and proper consultation with staff, unions, patients and local communities - after all, it's our NHS and we all deserve a say in how it is run and reformed." The Government has not produced a list of trusts where A&E departments have closed or are threatened. But the Tories say they have identified hospitals in 29 NHS trusts

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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