Still Too Early – But Perry Makes Some Points

Most here haven’t commented on the darting and illusory fortunes of the huge Republican field; I’d mentioned earlier that Perry would have trouble – double or triple BDS syndrome, a bit too much of an Aggie for Texas, God knows for the rest of the country. But that great t-sipper, Kevin Williamson, discusses the case for Perry after a strong speech. That’s worth reading and both Williamson & Perry are worth while.

Perry’s fighting, turning arguments around to free market principles, to the human: he did this earlier on the relatively friendly Fox’s Chris Wallace. Wallace pressed him on the number of uninsured Texans. Perry didn’t fight him on those grounds but on the far more important, far more serious, and far more consequential grounds of “access.” Access in Texas to health care has risen sharply with Perry’s policies. And, let’s face it, if there is enough access, all the assurances of insurance are pretty useless. Or, as Venzueleans found out, Chavez had promised to meet their every need – government promises of toilet paper and oil were there, access was not.

Almost any one who writes here – though especially Dr. Kennedy – knows more than I. So, I’m wondering. Does the entrance of CVS & Walmart & Walgreen as well as the increased number of local clinics indicate the free market is asserting itself? I’ve wondered if Obamacare’s high deductibles aren’t going to encourage a competitive medical market for the broken bones and blood work and pap smears of everyday life. (And knock down the prices, let doctors use their time more effectively – practice medicine rather than ride herd on a large administrative staff, and keep a larger percentage of what are likely to be reduced fees.) My kids can’t believe that insurance didn’t pay for our first child’s birth – we’d planned, saved, and, well, frankly it wasn’t all that expensive.

“Access” in Texas didn’t “just happen.” Not too long ago, doctors were in short supply in large parts of the state. But limiting punitive damages in liability cases, no state income tax, and our sunny environment flooded the state. A major factor had been juries who over-rewarded. But, that’s human nature when the payer seems a distant, impersonal insurance company and the payee a sad, suffering, specific & present case. Few have a vision strong enough to counter their instincts nor consider the consequences of sentimentality. But restraints have proven beneficial for the general good.

We watch Stossel every week to cheer us up in a gloomy time, his free market solution probably doesn’t answer as much as he thinks it does, but focusing on access remains a bed rock sensible consideration.

And Perry’s is one of the more thoughtful and philosophical of the attempts by candidates to use an accurate and attractive vocabulary for basic values that are broadly shared. But if he’s the best, he’s not the only. If I’m going to be represented by a woman, I’d rather it was of Fiorina’s stripe, who stands on her own feet & fights; if someone is going to defend the Republican stand on abortion, I’d rather it was Rand Paul. (I suspect more Republicans than not might want abortion legal – that may be up in the air. I don’t think it is up in the air that few if any Republicans would take the 9 month, partial birth choice of some Democrats. Indeed, few Democrats in an honest debate would.)

If Republicans accept the “available insurance” rather than access, the money for schools instead of the choices of schools, the length of unemployment insurance rather than the percentage working, they are going to lose. But these are not what people really want – they want freedom, they want access, they want choice, they want jobs.

17 thoughts on “Still Too Early – But Perry Makes Some Points”

  1. “My kids can’t believe that insurance didn’t pay for our first child’s birth – we’d planned, saved, and, well, frankly it wasn’t all that expensive.”

    My first three kids were born as uninsured and the cost was about $250. each. My fourth was born when insurance covered normal delivery and cost about $6000. The difference was 1965 to 1980. Hospitals used to use labor and delivery as “loss leaders” on the theory that people would seek care where they had their babies. The ER was similar. Now, at the hospital where I practiced for 25 years, a medical specialist with 30 years on the staff cannot admit a patient without the permission of the ER docs who function as “gate keepers.”

    The clinics that Wal Mart and some other stores are establishing with nurse practitioners are probably very good primary care. My wife (actually my ex-wife, we are back together after 25 years) worked as a nurse practitioner for years after our divorce. She worked for a busy GP who rarely had time for the supervision he was supposed to provide. When she had a question, she would call me. She was the “family doctor” for the parents and siblings of the young woman who married my younger son. They had a close relationship with her before they knew we had been married.

    I knew two women GPs who had an urgent care clinic in Dana Point for years before that term was in use. They had a small lab and x-ray in their office and took no insurance. They had a very busy practice that was mode up in large part by HMO members who did not want to wait in a clinic. They would rather pay cash.

    I think that the eventual outcome with Obamacare is that it will become an expanded Medicaid for the poor and the employed middle class will trend to a combination of cash primary care and catastrophic insurance for serious illness.

  2. >> The clinics that Wal Mart and some other stores are establishing with nurse practitioners are probably very good primary care.

    I’ve been advocating for that for years, and I’m happy to hear it’s coming about. For that matter, I don’t understand why RN’s – people with BS degrees or more in medical care – can’t operate clinics, albeit with a more limited mandate that a PhD.

    I’ve suspected for years that doctors, through the AMA and lobbyists, have been using regulatory capture to keep out the competition – PA’s and RN’s. I can’t prove that, but it makes sense to me. I also believe the trial lawyers were probably paying off legislators not enact tort reform. Either way, I hope both are coming to an end.

  3. I’ve long respected Perry for being a fighter – the type of person who will speak the unpleasant truths in ways that can be accepted and understood. This takes courage, the virtue that Plato considered the foundation of all other virtues.

    Too many of the other GOP candidates are mealy-mouths and that is the last quality we need to win. Americans are crying out for a leader and anyone who shows the courage to act like one (witness Mr. Trump) will be considered. But Perry is a seasoned government leader, far wiser than Mr. Trump. Perry has a track record as governor that gives us hope that he will be a great president.

  4. a combination of cash primary care and catastrophic insurance for serious illness

    Where can a US resident get true catastrophic medical insurance coverage? My premiums cover other people’s office visits, pregnancies, substance-abuse therapy and whatever else is mandated by state and federal regulation.

    I just left an independent PC physician because he went to a concierge system and now charges $3k/year up front. I don’t fault him but it didn’t make financial sense for me to keep him. (On top of what I pay for health insurance, which is probably on the low end for people my age, his fees would have raised my annual fixed costs to almost five figures and I am healthy.) I’d love to be able to get a major-medical policy for unlikely high-dollar risks, pay cash for everything else and bank the savings. But there are no such policies available, nor will there be, barring national reform legislation. So most of us are stuck with all-purpose first-dollar policies whose high prices are essentially a very inefficiently administered form of regressive taxation. And people who can’t afford these expensive insurance policies are essentially being shunted to Medicaid, where they pay the tax by waiting and getting lower-quality care.

    Obamacare killed many of the best parts of the current system, then took the worst parts and imposed them universally. It amazes me that to this day many people don’t understand what a colossal con job it is.

  5. Jonathan, what I think you are saying is this is a niche market (and a big niche) that someone out there should try to serve. I noticed after I sold my business that the local hmo was starting to offer a service that would have worked for my staff – I thought, they’ve noticed a niche out there. Of course, by the time Obama’s through he may have sucked the breath out of small businesses as well as medicine.

  6. I’d love to be able to just go see an RN about 95% of the time. Almost all of my yearly exams are almost totally done by a nurse and then I see the doctor for 5-10 min.

  7. “I’ve suspected for years that doctors, through the AMA and lobbyists”

    The AMA is a small lobby that exists to pay their own board members’ salaries. The last I heard, the AMA has about 25% of doctors as members and many of those are HMO docs whose dues are paid by the HMO. I quit years ago when I was a delegate.

    One of my pet peeves is the story of the CPT code book. The California Medical Association set up a reference called “The Relative Value Schedule” after World War II. Committees of specialists spent years of volunteer time deciding what different medical procedures were worth relative to each other. For surgery, they used “hernia units.” A hernia was determined to be worth half a gallbladder surgery. All procedures were ranked by complexity and skill relative to a hernia repair. That same was done with medical interventions like office visits. The doctor could then figure out his/her costs of practice and decide what an RVS unit was worth. If you were in San Francisco it was worth more than in Fresno based on office rent and salaries, etc.

    In 1972, just as I started practice, the Feds sued the CMA for anti-trust violation and won. All the RVS books had to be surrendered to the government. It was ridiculous. Even Medicare required the RVS code to bill so we all had Xerox copies of the book for several,years. Then viola ! the AMA came out with the same book but now called “Current Procedural Terminology.” They stole it using some federal intervention and now the AMA is funded by that f**king book. They have no credibility and are a total self interested bunch. Every month I get a “Dues Statement” in the mail in hopes my office manager will pay it accidentally. It goes in the trash.

    I have other AMA stories but they are crooks as far as I am concerned. I think they play NO role in medical economics except as a fig leaf for the feds.

  8. I just watched Perry’s speech, and it was quite good.

    I hadn’t heard anything about it until today, probably because it isn’t the type of message the media wants to get out.

    He’s exactly right that the best welfare is a job. I’m glad someone is saying it. If he gets it together during the debates then he’s going to be tough to beat.

  9. The late Carroll LeFon had a great analysis of Obamacare:

    The Mask Slips
    By lex, on November 10th, 2009

    The political calculus of the president’s health care agenda is revealed:
    ObamaCare serves the twin goals of “making the United States a more equitable country” and furthering the Democrats’ “political calculus.” In other words, the purpose is to further redistribute income by putting health care further under government control, and in the process making the middle class more dependent on government. As the party of government, Democrats will benefit over the long run.

    This explains why Nancy Pelosi is willing to risk the seats of so many Blue Dog Democrats by forcing such an unpopular bill through Congress on a narrow, partisan vote: You have to break a few eggs to make a permanent welfare state. As Mr. Cassidy concludes, “Putting on my amateur historian’s cap, I might even claim that some subterfuge is historically necessary to get great reforms enacted.”

    Daddy just wants to take care of you. For your own good.

    “Of all tyrannies a tyranny sincerely exercised for the good
    of its victim may be the most oppressive. It may be better to live
    under robber barons than under omnipotent moral busybodies.
    The robber baron’s cruelty may sometimes sleep, his cupidity may
    at some point be satiated, but those who torment us for our own good
    will torment us without end for they do so with the approval
    of their own conscience.” — C.S. Lewis

  10. Sorry, Ginny. I went off into the weeds a bit there. Who knows what comes next. The urgent-care/Walmart clinic route seems promising for a lot of routine care. It also seems likely that inexpensive automated early testing for many illnesses and conditions will increasingly become available. However, that still leaves a lot of medicine that requires highly-trained people and expensive equipment, and the current regulatory environment is driving away the trained people and distorting the incentives for capital investment. Perhaps the situation will improve with time and, if we are lucky, political movement away from the current regulatory extreme.

    (IIRC, the TX limitation on punitive damages passed when W was governor. Would that we could do something like that at the national level.)

    Michael, thanks for the reminder about your older post. It will be interesting to see what develops in the next few years.

  11. Where can a US resident get true catastrophic medical insurance coverage?

    Get a high deductible plan with an HSA. Mine has a $2,600 network/$5,200 out of network deductible, an $8,600 network/$17,200 out of network out of pocket limit. After I hit the deductible, which I don’t, it’s 10% network/30% out of network co pay up to the out of pocket limit. My employer kicks in $800 to my HSA and I kick in my max. I pay all current expenses with after tax dollars and will have the out of pocket limit in my HSA next year.

    I’m happy with real insurance instead of employer paid medical care.

  12. Thanks for the correction, Jonathan. Which shows you I suspect without 9/11 where Bush might have gone (I remember the press conference on changing soc sec – but . . . )

    Retiring, this is the last year for the flex plan. That, too, was a sensible idea, it seemed to me.

    And an argument that’s sensible is that we expect to pay for our oil changes, our tune-ups and often our fender benders; we want insurance for our cars not just because we have to – but because it is hard to replace a new one in most budgets and we sure don’t want our houses taken away because we made a wrong turn.

  13. Obama may have wanted to ensnare the middle class in his concoction but he has chickened out this far and I think it will never happen. Employer health insurance was supposed to b subject to the “Mandate” a year ago but it didn’t happen. I think the Democrats realized the firestorm that would follow such enforcement.

    So far, Obamacare is Medicaid for all. Even the California plan is collapsing. The OC Register has an interesting article that says the California system will be shut down.

    On June 25, the U.S. Supreme Court decided King v. Burwell, rewriting the law to allow the federal government to continue to pay tax credits through Although a disappointment for the rule of law, the decision gives California an off-ramp from the exchange business.

    The opportunity comes just in time. Until a few months ago, Covered California was able to disguise its problems because it was burning through federal grants. Nobody within the state was accountable for how the money was spent. Those days are coming to an end. Covered California has $100 million of federal cash left over to spend this fiscal year, but then that gravy train comes to a halt – and it will have to fund itself. This will be a struggle because its future funding depends on the number of enrollees, which is well below expectations.

    So, if there is a GOP president in 2017, is that going to continue ? I think the best plan is to just let it die, like Gingrich said about Medicare in the 90s and got into all that trouble. Don’t talk about it; just let it happen. Repeal will stir up all the anger. Let it die and enact a substitute for the middle class.

  14. a bit too much of an Aggie for Texas

    If someone can be too Aggie for Texas, then Texas isn’t Texas.

  15. And, let’s face it, if there is enough access, all the assurances of insurance are pretty useless.

    ITYM “And, let’s face it, if there is not enough access, all the assurances of insurance are pretty useless.”

    (Also, preview doesn’t work with Firefox 39.0 under OS X 10.10.4.)

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