The MAGA Doctrine Page 12

  The American public tends to think the same way. They aren’t hard-core ideologues, but they want politicians to keep their word, and they want policies that yield the results advertised. Those aren’t unreasonable demands. But they’re demands that are rarely met in politics. In politics, unlike the world of business, not accomplishing anything can be its own kind of success. The only “results” most politicians are interested in are the votes in the next election.

  Trump wants to solve problems. His emphasis on tackling the opioid crisis is evidence he’s not just indifferent to all recreational drug use. But he knows when to abandon a losing tactic, unlike most people in Washington who are content to keep trying the same strategies over and over again for decades (literally, in the case of the war on drugs, which has been going on for about fifty years now).

  He hasn’t quite yet decided to abandon the whole drug war—though at times he has expressed sympathy for letting the fifty states experiment with different approaches, one way to discover if there’s a policy out there that works better than what we’ve been doing. He knows, though, that locking up 0.7% of the population hasn’t done the trick, and more of the same probably won’t enable us to turn some magical corner in the drug war.

  Trump’s brother Fred died from alcoholism at age forty-three, likely influencing Trump’s own decreased consumption of alcohol over the years. Trump probably doesn’t think that raiding his brother’s home with a SWAT team at 3 a.m. and threatening to put him in prison would have been the most humane solution to his addiction. A great country doesn’t give up on its addiction-plagued citizens, and it doesn’t just shoot them or lock them up and throw away the key. It has the patience to keep searching for solutions, and that will probably involve changes in law, culture, and our understanding of psychology. As with broader criminal justice reform, it will be a long-term, evolving process.

  So, too, the reform of the healthcare system, which, as we’ll see, has a lot more problems than just excess opioid distribution.

  Chapter 11

  Making America Well Again

  The Republican Party repeatedly promised to repeal Obamacare—but there were grim pronouncements that the law was just too complex to get rid of cost-effectively. It was already shaping the behavior of too many doctors, hospitals, and insurance companies to uproot.

  A Republican-appointed Supreme Court chief justice, John Roberts, gave Obamacare the final blessing by voting not to overturn it, reasoning that the “individual mandate” at the heart of the Affordable Care Act wasn’t an authoritarian penalty, designed to make people engage in commerce they didn’t want to engage in. According to Roberts, the mandate was just a tax after all, and thus within Congress’s power to levy, even though the whole Obamacare package, the Affordable Care Act, had been shoved through Congress in part through the rationale that the individual mandate wasn’t a tax—and thus that finalizing the whole bill during a “reconciliation process” (the Senate and the House supposedly working out mere clashing details) was legally acceptable, no big deal.

  Obamacare wasn’t a tax when it needed to avoid being a tax, then it was a tax when it needed to be one to survive a constitutional challenge. Voila, socialized medicine in America takes another stealthy leap forward.

  But then Trump managed to undo that sometimes-a-tax-sometimes-not-a-tax, in an underappreciated detail of his 2017 tax reform bill. The bill didn’t formally repeal Obamacare. It just lowered the penalty for failing to buy mandated health insurance to $0. I can think of a lot more laws that would benefit from a penalty that size.

  The individual mandate summed up so much that is wrong with the way twenty-first-century liberals think about their role in society. Faced with the undeniable fact that some people have difficulty paying for healthcare—thanks in large part to regulations and tax rules decades ago that herded most employees into a tiny handful of corporate health insurance packages provided through their employers, erasing real competition and the price transparency found in most normal purchases—Obama-era liberals decided to “help” the uninsured by just ordering them to buy health insurance.

  Not so great for people who calculated that they could get by without it for a short time to pay other bills—but great for the insurance companies, who suddenly had a whole new swath of involuntary customers. It’s a little like the logic behind minimum wage laws: Liberals wish you had a higher-paying job, so they’re going to outlaw the lower-paying one in which you currently work. Gee, thanks.

  Trump’s approach to healthcare may be the best example of the new conservative approach. In the past, the parties have had to decide whether to side with big businesses, the insurance companies, the hospitals, or the American Medical Association if they wanted to get anything done. Instead, Trump has repeatedly sided with individuals and small businesses.

  One of the big criticisms of Trump’s elimination of the individual mandate is that if millions of young people seize the opportunity to stop paying for health insurance, Obamacare-linked health insurance programs will go bankrupt. They’ll be paying out to the old and the infirm without being subsidized by the steady flow of young, healthy (involuntary) customers they’d been counting on. Now, warn critics, the whole system may implode because of the financial imbalance.

  But is this the fault of Trump? Is this the fault of the young people being dragooned into participating in the system?

  It’s bad enough that we pay for things through insurance in the first place. No one can keep track of who owes what to whom: patients, doctors, insurance companies, pharmacies, and on and on. So much easier if you knew the price up front and knew when it was fully paid. But insurance companies, if they’re going to be involved in something as complex as healthcare at all, are surely responsible for doing their math homework to see whether their businesses are profitable. It shouldn’t be one giant pyramid scheme in which the young keep having to be suckered in—or thanks to Obamacare while the mandate existed, forced in—to keep the payments going out on the other end to the more infirm.

  There’s no reason an activity that could be run like any other free-market business—with competition to provide better service and lower prices—should be forced to operate like this. Even if we conclude that the government must subsidize poorer customers, let everyone make their healthcare purchases as individuals on the open market as they please. Then we can help pick up the tab for the very poorest among us, whether through charity or, if absolutely necessary, government.

  Our employers have more important things to do than shop for our insurance plans on our behalf, and continuing to rely on employer-provided healthcare is what makes our current system so uneven and opaque. Please leave my generation out of it, or at least let us start opting out if we think we can get a better deal. Or even take our chances without health insurance, while the current crazy system lasts.

  Whether giving employers tax breaks that they can only get by opting into a few big, government-approved health insurance plans, or forcing the young to get health insurance, it sure seems as if there’s a pattern, one that has existed for decades, of “progressive” reform plans always ending up giving a big boost to one industry or another, without necessarily rescuing the poor. Free-marketeers pointed out a similar problem on President George W. Bush’s watch when he pushed through a massive subsidy for pharmaceuticals for the elderly as part of Medicare.

  It sounds nice, but a subsidy for the drug purchases of the elderly is also, of course, a great big subsidy for the pharmaceutical industry. They were no doubt as worried about the older adults not buying drugs as the insurance industry was about young people not buying insurance. The answer is not to have government do the buying for industry. The answer might be for industry to compete to offer much better deals, not get locked in a big-government plan that may stagnate and not see any further innovations for decades to come.

  The thicket of regulations that has grown up around healthcare and health insurance—partly because employers wanted goo
dies to offer employees at a time when they were forbidden to raise wages by Nixon’s onerous wage and price controls—will have to be unwound with care.

  Trump’s proposed American Patients First reform plan should be a big step in the right direction.

  I would not, in any case, assume the Democrats know what a healthy America looks like when they see it. San Francisco, Nancy Pelosi’s district, has more drug addicts than students enrolled in public high school. Democrats destroy everything they touch, but they’ll always insist they did so for compassionate reasons and that the Republicans are cruel by contrast.

  One key element of Trump’s American Patients First plan, at least in its inchoate form in late 2019, is simply mandating that customers see the prices for medical services clearly and transparently posted before they agree to treatments.

  In any other business, this idea wouldn’t be regarded as the least bit strange. It’s not radical. It’s just common sense. Yet look at the nonsense words—disguised as free-market, consumer-friendly rhetoric—spouted by big businesses deeply enmeshed in the current healthcare regime:

  “Publicly posting privately negotiated rates could, in fact, undermine the competitive forces of private market dynamics and result in increased prices,” said Rick Pollack, CEO of the American Hospital Association, according to a June 25, 2019, article on ModernHealthcare.com. The group America’s Health Insurance Plans held a similar position.

  And according to the article, Justine Handelman, a senior vice president at the Blue Cross and Blue Shield Association, said, “We need to ensure consumers have information that is relevant to their decision-making, while ensuring disclosure of information does not raise costs or jeopardize the privacy and security of consumers’ personal health information.”

  If this were a simple transaction between you—the patient/buyer—and your doctor in a competitive market, this sudden concern for privacy might be understandable, but these are conglomerates produced precisely by the perverse public/private partnership created between government regulators, including tax collectors, and a handful of the biggest insurance companies. The idea that they don’t want you knowing how they calculate prices because you might become confused or because it might make the whole medical industry more prone to careless personal-data-sharing than it is already is just ludicrous.

  What the calcified health insurance companies are afraid of is that if you see how wildly and arbitrarily prices vary—and how much you’re being charged for real medical services vs. bureaucratic mark-ups—you and hundreds of millions of other Americans will wake up and start demanding real choice and flexibility, not just Options A, B, and C from your employer’s plan for your entire physical well-being (and likely that of your family).

  President Trump had his differences with the late Senator John McCain, but one of several things McCain got right during his failed 2008 campaign for the presidency was making the separation of employer and healthcare central to his healthcare reform proposal. While candidate Obama was dreaming of expanding government involvement in health and lying about whether his reform plan would enable you to “keep your doctor,” McCain wanted to sever the healthcare plan connection to your boss so that you’d be more likely to get the plan you want, providers would face new competitive pressure to keep more-mobile customers, and workers would be a little more courageous about switching jobs to boot.

  Make people less nervous about their health coverage, and they’ll behave a little more confidently in general. Transparency and transportability in health insurance is a good start. The alternative is an exercise in blind trust—hoping your boss and your doctor and your insurance company all know what they’re doing and care, really care, about you. Blind trust tends to erode after a while. Then people get suspicious.

  And from time to time, a suspicious populace engages in populist rebellion. Maybe healthcare is overdue for one.

  While the common citizen may be no expert, and may be wrong in some cases, the common citizens’ distrust of the establishment has been well-earned. That distrust is never stoked more intensely than when big government and big business collude. Those two forces are dangerous enough separately—and each pretends to be at war with the other, at least for about a hundred years now, ever since Teddy Roosevelt and Woodrow Wilson made it popular to denounce the power of corporations in a democracy. But what goes on behind closed doors when government and business join forces? Do they expect us to believe each side—either side—is fiercely fighting for our interests instead of its own?

  I do not mean to suggest that doctors want to neglect their patients or milk them for the most money possible. However, even doctors admit they have difficulty keeping track of which procedures are covered by which reimbursement amounts in both government-run plans such as Medicare and the insurance-company-run health plans the tax code steers employers into.

  Even if only on a subconscious level, this is an incentive for people who stand to benefit from the money sloshing around in the bureaucracy to steer coverage in the direction of their companies, their areas of medical expertise, or their insurance compensation rules.

  You probably know people who dutifully paid their health insurance premiums for years only to discover that, by some unforeseen technicality, they aren’t covered when a devastating health problem hits. The health insurance companies are rarely outright lying about the coverage—and your doctor may find the situation as infuriating as you do—but this is the deadening (and sometimes deadly) bureaucracy that arises when doctors, patients, insurers, and employers all get used to assuming that someone else is ultimately responsible for making the important decisions, for economizing and seeking efficiency, in healthcare.

  The long-term solutions to this problem will require overhauling about a seventh of the US economy—even as the average age of Americans increases and more of us require medical services as a result. But we should at least begin by throwing the harsh light of economic clarity across the health bureaucracy. Prices are signals, as the Austrian School economists teach us. They show us where to devote resources and what’s not worth it.

  Let us see those prices. Let us see the lazy, bureaucratic backdoor dealing going on between medical services, insurers, and government that ends up producing our incomprehensible and large bills. Making America’s healthcare system great again will first require knowing when we’re getting a great deal versus when the system is just adding insult to our injuries.

  Chapter 12

  The Tech Sector

  Trump has been called a conservative or nationalist—and called much worse things by his enemies—but also a populist, someone who rightly or wrongly presents himself as a sort of tribune of the people, offering to defend them against the elite. The last time America saw a boom in self-consciously populist politics, the late nineteenth century, that mood went hand in hand with “trust-busting,” that is, the search for checks on the growing power of corporations over American life.

  Today, we’d refer to similar efforts as “breaking up monopolies,” and it’s a controversial idea in conservative circles because it means government interference with free markets. When you look closely at a monopoly, you can almost always find a government-enforced barrier to entry. Instead of breaking up a major player, politicians are better off looking for ways to encourage more companies to compete with that major player. It’s never smart to fight overregulation with more regulation.

  Indeed, there was fear in the late nineteenth century that the trust-busting mood would lead to socialism. In the early twentieth century, both Republican president Teddy Roosevelt and Democratic president Woodrow Wilson took pains to say that as Progressives, they were offering a middle-of-the-road alternative to socialism. In the century since, the US government has become less of a hammer smashing monopolies and more of a deeply entwined vine, its regulations mixing at every point with corporate practices. The trusts were tamed instead of busted.

  Faced with the clash between corporations and socia
lism, then, the early twentieth-century Progressives instead opted to add just a little of the latter to the former. As a result, free-market advocates, including most conservatives, were delighted in the 1990s when the emerging Internet was treated as something government should largely butt out of. Even today, when virtually every nook and cranny of American life is taxed, it’s controversial to suggest taxing various online activities, even ordinary shopping. That’s a victory for the market and a welcome limitation on government.

  So, too, is the recognition that computer technology advances so quickly that bumbling federal regulators would probably do nothing but damage if they waded into the industry and started telling innovators what to do. They’d be recommending 1960s IBM solutions to a world changing so quickly Linux will probably be obsolete one day soon. And they’d be making their recommendations in long, boring hearings at which it would become apparent that some members of Congress weren’t sure what the Internet is.

  So, what, if anything, is to be done about Google? What, if anything, is to be done about the power of social media companies?

  Psychologist Robert Epstein, who describes himself as a past Hillary Clinton supporter and has been an NPR commentator and Psychology Today editor-in-chief, warned in a 2019 Senate Judiciary Committee hearing that Google could easily shift several million votes to one candidate or another in a presidential election, through just the tiniest of alterations to its algorithms, suppressing a negative article here, boosting the profile of a positive article there. Google swears it has done no such thing—indeed that it has never “manually” altered the ranking outcomes for search items.