Insurance Mandates

"Paul D. Clement, representing Florida and 25 other states objecting to the health care law, responded that 'it's a very funny conception of liberty that forces somebody to purchase an insurance policy whether they want it or not.'"
Quoted in a Washington Post article on Thursday on the final day of Supreme Court arguments about Obamacare.

“I’m in good shape, I don’t eat meat, I don’t drink excessively, I’ve never smoked,” said Mr. Lodor, 53, who estimates he would have to spend at least $1,200 a month to cover himself and his college-age daughter. “The last thing I’m going to do is not pay my rent because I have to pay for some state-mandated health coverage that I don’t think I need.”
Wayne Lodor, one of the (now only) 2% of Massachusets residents who do not have insurance under Romneycare, quoted in Wednesday's NY Times.

I need to hire Paul D. Clement.

New York State forces JABberwocky to buy Workmen's Compensation insurance for its employees.

New York State forces JABberwocky to buy Disability Insurance for its employees.

If I owned a car, New York State would force me to have insurance for my car.

My LIC apartment building forces me to have insurance with a specified liability coverage (if my washing machine floods the downstairs neighbor, the building wants to be sure I get to fix up my downstairs neighbor's apartment). My apartment building also required that my contractors and my movers had insurance.

State Form forced me to buy a business policy to wrap around my homeowner policy for my older apartment because they decreed the business was too big to be covered by a home office rider on the homeowner policy.

A prospective landlord for the JABberwocky office insists I show certificates for my workmen's comp policy and my business liability policy, which I will have to upgrade to have a higher liability limit in order to suit the landlord, costing me money.

I am annoyed that Paul D. Clement can make the most outrageous statement about liberty and insurance, and that there are justices on the Supreme Court who think he's living anywhere close to the real world, where I am made constantly to have insurance policies whether I want them or not -- and in some instances made to do so by state actors as opposed to private companies or citizens that have more freedom to require things of one another as part of their dealings.

And I'm sure Mr. Lodor takes the most wonderfully good care of himself, but is he willing to sign some kind of binding statement that if he falls off a ladder or has a bagel cutting accident in the coming days or weeks that he will 100% totally agree to pay for his emergency room care, at whatever inflated rates the hospital will give him vs. what they've negotiated with an insurance company, and that if for some reason he can't pay he won't max out and then bankrupt out of his credit card bills or do anything else at all that will force the rest of us to pay to heal his broken ankle or severed thumb? And that the same will apply if his daughter is standing on a baseball field, gets plunked by an errant throw that was supposed to go to the manager on the pitching mound, and gets a concussion (this just recently happened to one of my nephews, just as an aside I was quite impressed with the seriousness with which everyone was concerned about this, which is sea change for good from five or ten years ago). Mr. Lodor, as one of the 2% in Massachusets without insurance, should be every bit as ostracized by the Occupiers and by all the rest of us as the 1%.

Mind you, I agree that Mr. Lodor shouldn't have to pay so much money for his insurance, but Obamacare is the best chance we've got at getting those costs down, at least so long as we're going to remain tethered to our current health care system. I am happy to debate with anyone all of the so-called market-based solutions to health care, which are generally as untethered from reality as Paul D. Clement's statement that forced insurance is tyranny.

And if the Court accepts Paul Clement's argument, how do they chop down the mandate in Obamacare in a way that still guarantees Workmen's Compensation insurance for my employees, or mandatory auto insurance for car-owners, or a gazillion other things that we are required to do in the public sphere to protect one another? Under classic libertarianism, we wouldn't have a lot of these things, and I can respect the consistently principled classic libertarian even if I don't always agree, but the consistently principled classic libertarian is a rare bird.

Many of you reading my blog are fans of sf/fantasy. Every so often we in the sf/fantasy community are called upon to make donations to the SFWA Emergency Medical Fund or privately to help some writer who's met up with illness. I want to live in a place where we don't keep having to do that, because it's understood by everyone that the health and well-being of our citizenry is a shared obligation we all have to one another.

If that would happen, we wouldn't need a law that requires people to buy broccoli.

Public mores can change over time. The reaction to my nephew's concussion is an example of that.

Another example, in my time on Earth attitudes have changed a lot toward drunk driving. In the 1960s, who would have envisioned that the movie "Say Anything" would have a keymaster to model proper hosting of a teen alcohol bash. The term designated driver came to the US only in the late 1980s.

I could see a lot of good coming to the US not through forced legislation but through an understanding of the shared common good if we understood that health care was a shared common obligation of the citizenry. This in turn can lead to a long discussion of externalities and market costs, but we can have that discussion another day.

Good Business Thru Politics

I don't know how the health care debate going on in Washington will play out. I've come out clearly in favor of liberal non-market approaches. And I'll admit that I want very badly for some kind of reform to get passed, please please please. My insurance carrier will be telling me soon how much the JABberwocky premiums will be going up come March, and in the meantime I've gotten the good news in a letter entitled "Supporting member health and affordability" that they plan to make our coverage worse. With that title to the letter, on the outside of the envelope, what else could it mean! Copays will go up. If I need a wheelchair or other orthotics, prosthetics or durable medical equipment, I'll get to pay 20% of the cost, and there doesn't seem to be any limit to the size of that co-pay. There are new co-pays for ambulances chemo, and radiation.

If I need a wheelchair and have to pay 20% of the cost, it's safe to say I'll look to go to Joe's Pre-Used Wheelchair Discount Emporium unless I'm rich enough to buy the best wheelchair money can buy. No, that's not rationing. Because that's just screwing people who can't afford 20% of the cost of the nicer wheelchair. We're happy to ration care in this country based on ability to pay, and somehow or other that isn't rationing.

But that's not the purpose of this rant.

The purpose here is to explore why it is that some senators have such outsize power in the negotiations over the course of the health care bill, and the simple reason for that is that they're the ones who are most willing to say "no." Which means that I and all the other people on the side of making good health care a right, privilege and responsibility (yes, responsibility as well) of citizenship, who want to do something, don't have the leverage. It's the people who are "differently principled" to try and put it politely who have the power, because they're willing to say "no."

And this is a good lesson for any author.

When a publisher offers to buy your book, they are saying your book is something they want. If you ask for a better deal, maybe they'll say "no." But very rarely will they say "oh, well, if you don't like it exactly the way it is then we're going to withdraw it." Because if the offer will go away that quickly, then it's clear that they don't really want your book all that much. And if they want it that little, maybe you should'nt be selling it there anyway.

So don't be afraid to say "no."

That being said, there are right ways and wrong ways of saying no.

Much as Ben Nelson isn't on my Christmas card list this year, I can respect that he's always been opposed to abortion and is sticking up for a clear and consistent conviction. If I had a client like that, my one big thing would be that the client have expressed early and often and clearly any kind of deep-seated belief like that instead of discovering it only after the 4th round of back-and-forth between me and the publisher on the contract. The "I was for the Medicare buyout before I was against it" approach isn't so OK with me.

If I find a contract that's running up against one of the JABberwocky convictions after the second round with the publisher... Well, let's say the publisher is intent after I've tried a couple times on having an out-of-print clause that doesn't have a clear exit path because of the theoretically perennial availability of an electronic book. That's when I need to get the client on the phone, explain why I'm worried that we're two rounds into the negotiation, the publisher isn't budging on this, and it's a problem to me because... and then need to find out just how far the client will go in saying "no" to something I feel passionately about.

These games of brinksmanship don't have a clear set of rules. Sometimes problems come up in unexpected times in unexpected places. But I do feel very strongly that the health care debate does offer a powerful example of what can happen when you have something other people want, and you are willing to say "no" longer than those other people are. A good agent should be able to give you good advice on how badly other people might want what you have and how long you can or should say "no." A good agent should also pick up the cues the client gives on core convictions. And both client and agent should be more afraid to give those cues too softly or too inconsistently than to give them clearly, convincingly and (absent changing circumstances) consistently.

Health Insurance

I'm utterly baffled by this belief in the salubrious effects of taxing employer provided health insurance benefits.

The more ardent free marketeers love to tout the benefits of treating health care as a consumer driven market like deciding whether to go to McD's or Subway for dinner. We've been told how if we can just get consumers more involved with their health care costs will come down as consumers make better decisions. I don't think higher co-pays, deductibles, etc. really do that, though, because too much health care is done when the need is urgent, which does not lend itself to comparison shopping. Too much health care, well it's your life that's at stake so if the doctor tells you to take Tests x/y/z and Drugs q/r/s there's a certain reluctance to challenge the experts.

The argument for taxing health insurance is, simply put, that since it isn't taxed it costs less than it would if it was taxed. And since it costs less, we therefore spend too much money on it vs. things that cost more. If it is taxed, business owners will get more serious about getting a better buy for their health care dollar, just becoming better consumers, thus spending less.

The first part of that argument I kind of agree with. Yes, at a certain level decisions are guided by tax policy. Houses certainly cost more because we can factor in the benefit of the mortgage interest deduction, and thus pay more for a house than if we did not have a mortgage interest deduction. Which is why that is unlikely to go away, because the transition issues are so mighty.

Yet, real estate is an actual functioning marketplace, and people might buy more house than they would otherwise but still shop very carefully for houses. They look at many many houses over a period of time and carefully weigh pros and cons and the market functions. But health care isn't like that. Imagine if every house were to be purchased only in circumstances of immediate dire need, like if human babies gestated in nine days instead of nine months and you had to have that extra bedroom right away, or if you only took a new house when the job was moving, or etc. etc. Then the housing market would be like the health care market.

Because you see, health care is an expense. Business owners do not spend money lightly. I would happily keep my health care costs down if I could. And how can I do that? Basically, the more I screw my employees with deductibles and co-pays and shittier benefits, the less money I can spend on health care. Does this sound like the way we should run our lives? Some people would say yes, but I do not.

The big macro-questions that drive up health care costs are totally beyond my individual control. New York State wants to mandate certain minimum coverage, that's not something I control. The administrative costs that drive up health care costs? Beyond my control. Allowing drug companies to advertise directly to consumers? Beyond my control. Conflicts of interest where doctors can build their own MRI machine and then use it? Beyond my control. Breakthrus in technology or drugs that provide better care at higher cost? Beyond my control.

All I can control is how much I want to screw over myself and my employees by offering us all shittier health insurance, and then after I've gone to the shittiest possible coverage my % increase will still be driven by the overall costs in the health care market and I'm back where I was.

This isn't a functioning market. Taxing health care benefits will either raise my expenses without good recourse, or force I and my employees to have shittier health insurance.