Freedom and Tyranny in Health Care: 1984 in 2009

It’s popular to appeal to the idea of free choice when defending one’s position on health insurance reform. President Obama says that he wants to give people the freedom to choose a public option or some other form of affordable insurance in addition to the insurance choices available now. The insurance companies talk about the importance of avoiding a health care system where “Government-run health care” or “socialized medicine” is the only choice, and the tyranny involved in such a system. Senators like Ron Wyden talk about the importance of having a free choice among insurance carriers in the context of a nation-wide web-based exchange. And others talk about the importance of being free to choose one’s health care providers. But appeals to “freedom” in the health care area need to be viewed very carefully and skeptically because one’s person’s freedom is another person’s tyranny. Let’s see some examples of how that works.

First, the insurance companies want to be free of Government regulation, and, if they could, would like to maintain the status quo in health insurance. But for people who are denied coverage, whose policies are rescinded, who experience denial of claims and continual increase in costs one’s health insurance company is like an unpredictable, rapacious, and tyrannical government; and authority that without a moment’s notice can destroy one’s life: physical, financial, or social.

Further, if insurance companies must accept some regulation, then, of course, they, at least don’t want to see competition from a public insurance competitor, or even from other insurance companies in the context of people who already have insurance from their employers. That is, they want to be as free as possible from competition, and they don’t care that from the viewpoint of their customers, their freedom, translates to the tyranny of purchasing constraints on most of the individuals who might enter an insurance market under other conditions.

Second, President Obama talks about the freedom people will have under his program to get insurance coverage where they have not been free to get it before, and he also talks about maintaining the freedom people have now to keep the insurance they have if they like it. However, he doesn’t talk about the tyranny of the rules in current proposals to deny the proposed insurance exchange to those who have insurance offered to them by their employers. He doesn’t talk about the tyranny involved in being subject to insurance company arbitrary price increases until 2013, and perhaps beyond, if the market exchange suggested in current bills fails to lower or stabilize health insurance prices. President Obama also doesn’t talk about the tyranny involved in his preventing Medicare for All from getting serious consideration in the Congress by “taking it off the table.”

Third, even though many voices are raised in support of the importance of people having greater freedom to choose among private health care insurers, few talk about a possible trade-off between greater freedom in choosing insurers and greater constraints in choosing providers. Is there an inverse relationship between freedom to choose an insurance company and freedom to choose a health care provider. That is, is it true that the more freedom you have to choose an insurance company, the less freedom you have to choose providers?

At one end of the spectrum, it certainly seems to be true that if you have only one insurance source such as a Government-run insurance, you will have maximum freedom of choice of providers, since all the providers will either have to be part of the network accepting insurance funds; or else they’d have to operate without accepting insurance reimbursements at all. Here, of course, the providers have no freedom of choice, and the consumers have no freedom to choose an insurer; but certainly the consumers have as much freedom of choice of providers as they could possibly have in any system.

At the other end of the spectrum, however, if we imagine a national market of many private insurance companies embodied in a web-based exchange, consumer choice of insurance company would be maximized, and providers would also have the most freedom they could have to decide which companies they wanted to affiliate with. However, such a highly competitive free-wheeling situation will have a tendency to result in provider networks that may greatly constrain consumer choice of providers, because various providers have a limited capacity to affiliate with multiple insurance company bureaucracies.

To see this, we have to think about variations in rules, procedures, forms, and other administrative aspects of dealing with health insurance companies. If you’re a Doctor in a private practice, how many insurance company networks can you join without the administrative burden becoming so heavy that it will sink your practice. I think a relatively small number. And what if a consumer needs your services. Then it’s fine if that consumer is in an insurance company whose provider network you’ve affiliated with. But if that consumer has signed up with another insurance company, then their freedom to engage you is gone, unless they’re wealthy enough to pay you without resorting to insurance. In short, a national health care insurance exchange, of the kind envisioned in present version of the Baucus bill, will maximize freedom of company choice among private insurers for those who have the exchange available to them, but it will minimize choice among health care providers across the nation, once someone has selected an insurance company. Of course, those who have employer-based insurance will have neither freedom to choose their insurance company, nor very much freedom to choose their providers. So much for the principle of free choice.

Of course, the present situation in the US, provides neither freedom of choice in selecting insurers, nor freedom of choice in selecting providers. You can’t select among all the insurers since in many regions and local areas there are a very limited number or even one insurer who can sell you insurance. At the same time, these insurance companies have their networks, and if you sign up with one of them, and you need services outside of your insurance company’s network, then your freedom of choice is gone.

How about the kind of insurance system envisioned in a bill with a public option, like HR 3200. Well, to begin with, we have a national exchange similar to the one I’ve already discussed, except with the difference that there’s a public insurance organization which people who have access to the exchange can select as their health care funder. Does this materially change the situation? Somewhat perhaps; it provides even more freedom to choose one’s insurer, but whether it also provides more freedom to choose health care providers or not, depends on whether the public option network will be larger and more diverse than the networks available to the largest private insurers. Since the public option network may well have to build a provider network from scratch, it’s not likely that it will increase the freedom to choose providers beyond the freedom available from private insurers for some time to come, if ever.

Summarizing all this, I think it’s pretty easy to see the upshot of it. There’s at least a roughly inverse relationship between freedom of choice among insurers and freedom of choice among providers. The more freedom to select insurers, the less freedom to select providers at least at the global level. Of course, the status quo in the US system is the worst of both worlds. But, it’s also true that neither the system envisioned in the Baucus bill, nor the one envisioned in HR 3200 will increase choice among providers compared to the status quo, even though both will increase choice relative to insurance companies somewhat.

What about the Wyden-Bennett bill? Well, it would certainly increase freedom of choice among providers, as Ron Wyden claims. But if my analysis is right it will lead to even more fragmentation of provider networks, and probably to less freedom of choice of providers for consumers.

What about a strong public option reform bill in which all Americans could select the public option, and that public insurer could begin building its network of providers using the Medicare for Seniors network as a base? I think that proposal would provide the greatest simultaneous freedom of choice of insurer and provider of all the alternatives. However, it would not provide as much freedom in selecting providers as a Medicare for All system would. And since, over time, it would probably tend toward a Medicare for All system, choice of insurer would gradually decline, and might eventually disappear entirely.

So, here’s where we are: globally, freedom of choice of insurer and freedom of choice of health care provider are opposed to each other. We can’t maximize one without giving up much of the other. So what’s really important to us? My view is this.

Who among us really cares about choosing among health insurance companies for the intrinsic value of the insurance companies themselves? I think no one does. We care about insurance companies and insurance policies only based on whether or not they’ll pay our bills when we get into medical trouble; whether or not they have a provider network that will give us good service and that will give us a choice when we don’t like our doctor, hospital, or other provider; and whether or not the cost of the insurance is something we can afford. What then, if we could have an insurer that will always pay our bills, whose provider network was virtually unlimited, and who will see to it that our insurance is affordable? Would we then care about whether we had freedom of choice of insurers? I don’t think so. Can we have an insurer like that?

In a word, the answer is yes. That insurer is a Medicare for All program run by the Federal Government. Now I want to be clear on what I’m saying here. I’m saying that no one really cares whether one’s insurer is called Anthem/Blue Cross, or United Health Care, or Medicare. What one really cares about is delivery of services by the insurer, affordability, and freedom of choice of provider. The name of the insurer isn’t important. Neither is whether the insurer is public or private. And the freedom of choice that is important is the freedom to choose providers, not the freedom to choose insurers.

In George Orwell’s 1984, the slogan “Freedom is Slavery” is one of the striking expressions in the book. But, we can see from the health care debates that the opponents of health care reform, have, from the beginning in the 1940s, and right up to the present, been trying, in effect, to persuade the American people that “Freedom is Tyranny.” They’ve been telling us that the freedom to choose insurance providers is the freedom that we should always fight for, when actually that freedom is the tyranny of minimal choice of providers. They’ve also been trying to tell us that the system that would provide us the maximum freedom of choice of providers, Medicare for All, is not freedom but tyranny, because it doesn’t allow us to choose insurers. But we can see that their success in this campaign, over many years, is due to a confusion between Government-run health care and Government-run health insurance. They never make the distinction. They try to tell us that one is the other. But that is not true. They are different, and the importance of this difference is that the freedom to choose insurers is not an important freedom. But the freedom to choose providers is. And it is Medicare for All that will maximize that freedom for us. So, it is Medicare for All that we should have. And when the President and other politicians and interest groups tell us that Medicare for All is off the table, we should be very angry, because that move subjects us to the tyranny of limited choice of health care providers. And we should sustain that anger until the tyranny of the private insurance system is replaced by the freedom of Medicare for All, the freedom to choose the provider(s) we need to get well and stay that way.

(Also posted at the Alllifeisproblemsolving blog where there may be more comments)

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