Obamacare? Well, here’s the truth of the matter: America is addicted to medical care and demands that it be delivered in infinite quantity, in flawless quality, no matter the cost, as long as no one has to pay anything like full price, directly. Unfortunately, the cost does matter, and even if we were willing to devote infinite resources to medicine, we lack the human quality to provide what’s demanded. Short version: [Obama] had to do something; eventually we were going to bankrupt ourselves in the interests of keeping someone’s great-grandmama alive another day or so. I’m not sure what that something was, mind you, and I am pretty sure that Obamacare wasn’t it. But, be fair; he really had to try to do something. So will Donald Trump, and I don’t mean just repeal Obamacare. You may as well get used to the idea.
Tom Kratman, “Free at last! Free at last!”, EveryJoe, 2017-01-23.
February 3, 2017
May 13, 2016
Scott Alexander talks about the dispute between the junior doctors and the British government:
A lot of American junior doctors are able to bear this [the insane working hours] by reminding themselves that it’s only temporary. The worst part, internship, is only one year; junior doctorness as a whole only lasts three or four. After that you become a full doctor and a free agent – probably still pretty stressed, but at least making a lot of money and enjoying a modicum of control over your life.
In Britain, this consolation is denied most junior doctors. Everyone works for the government, and the government has a strict hierarchy of ranks, only the top of which – “consultant” – has anything like the freedom and salary that most American doctors enjoy. It can take ten to twenty years for junior doctors in Britain to become consultants, and some never do. […]
Faced with all this, many doctors in Britain and Ireland have made the very reasonable decision to get the heck out of Britain and Ireland. The modal career plan among members of my medical school class was to graduate, work the one year in Irish hospitals necessary to get a certain certification that Australian hospitals demanded, then move to Australia. In Ireland, 47.5% of Irish doctors had moved to some other country. The situation in Britain is not quite so bad but rapidly approaching this point. Something like a third of British emergency room doctors have left the country in the past five years, mostly to Australia, citing “toxic environment” and “being asked to endure high stress levels without a break”. Every year, about 2% of British doctors apply for the “certificates of good standing” that allow them to work in a foreign medical system, with junior doctors the most likely to leave. Doctors report back that Australia offers “more cash, fewer hours, and less pressure”. I enjoy a pretty constant stream of Facebook photos of kangaroos and the Sydney Opera House from medical school buddies who are now in Australia and trying to convince their colleagues to follow in their footsteps.
Upon realizing their doctors are moving abroad, British and Irish health systems have leapt into action by…ignoring all systemic problems and importing foreigners from poorer countries who are used to inhumane work environments. I worked in some rural Irish towns where 99% of the population was white yet 80% of the doctors weren’t; if you have a heart attack in Ireland and can’t remember what their local version of 911 is, your best bet is to run into the nearest mosque, where you’ll find all the town’s off-duty medical personnel conveniently gathered together. This seems to be true of Britain as well, with the stats showing that almost 40% of British doctors trained in a foreign country (about half again as high as the US numbers, even though the US is accused of “stealing the world’s doctors” – my subjective impression is that foreign doctors try to come to the US despite barriers because they’re attracted to the prospect of a better life here, but that they are actively recruited to Britain out of desperation). Many of the doctors who did train in Britain are new immigrants who moved to Britain for medical school – for example, the Express finds that only 37% of British doctors are white British (the corresponding number for America is something like 50-65%, even though America is more diverse than Britain). While many new immigrants are great doctors, the overall situation is unfortunate since a lot of them end up underemployed compared to their qualifications in their home country, or trapped in the lower portions of the medical hierarchy by a combination of racism, language difficulties, and just the fact that everyone is trapped in the lower portions of the medical hierarchy these days.
If Britain continues along its current course, they’ll probably be able to find more desperate people willing to staff its medical services after even more homegrown doctors move somewhere else (70% say they’re considering it, although we are warned not to take that claim at face value). I work with several British and Irish doctors in my hospital here in the US Midwest, they’re very talented people, and we could always use more of them. But this still seems like just a crappy way to run a medical system.
I don’t know anything about the latest dispute that has led to this particular strike in Britain. Both sides’ positions sound reasonable when I read about them in the papers. I would be tempted to just split the difference, if not for the fact several years of medical work in the British Isles have taught me that everything that a government health system says is vile horrible lies, and everybody with a title sounding like “Minister of Health” or “Health Secretary” is an Icke-style lizard person whose terminal value is causing as many humans to die of disease as possible. I can’t overstate the importance of this. You read the press releases and they sound sort of reasonable, and then you talk to the doctors involved and they tell you all of the reasons why these policies have destroyed the medical system and these people are ruining their lives and the lives of their patients and how they once shook the Health Secretary’s hand and it was ice-cold and covered in scales. I don’t know how much of this is true. I just think of it as something in the background when the health service comes up to doctors and says “Hey, we have this great new deal we want to offer you!”
January 11, 2016
In the same “Minerva” column, we learn that annual health checks on everyone between the ages of 40 and 75 are likely to be useless, at least as carried out in Britain, except possibly as a mild Keynesian stimulus to the economy. When the records of 130,356 people who had undergone such checks were examined, it was discovered that only about 20 per cent of those at high risk of cardiac disease were prescribed statins and even fewer of those with high blood pressure underwent treatment to lower it.
Since the beneficial effects of treatment with statins are a matter of controversy anyway, as being of value mainly to those who already have ischemic heart disease or have had a stroke, and since the treatment of high blood pressure is only marginally beneficial in the first place, so that the benefit of treating fewer than 20 per cent of those with high blood pressure is likely to be minuscule from the public health point of view, we can safely conclude that annual health checks as carried out in Britain are a waste of time — unless wasting time by occupying it is the whole object of the activity, in which case wasting time is not wasting time but using it gainfully. Gainfully, that is, to the person who wastes his time (the doctor) rather than has his time wasted for him (the patient). His time is well and truly wasted.
Part of the problem is the assumption that doing something must be better than doing nothing. Doctors of the past, because there was so little they could in fact do, employed a technique known as masterly inactivity: they assumed an alert watchfulness, giving the patient the impression, which was false but reassuring, that they would do what had to be done in the event that anything untoward happened. Since most people got better anyway, this seemed to confirm the wisdom of the doctor.
Masterly inactivity, however, is no way to increase your fee for service or gain a reputation for technical mastery. Patients too prefer to think that they are doing something rather than nothing to preserve themselves. That is why some of them are not merely surprised, but aggrieved when illness strikes them: for they have done all that they were supposed to do to remain in good health, from eating broccoli to regular bowel biopsies.
Theodore Dalrymple, “Dubious Cures”, Taki’s Magazine, 2014-11-30.
October 13, 2015
In the Telegraph a report on the dire financial straits of Britain’s NHS:
NHS trusts in England have racked up a deficit approaching £1 billion in the first three months of the financial year – the worst financial position “in a generation,” regulators have said.
The figure is more than the £820 million overspend for the entire previous year.
Experts warned of a looming winter crisis.
They said the “staggering” figures would result in widespread cutbacks to services, with lengthening waiting times and increased rationing of care.
The statistics for April to June show an overall deficit of £930m across England’s 241 NHS hospital trusts, with three in four trusts in the red.
The statistics show NHS Foundation Trusts had a deficit of £445 million. Other NHS trusts ended the first quarter of the year £485 million in deficit.
The foundation trust sector is under “massive pressure” and can no longer afford to go on as it is, the financial regulator Monitor said.
Regulators said an “over-reliance” on agency nurses and doctors to plug shortages of staff was fuelling the growing debt, which is forecast to reach a record high.
January 25, 2015
In Richard Lehman’s BMJ journal review, there was an amusing bit of interest to Ricardians:
King Richard III of England was 32 when he died at Bosworth and then famously suffered the indignity of being buried in a Leicester car park. I think I probably drew your attention to this account of his post-mortem examination when it appeared online last September. Had Richard III been spared avoidable mortality in the form of a bashed-in skull and a spear through his spine, he would probably have needed a walking frame by the age of 70. He was never in the best shape:
I, that am curtail’d of this faire Proportion,
Cheated of Feature by dissembling Nature,
Deform’d, unfinish’d, sent before my time
Into this breathing World, scarse halfe made up,
And that so lamely and unfashionable,
That dogges bark at me, as I halt by them.
(from The Tragedy of Richard the Third: with the Landing of Earle Richmond , and the Battell of Boʃworth Field by Wm Shakespeare c.1592, First Folio text 1623)
With his nasty scoliosis and his habit of moving around castles with smoky rooms and no hand rails on the stairs, Richard III would have needed an OT assessment and a dosset box containing all the drugs which are now compulsory for elderly people in the UK:
simvastatin 40mg to add 2 days to life and cause muscle aches
tramadol 50mg to fail to ease pain & cause dependency, falls, confusion
naproxen 500mg to cause GI bleeds and fluid retention
furosemide 20mg to reduce fluid retention due to naproxen
omeprazole 20mg to prevent GI bleeds, encourage C diff
senna 7.5mg to counter tramadol constipation
citalopram 20mg to cause serotonin syndrome with tramadol
trazodone 50mg for agitation due to serotonin, to worsen it & cause falls
gababentin MR 800mg to see if it will help pain
paracetamol 500mg because it hasn’t helped the pain
tamsulosin 400mcg for nocturia due to age and furosemide
lisinopril 5mg for “grade 2 CKD” due to furosemide & naproxen
Seretide inhaler for low FEV1 due to scoliosis
My kingdom for a bit of horse-sense.
January 24, 2015
At Samizdata, Natalie Solent shares a post written by “ARC” discussing why the National Health Service seems to be under such pressure lately:
1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort — delaying release and also using up time of staff in non-health work — and costs money.
This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years — “If the NHS were a patient, she’d be on the critical list” — was caused by this and the resultant bed-blocking more than any other one cause.
The problem with waving the regulatory wand to “solve” a problem like this is that it tends to create perverse incentives so that the artificial target can be achieved — like this post from a couple of years back where the regulators dictated a maximum time a patient could be kept waiting for admission to A&E. The reaction of the people running the system was to change the definition of “admission” so that now patients’ timers don’t start running until they’re unloaded from the ambulance … so the end result is people are spending more time in the back of ambulances waiting outside the hospital until there’s an open slot. This meets the artificial target, but creates a worse situation because patients are still waiting as long (or longer), but now they’re also tying up ambulances from attending other emergency situations.
Back to ARC’s list of NHS problems:
2) The new 111 service is sending many more patients to A&E.
2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.
2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).
From context, I assume the 111 service is a telephone health advisory service like Telehealth Ontario.
November 22, 2014
Back when I was active in the Libertarian Party of Canada, Quebec was an almost unknown area … there were so few libertarians or pro-free market people that we rarely tried to run a candidate in elections there. That apparently is now changing:
Published on 18 Nov 2014
“For a couple of years now, Canada has had a freer economy than the United States.”
That’s Martin Masse, one of the leading figures in the Canadian libertarian movement. Back in the late 90s, when libertarianism was a thoroughly marginal ideology in the country, Masse started Le Quebecois Libre, an online gathering place for allies to the cause.
Things have since changed. Free market ideas now inform Canadian public policy to a degree that’s probably surprising to the average American. Reason TV recently sat down with Masse to find out about this transformation and to discuss the future of liberty in our neighbor to the North.
June 25, 2014
Britain’s NHS came in for rave reviews in a recent study that compared healthcare systems in several European countries and the Anglosphere. There was, as John Kay points out, only one minor flaw in the way the measurements were weighted:
“NHS is the world’s best healthcare system” was a headline last week in The Guardian newspaper. However, six paragraphs in, the authors observed: “The only serious black mark against the NHS was its poor record on keeping people alive.” Further investigation was clearly required.
The newspaper was reporting a survey of health provision by the US-based Commonwealth Fund in 11 advanced countries: seven European states, the US and Canada, Australia and New Zealand.
The findings use measures of service quality, mainly derived from judgments by patients. The effectiveness of care is judged by the intensity of preventive activity – whether necessary tests are carried out, whether doctors advise on a healthy lifestyle – and the reliability of management of chronic conditions.
The safety of care is judged by the frequency of medical mistakes, and the incidence of hospital-induced infection. Good care is patient-centred and timely, with necessary treatment easily accessible. The survey also reports measures of efficiency, or more often inefficiency – how great is the burden of medical administration, how much unnecessary use is made of emergency services, how reliably test results reach medical professionals.
The UK’s National Health Service is at or close to the top on almost all these indicators, and its health spending per head is the second lowest in the survey. The US system scores badly on everything except preventive care, and US medical costs are off the scale when compared with other countries.
The problem, however, is that when it comes to keeping you alive, the World Health Organisation puts Britain tenth out of 11; only the US is worse. If your objective is to live a healthy life, go to France. Medical outcomes are judged by reference to three measures: avoidable mortality, infant mortality, and healthy life expectancy at age 60. And the NHS does not do well on these metrics.
May 23, 2014
The Wall Street Journal‘s James Taranto rounds up some amusing-in-hindsight bloviations by Paul Krugman about the efficiencies of the Veterans Health Administration:
There was no ObamaCare in January 2006, when former Enron adviser Paul Krugman wrote this:
I know about a health care system that has been highly successful in containing costs, yet provides excellent care. And the story of this system’s success provides a helpful corrective to anti-government ideology. For the government doesn’t just pay the bills in this system — it runs the hospitals and clinics.
No, I’m not talking about some faraway country. The system in question is our very own Veterans Health Administration, whose success story is one of the best-kept secrets in the American policy debate.
The “secret” of the VA’s “success,” Krugman argued, “is the fact that it’s a universal, integrated system.” That saves on administrative costs and allows for efficient record-keeping. Krugman acknowledged that the VA had a history of mismanagement and mediocre care, until “reforms beginning in the mid-1990’s transformed the system.” But wait. Hasn’t it been a universal, integrated system all along? Maybe the secret is something else. At any rate, the Phoenix revelations suggest it’s the system’s failures that are being kept secret.
Krugman lamented that his argument “runs completely counter to the pro-privatization, anti-government conventional wisdom that dominates today’s Washington.” That was 2006, remember, when Republicans had the White House and both houses of Congress. If Krugman is to be believed — a big “if,” to be sure — the Bush administration did a far better job running the VA than the Obama administration is doing now. Which reminds us of something Waldman wrote: “There’s an old saying that when they’re out of office, Republicans argue that government is inefficient and incompetent, and when they get in office, they set about to prove it.”
Krugman concluded that 2006 column as follows:
Ideology can’t hold out against reality forever. Cries of “socialized medicine” didn’t, in the end, succeed in blocking the creation of Medicare. And farsighted thinkers are already suggesting that the Veterans Health Administration, not President Bush’s unrealistic vision of a system in which people go “comparative shopping” for medical care the way they do when buying tile (his example, not mine), represents the true future of American health care.
“Good Glitches,” anyone?
Krugman managed to get two more columns out of the glorious VA. One, in September 2006, also damned Medicare Advantage and complained that the administration opposed the idea of letting elderly vets use Medicare benefits at VA hospitals:
“Conservatives,” writes Time, “fear such an arrangement would be a Trojan horse, setting up an even larger national health-care program and taking more business from the private sector.”
Think about that: they won’t let vets on Medicare buy into the V.A. system, not because they believe this policy initiative would fail, but because they’re afraid it would succeed.
OK, but think about this: According to The-Military-Guide.com, “if you’re eligible for any level of VA care, whether it’s high-priority or low-priority, you’re no longer eligible for ACA exchange subsidies.” (ACA is an abbreviation for PPACA, in turn an abbreviation for the Patient Protection and Affordable Care Act, ObamaCare’s official title.) There are worse things than being excluded from ObamaCare, of course — but the VA may be one of them.
May 21, 2014
J.D. Tuccille on the Veterans Health Administration:
Just a couple of years ago, Paul Krugman pointed to the Veterans Health Administration (VHA) as a “huge policy success story, which offers important lessons for future health reform.” He gloated, “yes, this is ‘socialized medicine.'”
Similarly, a letter touted by Physicians for a National Health Program trumpeted “the success of 22 wealthy countries and our own Department of Veterans Affairs, which use single-payer systems to provide better care for more people at far less cost.”
How could a bloated government bureaucracy achieve such low-cost success? As we found out recently, it’s by quietly sticking veterans on a waiting list and putting off their treatment for months — sometimes until the patients are far too dead to need much in the way of expensive care. Which is to say, calling it a “success” is stretching the meaning of the word beyond recognition.
And, while the White House insists it learned from press reports about the secret waiting lists, Press Secretary Jay Carney acknowledges that the administration long knew about “the backlog and disability claims” that have accumulated in the VHA.
This should surprise nobody. Canada’s government-run single-payer health system has long suffered waiting times for care. The country’s Fraser Institute estimates [PDF] “the national median waiting time from specialist appointment to treatment increased from 9.3 weeks in 2010 to 9.5 weeks in 2011.”
Likewise, once famously social democratic Sweden has seen a rise in private health coverage in parallel to the state system because of long delays to receive care. “It’s quicker to get a colleague back to work if you have an operation in two weeks’ time rather than having to wait for a year,” privately insured Anna Norlander told Sveriges Radio.
So the VA really is a good example of a single-payer, socialized health system. Just not in the way that fans of that approach mean.
February 21, 2014
As Eugene McCarthy, of all people, observed: “The only thing that saves us from the bureaucracy is inefficiency. An efficient bureaucracy is the greatest threat to liberty.”
Luckily the United States is blessed with one of the most incompetent governments in the developed world. It isn’t simply that the Americans have a bloated government, it’s that they have a bloated government that accomplishes far less dollar for dollar than the bloated governments of other leading nations.
This is why Americans should have no fear of Canadian style socialized health care being imposed on them, their government isn’t smart enough to run it. That said Obamacare is turning out to be something that makes Canadian Medicare look like the Swiss Army. I grimly await the flood of American health care refugees trickling north of the 49th. That’s bad news for them and worse news for us. What kept the Canadian system semi-functional was the American escape hatch. If upper middle class Canadians can no longer sneak across to Buffalo, Burlington or Seattle for treatment, that puts more pressure on our system.
From time to time I’m asked why government is so incompetent. It’s such a truism among conservatives, libertarians and classical liberals that it’s rarely reflected upon. February is cold in Winnipeg, governments are generally incompetent. We accept these things perhaps too readily. The truism is true, but in assuming it so blithely we fail to communicate its importance to reasonable people who are uncommitted.
Richard Anderson, “The Incompetence of Evil Government”, The Gods of the Copybook Headings, 2014-02-20
November 28, 2013
You’ll have guessed from the tone of my Obamacare links and comments that I didn’t think it was a good idea from the start and it’s been a great example of how not to implement a major government initiative. That said, it’s a sure bet that Obamacare will have influence on other countries as they consider their own health programs. Colby Cosh is surprised that the scandal-addled Canadian media hasn’t been paying more attention to the Obamacare train wreck as the wheels fall off in all directions:
Obamacare isn’t going to make major systemic change in either direction look more appetizing to Canadians. That’s an important Canadian angle right there. Not long ago it looked as though national pharmacare was likely to become an election issue here, quarterbacked by the NDP and perhaps the Liberals, too. The concept has plenty of support among economists and other health policy experts—the same class of kindly boffins that, in the U.S., lined up almost unanimously behind the Affordable Care Act.
For better or worse, nationalizing prescription-drug insurance seems likely to be a much tougher sell here in the immediate future. Any large, complex health care experiment will be. The more wise heads support it, the easier it will be for supporters of the status quo to shout, “Unintended consequences! Ivory-tower tomfoolery!” Indeed, political strategists may already be saying it to themselves.
American commentators are already starting to wonder if Obamacare’s difficult start and increasingly troubled prospects may end up as a victory for small-government conservatism. The problems for the program do not end with the calamitous state of the federal insurance-exchange website, or even with the nasty surprises handed to the self-employed and freelancers in the “individual market” who were falsely promised: “If you like your plan you can keep your plan.” Some Obamacare buyers are finding themselves shut out from their preferred doctors and hospitals; employers are junking non-compliant health plans; and many in the middle class who liked the Obamacare concept are facing sticker shock.
The redistributive aspects of Obamacare were undersold, and possible pitfalls obviously not foreseen. The neoliberal Democrat Walter Russell Mead put it neatly the other day: “President Obama may be the Democrat who ends up convincing millions of American millennials that Ronald Reagan was right, and that the progressive administrative state is neither honest nor competent enough to solve the problems of the American people.” If that is the case, the effects cannot be confined to the U.S.
October 18, 2013
[W]hen negotiating with other governments, pharmaceutical companies operate at a severe disadvantage, not because the governments’ buying power is so vast (the national health-care systems of Canada and many European countries cover fewer people than Aetna), but because the people you’re negotiating with can change the rules under which your product gets sold. At any point they can say, like Lord Vader, “I am altering the deal. Pray that I do not alter it any further.”
But if Canada started paying more, that wouldn’t mean we’d pay less. Drug companies are charging what they think we will pay. The result of Canadians and Europeans paying less is not that we pay more for drugs; it’s that fewer drugs get developed. To the extent that they are harming us, it is in hindering the development of cures or better treatments that we are missing, and don’t even know about.
Unfortunately, this is a classic case of Bastiat’s dilemma. It is easy for each country’s government to see the high prices that people are paying and intervene to lower them. It is hard for each country’s government, much less its citizens, to envision the new medical treatments that they might get if they paid more for drugs. So their incentives are heavily skewed toward controlling the price here and now, even if that means losing future cures.
Drug development is essentially a giant international collective-action problem. The U.S. has kept it from being a total disaster because we don’t have good centralized control of our insurance market, and our political system is pretty disorganized and easy to lobby. If that changes — and maybe we just changed it! — we’ll knock down the prices of drugs to near the marginal cost using government fiat, and I expect that innovation in this sector will grind to a halt. Stuff will still be coming out of academic labs, but no one is going to take those promising targets and turn them into actual drugs.
Megan McArdle, “U.S. Consumers Foot the Bill for Cheap Drugs in Europe and Canada”, Bloomberg, 2013-10-14
October 4, 2013
Jonah Goldberg on what sets the current US government “shutdown” apart from all the others in recent memory:
Obama has always had a bit of a vindictive streak when it comes to politics. I think it stems from his Manichaean view of America. There are the reasonable people — who agree with him. And there are the bitter clingers who disagree for irrational or extremist ideological reasons.
In his various statements over the last week, he’s insisted that opponents of Obamacare are “ideologues” on an “ideological crusade.” Meanwhile, he cast himself as just a reasonable guy interested in solving America’s problems. I have no issue with him calling Republican opponents “ideologues” — they are — but since when is Obama not an ideologue?
The argument about Obamacare is objectively and irrefutably ideological on both sides — state-provided health care has been an ideological brass ring for the Left for well over a century. But much of the press takes its cues from Democrats and sees this fight — and most other political fights — as a contest pitting the forces of moderation, decency, and rationality against the ranks of the ideologically brainwashed.
What’s unusual is the way Obama sees the government as a tool for his ideological agenda. During the fight over the sequester, Obama ordered the government to make the 2 percent budget cut as painful and scary as possible.
When Republicans vote to fund essential or popular parts of the government, the response from Democrats is, in effect, “How dare they?” Nancy Pelosi calls the tactic “releasing one hostage at a time” — as if negotiators normally refuse to have hostages released unless it’s all at once.
In the 17 previous government shutdowns since 1977, presidents have worked to avoid them or lessen their impact. Obama has made no such effort out of an ideological yearning to punish his enemies, regardless of the collateral damage.
September 30, 2013
Mark Steyn explains just how big the effective nationalization of the US healthcare system really is:
No one has ever before attempted to devise a uniform health system for 300 million people — for the very good reason that it probably can’t be done. Britain’s National Health Service serves a population less than a fifth the size of America’s and is the third-largest employer on the planet after the Indian National Railways and the Chinese People’s Liberation Army, the last of which is now largely funded by American taxpayers through interest payment on federal debt. A single-payer U.S. system would be bigger than Britain’s NHS, India’s railways, and China’s army combined, at least in its bureaucracy. So, as in banking and housing and college tuition and so many other areas of endeavor, Washington is engaging in a kind of under-the-counter nationalization, in which the husk of a nominally private industry is conscripted to enforce government rules — and ruthlessly so, as Michelle Malkin and many others have discovered.
Obama’s pointless, traceless super-spending is now (as they used to say after 9/11) “the new normal.” Nancy Pelosi assured the nation last weekend that everything that can be cut has been cut and there are no more cuts to be made. And the disturbing thing is that, as a matter of practical politics, she may well be right. Many people still take my correspondent’s view: If you have old money well managed, you can afford to be stupid — or afford the government’s stupidity on your behalf. If you’re a social-activist celebrity getting $20 million per movie, you can afford the government’s stupidity. If you’re a tenured professor or a unionized bureaucrat whose benefits were chiseled in stone two generations ago, you can afford it. If you’ve got a wind farm and you’re living large on government “green energy” investments, you can afford it. If you’ve got the contract for signing up Obamaphone recipients, you can afford it.
But out there beyond the islands of privilege most Americans don’t have the same comfortably padded margin for error, and they’re hunkering down. Obamacare is something new in American life: the creation of a massive bureaucracy charged with downsizing you — to a world of fewer doctors, higher premiums, lousier care, more debt, fewer jobs, smaller houses, smaller cars, smaller, fewer, less; a world where worse is the new normal. Would Americans, hitherto the most buoyant and expansive of people, really consent to live such shrunken lives? If so, mid-20th-century America and its assumptions of generational progress will be as lost to us as the Great Ziggurat of Ur was to 19th-century Mesopotamian date farmers.