How to Build a Marionette

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On January 18, 2011, on the floor of the House of Representatives, Congressman Steve Cohen of Tennessee said that those who characterize the new healthcare law as a “government takeover of healthcare” are purveyors of the “big lie. Just like Goebbels.”

A quick browse round the web reveals wide agreement that Mr. Cohen’s insertion of the Reich Minister’s name into the healthcare debate did little to encourage reasoned discourse. The next day, Mr. Cohen himself felt the need to clarify, saying, "Not in any way whatsoever was I comparing Republicans to Nazis."

A consensus seems to have emerged that, while the congressman is given to using inappropriate language, he means well, and that the matter should be gently set aside. I agree, and will do so right after addressing two small questions.

The first is straightforward: Is it a “big lie” to say that the implementation of the new healthcare law would result in a “government takeover of healthcare?” The second question is more speculative: what would Dr. Goebbels have thought of the new healthcare law?

Regarding the first question, anyone who considers the increased government regulation contained in the new law to be inadequate would almost certainly find the “takeover” accusation questionable. Those who favor the single-payer system of government-run universal healthcare insurance, for example, would probably find the characterization of the new law as a “government takeover” simply laughable. Their fondest hope is that the government will become the sole insurer of health, eliminating the need for private health insurance entirely. Because that hope is not fulfilled by the new law, from their vantage point the “big lie” charge may seem true. After all, they want a government takeover. It seems likely that Politifact, the Pulitzer-winning website that first called the “government takeover” charge the “biggest lie of 2010,” shared that hope.

But there is more than one way to take over a healthcare system.

Guess how many Americans already have their health insurance provided by the government? Come on, have a go.

According to the National Council of State Legislatures, more that 90 million Americans were covered by Medicare and Medicaid in 2009. The website Health Policy Gateway gives us additional government-insured group totals, also for 2009: 11 million covered by the military system, 7.8 million covered as federal employees, and 30.3 million covered as state and local employees. The Indian Health Service tells us that it serves some 1.9 million Native Americans. The Bureau of Justice Statistics counts 2.4 million who get their government healthcare behind bars.

So, even before the new law was passed, the government, in one form or another, was already insuring about 143 million Americans, or about 46% of the 2010 US Census total of 308 million. Not quite half.

How about the other half?

Under the new law, the government becomes a puppeteer and private health insurance companies its marionettes. Let’s look at a few of the strings.

The first string is called “guaranteed issue,” which means that the insurance companies will no longer be allowed to deny coverage to anyone, regardless of pre-existing conditions. They’ll have to take all comers.

The second is “community rating,” which means that insurance companies will be required to charge the same amount to all people of the same age, sex, and geographical location — again, no matter how serious the pre-existing conditions, and no matter what other risk factors may be present. One size fits all.

The third string is “minimum coverage standards,” which means that the minimum scope of coverage will be decided by the government. Have it our way.

The fourth string is “rate review regulation,” which means that Health and Human Services will judge whether proposed premium rate increases are unreasonable or excessive. (At this point the regulations indicate that while HHS will issue its judgment, “whether or not an insurer can implement an increase determined to be unreasonable by a state will, of course, depend on state law.”)

Now imagine that you are a healthcare insurer. Under this law, you have to sell insurance to everyone who wants it, you have to charge them all the same amount (except for age, etc.), your product (scope of coverage) will not be determined by you, and the amount that you can charge is subject to the approval of the government, whether state or federal.

If you are running an insurance company and you are told what you must sell, what you must charge for it, and to whom you must sell it, you are not running an insurance company.

The health insurance industry will be like a giant Howdy Doody, with Secretary Kathleen Sebelius holding the strings.

Note that this list is not comprehensive and does not include, among other things, the bizarre part of the law that compels citizens who are otherwise uninsured to buy health insurance from Mr. Doody.

So, regarding the first question, while it may be an exaggeration to say that the new healthcare law in itself constitutes a “government takeover of healthcare,” calling it a “big lie” stretches the truth. After all, whoever controls health insurance controls the health providers by deciding who will be paid how much for which procedures. There must be a way to put it more fairly. How about this: if implemented as written, the new healthcare law would constitute, in what has been a decades-long journey down the road of ever-greater government control and regulation of the country’s healthcare system, a great leap forward.

Now, what would Dr. Goebbels have thought of all this?

While the National Socialist Party never implemented a single-payer system, it did build on the government-sponsored healthcare system created by Kaiser Wilhelm II. In 1934, a national director was appointed for all sickness funds. Another director was created to be responsible for all other insurance funds. Both these directors reported directly to the central government. Then, all funds, community health services, and non-governmental healthcare organizations were put under direct central government leadership. By 1945, health insurance had been expanded to all pensioners, and accident coverage had been expanded to cover all workers, regardless of occupation. A 12-week, job-protected maternity leave had been introduced, and limitations on sick leave had been eliminated. In short, during the Third Reich, in keeping with Hitler’s leadership principle, or Führerprinzip, the central government increased its control of all aspects of the healthcare system. (See James A. Johnson and Carleen Harriet Stoskopf, Comparative Health Systems: Global Perspectives for the 21st Century, Jones & Bartlett, 2009.)

One can’t be sure, of course, but it seems reasonable to say that Goebbels approved of these developments in the healthcare system of Germany. He was, after all, a committed National Socialist and a close friend of the Führer. It also seems reasonable to infer that, were he alive, he would approve of America’s new healthcare law, which has the same sort of centralization of control that was evident in Germany during the decade from the mid-’30s to the mid-’40s.

In pointing this out, it needs to be said that I am not in any way whatsoever comparing supporters of the new healthcare law to Nazis.




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