You’ll love health care rationing—trust us.
To paraphrase Freud: Liberals, what do they really want? Not the communism or socialism of the right’s fever dreams. They know that didn’t work. Today’s liberal agenda is more akin to the corporatist vision of the 1920s and ’30s—an economy in which the state directs the activities of the private sector to achieve ideologically desired ends. But even that description doesn’t quite get to the nub of it. Liberals today seek to create a stable, and what they perceive to be a socially just, society via rule by experts—in which most of the activities of society are micromanaged by technocrats for the economic and social benefit of the whole. In other words, social democracy without the messiness of democracy, like the European Union’s rule-by-bureaucrats-in-Brussels. This is the “fundamental transformation” that President Obama seeks to implement in this country.
The siren song of technocracy attracts members of both parties. Left-wing types tend to believe in issuing direct government commands. Think Nancy Pelosi or Mayor Bloomberg. Big government right-wingers prefer to induce “desirable” behavior through incentives. Think Newt Gingrich at his most utopian.
Since technocrats believe their job is to protect us from ourselves, preventing people from getting hurt becomes the prime directive, the equality that matters most is equality of outcome—not opportunity—an unattainable goal, which conveniently means a technocrat’s work is never done.
Europeans generally accept this benign statism as the best way to maintain peace and social stability. It has been somewhat rougher sledding in the United States because technocracy undermines individual liberty and the American dream. Hence the widespread outrage over “You didn’t build that.”
But with the coming of the Affordable Care Act (ACA), aka Obamacare, the technocrats have broken ground for a full-bore, EU-style bureaucratic state. Leading the charge is the Independent Payment Advisory Board, governed by 15 “experts” appointed by the president and confirmed by the Senate. Established to control Medicare costs, IPAB possesses the raw power to force Congress to legislate via its “fast track authority”; IPAB’s financial targets must be enacted into law by August 15 of each year, beginning in 2014. Not only that, if Congress refuses to legislate the level of cost containment demanded by IPAB (or if the president vetoes the bill), IPAB’s original recommendation is automatically imposed. In other words, IPAB’s cost-cutting word is law. And if that isn’t enough: Congress can’t dissolve IPAB until 2017—and then only by a supermajority vote of both houses.
Defenders of IPAB claim that such extraordinary authority is necessary because Congress can’t be trusted to cut costs. We should never underestimate Congress’s cravenness, but that is no reason to bulldoze democratic accountability or devolve power from the elected organs of government to a semi-sovereign bureaucracy.
Defenders also tell us not to fear because IPAB’s cost-cutting weapons are limited primarily to controlling payments to doctors and hospitals—never mind that draconian cuts in compensation could make it extremely difficult for Medicare beneficiaries to find doctors. But the broad power given to IPAB was not designed to remain limited. Even before it is up and running, President Obama has said that IPAB should be “strengthened.”
More specifically, Christina Romer, the former head of the president’s Council of Economic Advisers, suggested in a July 22 column in the New York Times that IPAB “could be empowered to suggest changes in benefits or in how Medicare services are provided,” once it has a “track record”—meaning, once it becomes an accepted reality. But as we have seen, IPAB doesn’t merely “suggest,” it dictates. Thus, Romer is actually arguing that IPAB could eventually be granted absolute authority over Medicare policy, including, perhaps, health care rationing power that would be the envy of any EU technocrat.
Former Obama Treasury Department adviser and New York Times columnist Steven Rattner specifically urged transforming IPAB into a rationing board in a September 17 column. “No one wants to lose an aging parent,” he wrote. But the cost of caring extensively for the elderly “imposes an enormous societal cost that few other nations have been willing to bear,” and so we too must jump into the rationing pool:
Take Britain, which provides universal coverage with spending at proportionately almost half of American levels. Its National Institute for Health and Clinical Excellence uses a complex quality-adjusted life year system to put an explicit value (up to about $48,000 per year) on a treatment’s ability to extend life.
At the least, the Independent Payment Advisory Board should be allowed to offer changes in services and costs. We may shrink from such stomach-wrenching choices, but they are inescapable.
Once we turn our affairs over to the technocracy, bureaucrats even get to decide which of us has greater value and which of us can be kicked out of the lifeboat.
Technocracy is ultimately not about expertise but about determining the common moral values of society. It does not countenance competing centers of moral authority. It is no surprise that the first major regulation promulgated under the ACA by the Obama administration directly attacked freedom of religion by requiring sectarian institutions and private businesses to provide their employees free birth control and sterilization surgeries even if it violates their religious consciences.
Obamacare is also a splendid vehicle for imposing liberal social values that technocrats favor. Thus, the next time the Democrats enjoy one-party rule, expect them to amend the ACA first to permit, then to mandate, abortion coverage. Indeed, Obamacare could easily become the vehicle for enacting many profoundly culture-changing policies, such as requiring employers to cover free in-vitro fertilization, not to mention sex reassignment surgery, and eventually assisted suicide.
The issue isn’t whether there should be regulation. Only the most radical libertarians favor laissez faire. The concern is the Obama administration’s apparent eagerness to cross the border from reasonable regulation to the land of technocracy—and not just in health care. In this sense, the current election is about far more than policy issues such as taxation, spending, and terrorism. More profoundly, we will find out whether the voters are ready to allow a second term President Obama to transform Washington, D.C., into Brussels on the Potomac.
Wesley J. Smith is a senior fellow at the Discovery Institute’s Center on Human Exceptionalism. He consults for the Patients Rights Council and the Center for Bioethics and Culture.