The health care debate is like a schoolyard skirmish among 6-year-olds. All of the challenges and accusations made by any "side" are diversions, digressions or downright irrelevancies

The health care debate is like a schoolyard skirmish among 6-year-olds. All of the challenges and accusations made by any "side" are diversions, digressions or downright irrelevancies

At the core of the politics is the premise of income redistribution, and to my fellow conservatives I say, get over it! Accept it as the "not-so-new" normal. Whether for safety and security, nutrition, shelter, health or education, governments will continue to take money from people who are better-off and, either directly or indirectly, give it to those who are less well-off.

What we should be concerned with is not so much redistribution per se, but the value that is delivered for each dollar that is transferred. In the case of the ACA, that means fixing the system, on several fronts, in ways that minimize the "leakage," the waste, the inefficiency, and the dilution of value that is delivered. Where the ACA is really a blatant failure is not on the website (because that can be fixed), but in its outrageous disregard for the features that would have dramatically improved the value of the program to both the funders and its consumers.

Unfortunately, nothing is built into the law to ensure that value is delivered. So, any critique should not focus on the hollow promise of defunding or repealing the law; rather, it should make cogent and compelling arguments for immediate changes in the law that address its blatant voids:

Patient Accountability:

If one pays a fixed price that guarantees unlimited access to a service at virtually no incremental cost related to level of consumption, chances demand for the service will be unbridled. With virtually no "skin in the game", patients have no interest in controlling consumption. For the system to maintain fiscal integrity, all patients must pay something meaningful for the services they receive. If the ACA can determine insurance premiums based on economic means, then it can determine co-pays on the same basis, and thereby put patients "back in the game." But, that is only half of the patient accountability equation.

Ask any health care workers to describe what they see in their world, and they will tell you that the most afflictions either directly or indirectly self-inflicted. Alcohol, tobacco, drug abuse, obesity and lethargy. If these patients are going to continue with their errant lifestyles, then they (not those "others" who are taxed) should bear an increasing burden of the cost of their care. All other forms of insurance match premiums to actuarial risk; so any plan funded by the taxpayer must hold patients accountable for the behaviors that increase the cost and risk of their health care coverage.


Insurers' oligopolistic control of their markets is, in today's web-dominated marketplace, archaic, to say nothing of inefficient. But for the insurance lobbies, the ban on interstate competition is perhaps the easiest deadlock to break. We need one set of standards and operating policies for the entire industry across all 50 states (and we're already halfway there with the ACA's coverage standards). Consider the effects of real competition, with hundreds of insurers negotiating with hospitals and other providers across the country. Competition works in most other facets of our lives; why are we restricting it in the arena that is one-sixth of this economy?

Outcome Accountability

As we move toward a system that controls payments for individual services, and almost instantaneously adds millions of consumers drawing on the semi-fixed universe of providers, only one result is possible: the providers of the service will figure out ways to increase productivity — throughput — so they can maintain their income stream. In any production system, there is a natural "competition" for priority among volume, quality and cost. The ACA suggests that patient outcomes will become the quality metric that counterbalances the drive for throughput. But, the "best practices" panel appears to have a very strong cost-control bias. So, we have an obligation to argue for value — the proper trade-off between volume and quality, with a much broader definition and embodiment of outcome accountability in the law.

Legal Rationality

Estimates of the cost of malpractice risk embedded in the health care system range from 20 percent to 40 percent, depending on whether direct (insurance premiums) or indirect (overuse of diagnostic resources) costs are included. And, these costs are the result of the uninsurable risk of uncapped punitive awards. Putting practical caps on these awards is a mandatory step in making this law affordable, but the politicians remain steadfast in their protection of the tort lobbies.

It is time for us all to accept income redistribution as inevitable and inescapable. In place of a hollow protest, we must take on the challenge of demanding value for the dollars that are transferred, so that smaller transfers are required and more capital is left for the job- and wealth-creating engine of private enterprise.

In the instance of the ACA, we must point emphatically at the titanic weaknesses of the law, where value is seeping from its every pore into the open sumps of governmental excess, and stridently advocate for all citizens who work for a living and who want to enjoy the entirety of their labor's fruits.

Rick Berlet lives in Ashland.