Sunday, December 16, 2012

Affordable Care Act as a monumental Baptist and Bootlegger morality tale

 "We are pattern-seeking,story-telling animals".

From chapter 1 , Macroeconomic Patterns and Stories, Edward E. Leamer


In a 1983 article in the journal Regulation, the economist Bruce Yandle introduced the concept of the Baptist and the Bootlegger (B+B). It refers to the situation in which a given legislation or regulatory action is supported by some group on high moral grounds as in denouncing the evils of alcohol.Support also comes another group who stand to get economic gain from that legislation such as bootleggers would if alcohol sales were banned. The Mafia rule of "follow the money" is useful in seeking out who might be the bootleggers in a given situation.See here for some classic examples of the B+B pattern including the acid rain story and the tale of  spotted owl.

After I became aware of the B+B pattern I seem to see it in many places, even in the Affordable Care Act.So here is the story.

I can see the medical progressives as the Baptists. Medical progressives believe (many of them sincerely) that health care or medical care is too complex,complicated and important to be left to the individual patient and his physician.Rather it should be determined by the elite who using a utilitarian ethic with the tools of cost effectiveness research will be able to find practices that will benefit society as a whole.But control is not the what the medical progressives explicitly argue for in their advocacy but rather it is the furtherance of the social justice that will be fulfilled as millions will now have access to health care and health care inequality will be greatly diminished. No, not  all physicians who  supported ACA  fall into that category.There are many sincere physicians who believe the statute is the way to obtain health care for  millions who are now under served and who are not part of the progressive medical elite but typically it is not their voice we hear from the pulpit.

I can see a coalition of bootleggers at work in the formulation of the many pages of dense, self referential legal prose that comprises ACA. The Mafia rule works well here.

Who would gain from millions of new clients with health care insurance?

Easy answers. The hospitals would gain simply as there would be many more  clients to be able to seek out and pay for their services. Similarly the big health insurance companies would welcome millions of more clients who are forced to pay for their product.Big Pharma would be in the position of more customers who could buy their products with other people's money. Information technology companies would relish the legislation to force or nudge physicians to buy and maintain computers systems.

But there is more.While the Baptists were singing hymns of praise for social justice,equality,elimination of waste, and the millions of uninsured Americans,the bootleggers and their lobbyists were busy working with the movers and deciders on the hill (eg. Max Baucus and his adviser, Elizabeth " revolving door" Fowler) to work out the important details. Big Pharma was able to get restrictions on the re importation of generic drugs,big hospital was able to be exempted from the actions of IPAB until 2020 and big health insurance was able to keep the public option from being included in the statute.

 Of course, metaphors and other figures of speech only can go so far,the reality flows over the cup.What about the medical professional organizations such as AMA, ACP, AAFP, etc.Many of these talked the talk of the preachers.Yet some had something to gain. The AMA  gathers more cash flow from its monopoly on coding than from the decreasing number of members' dues and coding will only increase as more patients are seen by physicians.Why did ACP and AAFP and others advocate for passage of Obamacare? Did they have anything to gain or were they merely dedicated preachers? Maybe the metaphor does not allow for much moral ambiguity.

The preacher who is pure in heart and sincere in belief gains only the satisfaction of doing the right thing.Preachers rarely have part time jobs as bootleggers or renounce the cloth and become a full time dealer in illegal sales of a prohibited substance. 

Folks with MD degrees who advocate for universal health care and alterations in medical ethics favorable to third party payers who either before or after that advocacy hold executive positions in major health insurance companies might gain more than self satisfaction. Maybe some people can really do well by doing good and that would be true in this instance if in fact passage of ACA is considered a good thing. Sometimes it is hard to tell the Baptists from the Bootleggers .






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