- The Washington Times - Wednesday, February 12, 2003

WASHINGTON, Feb. 12 (UPI) — The UPI think tank wrap-up is a daily digest covering opinion pieces, reactions to recent news events and position statements released by various think tanks. This is the first of three wrap-ups for Feb. 12.

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The Reason Foundation

LOS ANGELES — Is health care a commodity? Things might be better if we treated it more like one

By Ronald Bailey

The drumbeat for nationalized health care is growing louder again. Marcia Angell, a former New England Journal of Medicine editor and now lecturer in social medicine at Harvard, declared in the New York Times last October that our health system is near collapse.

To prevent this calamity, she claims: "What we need is a national single-payer system." She would model a national single-payer system on Medicare and finance it "through a new tax on income earmarked for health care."

We should do this, Angell argues, because medical care is an essential service "like education, clean water and air and protection from crime, all of which we already acknowledge are public responsibilities."

Never mind that many Americans don't believe that public agencies are in fact providing adequate schooling, pollution control, and crime prevention. Angell nevertheless insists: "The fatal flaw in the system is that we treat health care as a commodity."

The fatal flaw is really that we don't treat it enough like a commodity. Necessities like food, clothing and housing are generally provided here through private for-profit markets — markets in which we can choose for ourselves, with an enormous range of options, exactly how much of any given thing we want to purchase, and are using our own dollars to purchase it.

It is true in a sense that health insurance in the United States is still provided mostly through private markets. It's a product that is purchased, though in most cases Americans get health insurance through their jobs as a form of compensation and have to take what's offered that way. This limits the ability to shop around for exactly what you want to pay for.

Another big difference between health insurance and things like food is that state insurance authorities mandate the minimum level of benefits that insurance companies are allowed to offer. This means that Americans who are insured generally get fairly extensive coverage, but at a high price — and with severely limited choices.

In other areas, we accept that the distribution of wealth is unequal: that some people live in small condominiums while others dwell in McMansions. Some eat at Jean-Georges, while others are lucky to dine at Carl's Jr. And some shop Ross Dress For Less while others browse through Saks.

And these decisions seem to work out pretty well, with people for the most part getting what they need, if not always what they want. But imagine if state regulators insisted that only haute cuisine and high fashion could be offered?

Costs would obviously get prohibitive for many. Why do state regulations stymie this process of choice and differentiation leading to cheaper, more available options in health care? Is there a better way?

There is, and South Africa, of all places, hints at how it works in practice. It's true, of course, that South Africa is still quite poor compared with the United States and thus, according to Eustace Davie, a director of the Free Market Foundation of South Africa, only 7 million of South Africa's 44 million citizens purchase private health insurance.

But the country's health insurance industry at least is able to begin pursuing a solution to the problem of money and coverage: It offers different levels of coverage to fit different levels of income.

Since 1992, a private health care provider called Discovery has enrolled over 1 million members and is growing rapidly. Discovery offers "American style" fee-for-service health insurance combined with medical savings accounts, called personal medical funds. It has launched an American subsidiary called Destiny Healthcare, offering the same sort of package.

Discovery offers a number of incentives for healthy living. For example, your fees go down if you join a gym and exercise there a certain number of times per year. Also, the plan includes an annual physical checkup. In addition, as incentives, Discovery offers low-cost airline flights and even cheap movie tickets.

Typically, health insurance from a company like Discovery costs about $240 per month for a family. Comprehensive policies, without the medical savings account and high deductibles, cost about $300 for a family of four. This puts Discovery out of range for many South African blue-collar workers.

Blue-collar workers in South Africa can also choose the Protector Group. It offers an HMO option with unlimited benefits within its system (no choice of service provider) for about $100 monthly and a Clinicare option that caps benefits at $10,000 for as low as $28 per month, rising in tandem with the insured's income.

An even cheaper option, particularly popular with South African miners, is offered by the Ingwe Health Plan, which features a variety of low-cost options. Ingwe has a network of its own hospitals and contracts out with a number of service providers. The cheapest health coverage plan offered by Ingwe costs about 3$30 to $50 monthly. The Ingwe plan typically appeals to black South Africans moving up in the job market.

In contrast to the robust commercial health care sector, South Africa's public/government health care system is falling apart, according to Davie. The post-apartheid South African government declared in 1994 that it would offer universal health care by 2008, but the government is beginning to back down from that goal. Corruption and outright theft are growing problems in the public hospitals, Davie says.

Nevertheless, excellent health care can be obtained in the private sector. With the fall in the rand's value, medical tourism is catching on. The South African government even touts this trend toward "Sun, Surf and Surgery" package tours.

A coronary bypass operation that would typically cost $30,000 in the United States costs the equivalent of $7,000 in South Africa. Medical tourism is particularly popular among Britons who are seeking faster and better care than they can get under their own socialized medical system.

Clearly, as the example of South Africa shows, markets can provide health insurance for people earning very different levels of income. And in a country much richer than South Africa, like the United States, the effect of that more diverse market on the percentage of citizens covered is apt to be far more dramatic.

By allowing more differentiation in health insurance markets, many, if not most, of those Americans who are uninsured could buy a basic level of health coverage.

Furthermore, even insured Americans could opt out of the third party payment system and purchase the insurance they want rather than be locked into whatever plans their companies impose.

Finally, Americans offered a choice of health insurance plans would be empowered to decide what level of coverage they are comfortable with and able to afford. In other words, freely functioning, less regulated markets in health insurance would go a long way toward alleviating the "health care crisis."

(Ronald Bailey is Reason magazine's science correspondent.)

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LOS ANGELES — Sane enough to kill? Court decision shields juries from evidence of psychosis.

by Ronald Bailey

It is wrong to punish, much less execute, insane people who commit crimes. This has been the law since the 19th century.

Although standards for applying the insanity defense in criminal matters vary among states, in general, a defendant will be found "innocent by reason of insanity" if "at the time of committing the act, he was laboring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong."

This is the so-called "M'Naghten rule" established in the 1843 case of Daniel M'Naghten. M'Naghten, suffering from delusions, believed that the pope and British prime minister were conspiring against him. He killed a man as he tried to assassinate British Prime Minister Robert Peel.

Today, about half of the states have modified the insanity defense to a slightly broader standard devised by the American Law Institute. The ALI test holds that a person would "not (be) responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of law."

Although TV crime dramas might give the public the impression that defendants regularly resort to the insanity defense, this is not the case. A 1991 National Institute of Mental Health study found that the insanity defense was used in fewer than 1 percent of criminal cases and was successful in only 26 percent of those cases.

Furthermore, those who successfully argue that they aren't guilty by reason of insanity do not just get off. Most are committed to mental health facilities where they are often confined longer than they would have been had they been convicted of the crime they committed.

Which brings us to the case of Charles Laverne Singleton reported on the front page of the New York Times on Tuesday. In a 6-to-5 decision, the U.S. Court of Appeals for the 8th Circuit ruled that Singleton could be forced to take anti-psychotic medications to make him sane enough to be executed. Singleton must be forced to take the drugs because the U.S. Supreme Court has prohibited the execution of insane people.

Singleton murdered a grocery store clerk in Arkansas 24 years ago. Apparently, when he was convicted in 1979 he was considered sane; that is, the jury believed that he knew what he did was wrong. However, in capital cases, the appeals process averages longer than 10 years. As Singleton's case was wending its way through that process, he evidently began to experience psychotic delusions. By 1987, he believed that his cell was inhabited by demons and that his doctor had implanted electrodes in him.

It is troubling that courts often require defendants to take psychiatric medications so that they will be "competent" to stand trial. The idea here is that defendants need to be able to participate intelligently in their own defense. However, let's assume that medication actually works, and that a defendant using it is aware of right and wrong and able to conform his or her conduct to the dictates of the law. That still tells us nothing about his or her state of mind when he or she committed the crime in question.

Such defendants might well be horrified by what they did while out of their minds. If defendants can be restored by medication to complete sanity, we still don't punish them if they were insane at the time they committed their crimes.

It is true that the defense can offer evidence and testimony about the defendant's state of mind during the commission of the crime, but that evidence will rarely be as effective as actually experiencing someone who is in a psychotic state. A defendant who is sitting medicated in the courtroom would give the jury a very different impression than one who is showing signs of full-blown psychosis.

Apparently the U.S. Supreme Court will soon be taking up the issue of whether or not a non-violent defendant can be forced to take anti-psychotic medication in order to be made "competent" for trial.

Setting aside general arguments for and against the death penalty, did the 8th Circuit decide Singleton's case rightly?

First, it would clearly be wrong to execute Singleton while he is still delusional.

It would be, in the words of Justice Thurgood Marshall, "the barbarity of exacting mindless vengeance." We punish people both to provide an example to others and to exact vengeance. In Singleton's case, executing him while he is delusional will not send a message to other insane people not to murder.

Nor would his execution satisfy vengeance in which the wrong-doer knows that his fellow citizens regard his act as so heinous that he must be cut completely out of the life of the community.

But what if Singleton is forced to take anti-psychotic medication and his delusions abate, restoring him to sufficient sanity so that he knows that murdering that grocery store clerk while he was sane in 1979 was wrong?

Then perhaps the requirements of being both a warning example and vengeance would be satisfied. Then again, some might say that suffering psychotic delusions for the rest of one's life would be punishment enough.

(Ronald Bailey is Reason magazines science correspondent.)

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