In his latest column, Paul Krugman of the New York Times points out that covering every American with Medicare would be cheaper than America's current health care system. No doubt that those who profit from the current system will label him a communist, a socialist who wants the government to pick your doctor, or a traitor. Such labels are a price of speaking the truth these days.
Krugman's analysis centers on the "medical cost ratio", which he defines
as the percentage of insurance premiums paid out to doctors, hospitals and other health care providers.
Krugman states that Medicare spends "about 98% of its funds on actual medical care", while
Aetna spends less than 80 cents of each dollar in health insurance premiums on actually providing medical care. The other 20 cents go into profits, marketing and administrative expenses.
The University of Maine came to similar conclusions in a 2001 paper entitled “The U.S. Health Care System: Best in the World, or Just the MostExpensive?”. (It is available at http://dll.umaine.edu/ble/U.S.%20HCweb.pdf) found that “the United States has by far the most expensive health care system in the world,” and that the reasons for this high cost include
The high administrative costs resulting from the complex multiple payer system in the U.S. For example, it has been estimated that between 19.3 and 24.1 percent of the total dollars spent on health care in the U.S. is spent on simply administrative costs. The growing shift from non-profit to for profit health care providers, such as the grown of for-profit hospital chains, has also contributed to the increased costs of health care.
In personal terms, assume that Aetna or any private (for-profit) insurer decides to cut costs. Will they a) cut into their own profits or b) cut your treatment and services while increasing your deductibles and co-pays?
Krugman acknowledges other factors that contribute to the high costs of our health system. The lesson to be learned is that our country’s choices in health care, like all choices, carry consequences and costs of their own. Our country’s choice to hand public health over to for-profit corporations brought the cost of an unraveling public health care system where we all pay executives to figure out ways to cut our health care even further. By enabling it, our Republican and Democratic Senators and Representatives are showing their genuine compassion and dedication to the little guy, like they did by passing the recent bankruptcy bill that the credit card companies bribed them to enact.
We can learn from our national experience with private health care. Conservative proposals to make cuts in other benefits programs are presented as difficult but necessary decisions to keep your tax dollars in your pocket. But won’t there be costs to those decisions too? Why don’t Republicans ever talk about those costs? It is because they have a little secret. They will not feel the impact of those costs. But you will.
Some conservative politicians despise nearly all kinds of government assistance that promote the general welfare. Dick Cheney is a "starve the beast" politician; instead of publicly legislating away programs like Medicare and Medicaid, he would prefer to quietly desiccate them by drying up their funding. Of course that would free up more borrowed money for Halliburton. More despicably, Americans will find their cash-starved government services ineffective and unresponsive, furthering the conservative myth that government cannot do anything right, and should be despised.
Bush presents the gutting of social programs as "tax cuts" or “reform” and talks about how these "cuts" will let more people keep the money they earn. "It’s your money," he tells us. In reality Bush’s tax "cuts" benefit primarily the already wealthy, and no, it is not their money, since there is a deficit. Instead, tax cuts for the wealthy are borrowed from your children and grandchildren, and foreign interests, such as China, hold the notes.
What will the costs of Bush’s cuts? Imagine the elimination of childhood vaccinations to pay for more tax cuts. Millions of dollars would be saved in the short term. Will we still be saving money when smallpox, polio, and diphtheria make their triumphant return, overwhelming our health care system, overflowing our hospitals, and bankrupting our local governments? Who will pay for all of those consequences? The very wealthy? Would the Administration of Personal Responsibility take personal responsibility to pay for it all? Or would local government clean up the mess and the bodies. With local taxpayers picking up the tab? That’s just the beginning. Imagine the closed businesses, the lost income, the foreclosed homes and ruined lives. Would Bush manage that crisis as competently and ethically as he handled Katrina?
If that example strikes you as too extreme, then consider the basic principle involved; early intervention into almost any problem is going to be 1) cheaper and 2) more effective. If there is a flaw in that reasoning, please post it.
Costs are not always measured in dollars. Managing a household requires financial decisions, but they are made in a larger context of how to distribute and use finite resources. In your own life, is it in fact a wiser use of resources to change your oil and filter often, or is it a better choice to not bother with checking the oil? Is it a wiser use of resources to educate and nurture children, or to ignore them and build prisons to house them down the road?
Cutting a program, never changing your oil, or not taking action early in the life of any problem will always result in higher costs and less effective remedies. Taking thoughtful action as early as possible during a problem will be more effective and less expensive.
Federal tax cuts result in cuts to social service programs. While many programs are imperfect, the pattern described above still applies. There will be many costs to social program cuts, and George Bush and Dick Cheney will not pay for them. You and I will pay dearly.
Street-level Reality
In 1999 I was a public defender involved in the creation of Seattle Municipal Court's Mental Health Court, or MHC. MHCs are criminal courts that because of the expensive uselessness of repeatedly and cruelly processing people with mental illnesses through the traditional criminal justice system. Seattle's MHC is staffed with mental health professionals with clinical education and experience, and who have a working knowledge of the public benefits systems like Social Security and Medicare. Among the goals of the MHC are the identification of existing and potential resources of any kind for the client early in the process. This can lead to earlier, if not immediate releases from the expensive jail into a more structured, stable life in the community. Both the client and the public are served by such an approach, since the client’s quality of life and public safety are improved at the same time.
There are legitimate criticisms of the mental health court movement, but they are still a step in the right direction? Well, since Republicans are so obsessed with taxes, they should know that placement in the community is less expensive than jail. The City of Seattle spends about $100.00 per day housing one person in the County Jail, even if they stole a small can of tuna because they were hungry. You can get tough on crime all you want, but it will cost you. At $100 per day, 30 days in jail is $3,000.00 of your money. Sixty days in jail? $6,000.00. The cost of sentencing one person to 180 actual days in jail? $18,000.00. Prosecutors often endorse "progressive sentencing", which means that a person’s jail sentence should be increased for each subsequent conviction. But $18,000.00 sounds like a lot of justice for three ounces of tuna. And could there be other things we could do for such a person for $18,000.00?
If that person has an untreated mental illness that causes his or her problem behaviors, is it fair to house him in a squalid jail cell while local citizens hemorrhage $18,000.00 to pay for it? What if we used just a fraction of that money to provide treatment, medications, housing, and even education or training? What if that person eventually became a taxpayer? Woe to the national politician who dares to talk about this, because some conservative crackpot will be there to accuse her of being soft on crime or coddling criminals, which is, of course, gibberish in its highest form.
There have been a number of studies on the costs of subsidized housing, treatment and education for the mentally ill and chemically addicted as opposed to criminalizing their behaviors and jailing them. One of our mental health professionals estimated that the cost of support and treatment in the community was in the $36.00 per day neighborhood. So, $100.00 per day for local taxpayers to jail people, or $36.00 per day spread out over the entire country in the form of federal benefits that help support them in the community. Which one sounds like a tax cut to you?
A concrete example of the cost of tax cuts comes in the form of how states like Washington use the money they receive for the Medicaid program. Medicaid is a medical benefits program administered by the states, financed by the federal government and the states. It is means-tested; the federal government sets the eligibility requirements, so not all low-income people are eligible.
The federal money for Medicaid is distributed to a state based on its anticipated need for services for the number of people receiving Medicaid in that state. During the Clinton administration, once all Medicaid services had been paid, a waiver allowed Washington's Department of Social and Health Services (known as DSHS, the state agency that administers the Medicaid program) to use the leftover funds for people not on Medicaid, and for services not allowed by Medicaid. That may seem like a waste at first. But these funds allowed more services for already marginalized people, and help pay for services like in-patient treatment, residential treatment and more.
The Bush administration caused a crisis in Washington's budget when in 2004 it announced that it was re-interpreting federal regulations in a way that would not allow any leftover Medicaid funds to be used for non-Medicaid people or services. In Washington, the leftover funds could reach $32 million per year. Washington has tried to make up for some of these funds, but budget planning for 2005 anticipated a shortfall of as much as $18 million for King County alone. What does that mean for local taxpayers?
Many of the leftover Medicaid funds serviced marginalized people in rural areas. The funds enabled many to stay on their medications, stay in their housing, and live as stable a life as they could, often just barely. But when those funds are cut, and people lose their housing, medications and other structure, where will they go? They migrate to the cities like Seattle, where there are shelters and food programs for the homeless. They will go where the resources are. When a city has an influx of marginalized, homeless people, some of whom being mentally ill but no longer having their medications, there will be problems. Some of those problems will be addressed in the County Jail, at $100 per day. Or, they will crowd the streets, sleeping in doorways and sometimes freezing to death.
Like so many of us, marginalized people with fewer and fewer benefits have to get through the day too, except that instead of a martini, they might have a friend share a little crack or pot with them. Their home is what you and I call “outside”, so the police can see right into their home. Drinking in public (their home) brings a citation. Share a little pot or crack, and it’s off to the $100.00 per day jail, courtesy of the taxpayers. Is all of that a wise use and distribution of resources? Does it sound like the "starve the beasters" really have a tax cut for you in mind when they cut social service benefits? If you like your city streets teeming with addicted people, or if you like paying $100 per day to jail them, that is your choice. But don’t complain about your taxes or wonder why your city is becoming less livable.
As social services are demonized by those who feel separated from the social system in which they live, and as the funds are cut even further, there will be a cost, it will be high, and it will fall upon you and me, not upon those who made the cuts. A Republican I respected deeply used to tell me, "I don't want to pay for these people!" The fact is you are going to pay for "these people" whether you want to or not. So rather than whining about the inevitable, why not engage in rational discussion about the distribution of resources? Practical, real work on the street level of local government where costs are immediate and real instructs us that doing the right thing by our fellow human beings is less expensive and more humane, dignified and effective.
In the MHC, the joke is on the federal government, in a way. When clients come through without resources or benefits, they receive assistance in applying for and receiving federal benefits. It is our little way of saying "right back atcha" to the federal government for its criminal behavior in allowing huge numbers of poor, afflicted people to live like animals when they do not have to.
For those who disagree, start by pointing out the flaw in the logic of early intervention in any system suffering from a problem. Explain why childhood shots are inefficient. Why prisons are a better use of resources than are schools. Explain why it is better to pay a mechanic thousands to repair or replace your engine instead of just checking your oil. Announce to your family that you have decided to save money by cutting out soap, toothbrushes and medical care, and see how that works out, in terms of household environment and costs.
Your government is lying to you. Social programs are not cash giveaways to welfare queens who have children just to get money. It does not save you money to cut the programs. No one advocates throwing cash at social problems. But criminalizing behaviors resulting from addiction and mental illness is not the answer either. More programs are needed that will help people out of their cycles of poverty and despair. Treat their illnesses, educate them, assist them to be critically thinking, tax-paying responsible people.
There is no national social policy on these issues now. Those in power seem to believe that capitalism is a form of government, rather than an economic system. Perhaps they think that because they sold themselves to their corporate masters.
Krugman is right; Medicare should be extended to all citizens. Perhaps those in congress should also be limited in their benefits to those that they authorize for the poor.
Dick Cheney may not see the good in tax dollars going to the needy. I'm having a problem seeing the good in tax dollars going to the already rich, like Cheney.
Finally, how conservatives managed to claim Christianity as their turf while gutting assistance to the poor, and giving to the rich, is beyond me. I thought Jesus said that if you give a man a fish, he eats for a day, but if you teach him to fish, he eats for a lifetime.
It sounds to me like Christ was calling for intervention, teaching and the opportunity to become independent. He was advocating for the promotion of the general welfare. How does the Republican agenda fit with that? Just curious.
The story goes like this: Negroponte is unhappy with Goss. Negroponte goes to Bush for help in getting rid of Goss. Bush approves. Goss is fired. Hayden is looked upon as a likely replacement. Bush will announce on Monday that Hayden is the new CIA Director.
Michael Hayden, the Defense Department and Dick Cheney (even perhaps Negroponte) may be jockeying to take advantage of the power struggle caused by Goss's departure but it is not plausible to conclude that they were the primary cause of his departure. The New York Daily News 
