A Modest Proposal for Health Care Reform
Like most of us, I'm not an expert on Health Care. If I claim to any special expertise on anything, it would be in the general area described by the expression, "Common Sense". One of the attributes of Common Sense is that it has the capacity to find simplicity almost anywhere - even deep within the brambles of a thorny, complicated set of expert-laden, statistics-crammed issues like this one.
What are the simplicities here?
(1)First, focus on the desired RESULT. Given absolute authority, where do we want to come-out at the end? What is actually RIGHT, in terms of its best long-term benefit to the country? If we can't visualize that goal NOW, we are certain to get prematurely bewildered by the morass of worrisome details standing guard against action on the front-end of ANY complex problem. ("If you don't know where you're going, any road will take you there." - Anonymous philosopher of Common Sense). How did Alexander the Great untie the Gordian Knot?
(2)To make a long story brutally short, here's the result we SHOULD want (I know that's a bit didactic, but I'm keeping it simple):
Responsible, minimal, economically-sensible, cost-rational, permanent coverage for every Amercan citizen - cradle to grave, with or without either a job or the ability to pay.
(That last part means it must be a Federal program, paid by public taxes. Bill Gates and his gardener qualify equally).
There's our MISSION, in a couple of sentences.
(3)How do we get there? As Americans with a uniquely American problem-solving sensibility, that's really the LEAST of our problems. If we're broadly agreed on (2), history repeatedly warns not to bet against us. I recall reading about a meeting among the Allies during WW2. The British were not sold on invading France, and were introducing all sorts of detailed negative considerations. After a lot of to-and-fro, a Russian general told the assembly (including Gen. Marshall), "If you think about it, you will do it." Marshall was deeply impressed by the profound simple truth of that statement, and it was that simple observation that put us on the way to what became D-day. This isn't so different.
(4)A few rough concepts to help cut a little more brush out of our way: (a)Every segment of our society must work for the betterment of the whole, and not the other way around - if physicians, or insurance executives, or individual employers, or ANYONE ELSE is unwilling to do their part to pull the wagon out of the ditch to a better place, to H--- with them. Better to do it with them, but it's going to be done one way or the other. (b)A minimal floor does not have to be a ceiling - any person, or any employer, or any other entity who wants something more or something different should not be prohibited from seeking it out from any private enterprise that cares to provide it. This simply means no one is under any burdensome OBLIGATION to consider these distracting matters in lieu of their normal business.(c)Don't be overly deterred by COSTS. This is a national public crisis that MUST be addressed - no different and no more restrained by an inappropriate concern for costs than WW2 was. It is simply going to cost what it costs, but we are not allowed to ignore the equally valid (and arguably greater) costs of doing nothing.
ANYONE ELSE is unwilling to do their part to pull the wagon out of the ditch to a better place, to H--- with them.
That's easy to say in principle, however, if you take a look at this chart in the New York Times today
http://www.nytimes.com/interactive/2009/06/18/us/politics/061809-health-care-proposals.html
and scroll down to "Ways to Pay For An Overhaul,"
you'll see where that falls apart in all the plans that are being worked on. Who shall it be that gets the most skin off the hide? Medicare recipients? Labor unions who don't want their benefits taxed? Teaching hospitals? Looks to me that the situation right now is that whichever of those groups that doesn't speak up now with real loud lobbyists might end up paying more than their fair share. And it looks like the House is considering a value-added-tax, that should go down like a lead balloon during a serious recession, great way to make people spend even less.
Nobody is going to raise their hand and say "I want to pay for it."
And it surely doesn't seem like potential unintended counterproductive blowback is being carefully considered in the who-is-gonna-pay-for- it equation.
Even many of the uninsured, like me. We have to live with a lot of fear and worry, but at the same time many of those without major problems have probably also have gotten quite used to not having to pay premiums. When they say, ok, next year, you have to buy insurance at $XXX per month, and have to file a lot of income forms to get any subsidy, or get it in income tax refund a year later, how's that going to go down?
Right now, everyone's got this pie in the sky hope that someone else will pay for it. I wonder how much support for doing anything at all is going to fall once it comes down to getting much stricter about what granny can get from her Medicare. or actually requiring the liberal thirty-something freelancers with no health insurance and no premiums, to start paying them or union guys with the good coverage they fought for seeing a bigger cut out of their paycheck because there's taxes on it now.
More and more I see that the biggest benefit of single payer would be that everyone just gets the equivalent of another FICA tax and we're done with all of the cost shifting games. But I think that's pie-in-the-sky for right now, too.
I think it's going to be a tough period, this transitional one. I think all of the Dem candidates for president knew we would have to go through such a tough period before the public was ready (fed up enough) for single payer and the economy (and investors in health insurance related companies) were ready for the destruction of the health insurance companies. We are basically going to go through a long, slow demolition and rebuild. It will be like living in your house while it's being rehabbed.
I am currently going to a university dental school for needed discount care. I mentioned something to a friend about my student dentist, I wondered whether her doctor parents were unhappy that she wasn't becoming a doctor instead. My friend said probably not, because if her parents are doctors, they know that all the big money in the future is going to be made by dentists because they are not going to be so involved in the slow rehab of health care.
P.S. The only one of the "ways to pay for an overhaul" that sounded real smart and not just painless, but positive, to me was "impose a $37 billion tax on drugmakers by denying deductions for advertising prescription durgs." But on second thought, I thought: but the lobby for the advertising industry is going to be screaming bloody murder, and then the TV networks, they will surely miss those ads, it's a lot of the advertising these days.
June 19, 2009 12:01 PM | Reply | Permalink
To go back to the chart @ my link, it is interesting to note after seeing the warm reception to Obama's speech at AMA, that their platform on a public plan option is
The American Medical Association "opposes any public plan that forces physicians to participate, expands the fiscally challenged Medicare program or pays Medicare rates. The group is willing to consider a co-op health plan.
Isn't there, er, a big disconnect, with this and the "Ways to Pay for an Overhaul" section where all the Congressional talk is of cutting Medicare more?
I foresee a lot more current doctors opting out of Medicare than already are. I foresee the cheapest plans having many of the lousiest doctors for quite some time, and not enough of them, until new kind of doctors are coming out of new kind of medical schools with lower debts and expectation of only salaries and not other kinds of income.
June 19, 2009 12:15 PM | Reply | Permalink
You're right about the pain we'll all be experiencing during this transition AA. Which makes it seem all the more obvious we need to figure out where we want to end up with healthcare reform, and plan how to get there as quickly and painlessly as possible. The driving factor with healthcare is cost, and as wilson says, our response to controlling those costs is as critical to our national viability, (figuratively and literally), as our response to the financial crisis, or WWII was. I think we will eventually end up with a publicly financed single payer system for all of the reasons you and wilson describe. It makes the most sense in that it will provide ways to reign in anomalous, or extortionist costs that a multiple payer system does not. Since I was forced out of medical coverage, I find it cheaper and easier to 'self insure' my medical needs, and. like you and many others don't look forward to having a new private plan forced upon me. Once we get past looking at healthcare as a commodity and recognize it as a human right these changes should be easier for all but those with vested financial interests in the sector to accept that change is necessary, and the best way to distribut cost as well as risk is with a publicly funded single payer plan.
June 19, 2009 12:25 PM | Reply | Permalink