Health Care (INCOMPLETE, draft, will never get finished, for my own eyes mostly.)

 

I really haven’t known what to think about the passage of this historic bill (and whatever you think about it, it is historic.) I’m really torn about it, and finding the reality amidst the rhetoric is tough.  The projected savings and costs are simply stabs in the dark, and are wildly dependent on the assumptions one makes.  There are  two things that seem fundamental to any health care overhaul – universal coverage and eventual cost savings. I’m not entirely sure how the bill satisfactorily addresses either one, let alone both.

I’m really torn about this. On one hand, I’m a dyed in the wool liberal – at one point, a card carrying member of the ACLU. I favor basic universal healthcare. Not only from a human “right” (I get a little queasy about that exact word, but not completely nauseous) and moral point of view , but also from a standpoint of strict self-preservation. A healthy society is in everybody’s best interest, from protecting me and my family from disease to making sure there is a healthy and productive workforce and all the benefits that entails.

The key word though is “basic”.  I would of course be for covered vaccinations and birth control. (In fact, if we *could* mandate vaccinations without the opportunity to opt out, I’d be all for it, personal rights be damned. This is one case where the overwhelming benefit to the individual and to the community overshadows the slight risk to the individual. No matter what Jenny McCarthy says.) Mammograms,  broken bones, flu,  pneumonia, sure. But the waters quickly get murky as you  advance, especially considering that a disproportionate amount of money gets spent on end-of-life care. Is it worth to prolong a life for a year if it cost a million dollars? Maybe. But 6 months? 3 months? 1 day? Where does the cost  outweigh the benefit? To kick that question into medical hands – irrespective of cost – is fine for those who can pay for it. But if the cost gets passed to others (and eventually me!) there needs to be safeguards in place. Death panels? What do you call insurance companies now? I’d almost rather an organization ultimately responsible to society be in charge of those determinations than an organization ultimately responsible to its shareholders.

On the other hand, I’m also a  fairly passionate believer on what fair  and free markets can do in the hands of a free, educated and fully informed public.  The government is a slow and cumbersome beast, subject to the whimsy of political winds and convenience. The textbook answer as to why free markets are great is that they are truly the best way to allocate scarce resources to those who deserve it. It’s a basic truth that we *always* act in our selfish interest. Altruism is all well and good, but it’s a fickle emotion that’s hard to harness consistently. What better way to harness basic human psychology than the free market? Organizations get money to grow (and consequently grow the economy and provide jobs), individuals participate in that growth and prosper ; it’s breathtaking in its simplicty and beauty, it really is.

But the key word in *this* case is “fair”. A level playing field for all players. Fair means that each person has the same opportunity as the other. Not the same capability, or the same resources, but the same opportunity. That means, in part, that the true costs to society of any activity should be taxed fairly so that they are adequately covered. To fund a strong national defense, because the world hasn’t evolved to the point where we don’t need it. A strong EPA to  make sure that companies are not polluting the environment and if they are, making sure that they bear the full weight of that  cost – both financially and morally.  A strong SEC (or whatever the latest financial regulatory agency du jour is) to make sure that companies are following all the rules and not unduely using their size or clout to their own benefit. . And yes, a strong IRS that is able to collect the fair measure of what is due.

Yes, I’m a moderate. And I think – give a take a few beliefs here and there – most people (at least, the ones I associate with) are in the same ballpark in terms of foundational belief.

So from this standpoint, it’s hard for me to get excited about this bill. The devil, as it were, is in the murky details.

As far as cost, we’re obviously adding billions in taxes and additional costs to the insurers, which eventually trickle down to us. My supposition is that the supposed cost savings are supposed to come from increased competition in these health care exchanges that are to be coming. I can dig that, but as I understand it, these exchanges are specific to each individual state, and doesn’t cross state lines. In addition, the individuals that have access to these exchanges will be limited to those working for small companies or those individually insured. While there is a benefit to them, the state restriction is ridiculous and contrary to the spirit of the effort. Why not have a West Virginia plan compete with a California one? The whole CONCEPT of insurance is to spread risk out against the biggest population possible, to provide the lowest marginal cost. So, of course, let’s limit the type of people that can participate and limit what they can participate in. Ridiculous! This particular limitation will ulimately be the undoing of these exchanges, and therefore any hope of cost containment through competition.

As far as coverage. I applaud that many millions of additional Americans will get covered, and for that I’m grateful. There is some genuinely good stuff for “middle class” and lower income Americans. At a cost, yes, but I’m willing to pay to make sure my fellow citizens are covered. But there are still significant gaps there, despite the staggering cost. And I’d be okay with the cost if I believed it was sustainable, but I don’t. Without a way to genuinely change the game to control the costs, ultimately universal (or seventyfivepercental, or whatever percentage ends up being the case) is unsustainable.

What frustates me the most is that there was a genuine opportunity for true reform here.  I could have easily got behind a single payor system. It was a radical notion that never really had a chance to fly – the insurance companies are too entrenched. But even thought it flied in the face of what I believe in terms of the market based  economy, the benefits of such a proposal would have outweighed the negatives.

Barring the public option, what a good law would have done is intelligently and elegantly tap into how we behave, rather than trying to impose it’s own reality. Medical costs are increasing, in part, because of the way insurance works currently. It’s not like car insurance, where your premium is a result of how much risk you’re willing to take (by way of deductible and coverage limits.). WE don’t charge every little repair and oil change to insurance, insurance is meant for catastrophic coverage in the case of a major problem.

Health care insurance is quite different. Once you meet your deductible, most of what you get is covered. And once you pay your premium, there’s almost a sense that you need to get your money’s worth when you do need medical care. Ever overeat at an all-you-can-eat buffet? Same principle. Now, I’m not saying that you’re going to break your leg just to use your medical insurance, but when you do go to the doctor, if you are covered by insurance you pretty much don’t care what it costs for the tests you need or the procedures that need to be performed. The immediate bite of that cost doesn’t affect you, so you’re less incentived to care.

I’m jaundiced enough to know that whatever system is in place, there will be ways to play the rules to ones benefit. The reluctance to tamper with any existing system is understandable, given the law of unintended consequences. But the status quo of health care is so untenable, it *has* to change. I’m glad that we

 

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