Talk You Don't Want to Hear about Health Care
(Revised 12/2009)

Everyone (well, almost everyone) seems to agree our health care system is in trouble.  The two primary complaints seem to be that (1.) it already costs too much and the costs continue to expand apparently without limit, and (2.) too many people in America don't have health insurance.

Most everyone also seems to feel we should have adequate & universal health care, that EVERYONE should be able to receive reliable, decent health care regardless of their situation in society.  In other words, that society should take care of all. (Except maybe for people they don't like, but that's a side issue I will deal with below)  I'm willing to accept this idea, because it makes sense, and anyway, we already have universal health care in America.

Here's why I say we already have universal care:  An astounding number of people keep repeating the lie that there are vast numbers of people in America who have no health care.  This is total bullshit, as anyone who has visited an emergency room knows full well.  The emergency room system provides health care for everyone who walks in, whether or not you have any insurance.  That is why every emergency room is packed with people who are, in Southern California at least, mostly of Latino descent and accompanied by hordes of kids who mostly have the flu or something similar.  Scattered among them are people with actual emergencies who, hopefully, will get put near the front of the line. But eventually, everyone gets care, insured or not.

So contrary to what is so often alleged we DO have the stated objective of "universal health care" in America already, it's just provided by an unwieldy, extremely inefficient and very expensive "system", if you can call it that. Kluge is a more accurate term.  What we need to do is rationalize the system that takes us to the objective.

Right at the moment (late 2009) we are engaged in a huge fuss over "Obamacare", which seems to refer to a amorphous collection of individual ideas and trial balloons that as far as I can determine will only expand and perpetuate our existing kluge.  I don't like it, not because it is too radical but because it is not radical enough.

Here's the deal:  I am a staunch life-long conservative, virtually always vote Republican, and think that in many areas we have way, way too much government already.  But there are things that free enterprise capitalism is not well suited to manage without extreme regulation, and I have reluctantly concluded the implementation of true universal medical care coverage is one of them. 

Health care is a non-political sort of thing:  Everyone will need health care to some degree during their lifetime regardless of their political views.  But our needs, as individuals, are wildly variable.  Some people seem to live at the doctor's office, averaging dozens of visits each year, while others, such as myself, may not need to visit a health care professional for years at a time.  And any person may be suddenly struck down by some ailment that requires immense and immensely expensive levels of care. 

How do we handle paying for this huge variation in needs? The answer is "insurance" in some form.  The whole idea of insurance is of course to gather together a large group, who will each contribute some presumably reasonable amount into a pool of money that will be sufficient to handle the expense of caring for the whole group.  The concept works well, for while the majority who have minimal to average needs will end up tremendously subsidizing the minority who are heavy users, all group members do get care and are protected from catastrophic expenses.  But insurance works best when the group is very, very large so that the huge spikes are smoothed out by the mass of the group.

This leads me to my prescription for overhauling health care:  Bite the bullet and maximize the insurance group size to its ultimate limit.  Make it a single group composed of everyone, with everyone who pays paying into one single "insurance" pool.  This is the much-maligned and much-feared "single payer" concept.  But if we as a society are going to provide universal medical care this is the only efficient way to do it.  It makes no sense at all to finance universal care via a payment structure that is split into dozens of separate groups, with some covered by the "no insurance-insurance" of emergency room care, some covered by private insurance, others under government insurance, others on Medicare, others on programs like California's MediCal, and all groups having different criteria for coverage.

So here's how I would do it if I were dictator: 

Single Payer: One insurer who pays all bills, a non-profit quasi-government entity structured so that that it couldn't be raided for extra funds to divert into other government activities.  I am a capitalist but logically if we are to have universal care financed by society at large I don't see any valid reason to go through stockholder-owned insurers whose basic function is to divert part of the money into shareholder profits before it is spent on actual medical care.  There is a whole world of other enterprises to invest in.

From whence cometh the money, or: Who Pays for the Payer?  First off, "my" plan will NOT be yet another income redistribution scheme. Everyone benefits, everyone pays, and pays as equitably as we can make it. Everyone, even welfare and Social Security recipients, pays. Self-employed pay.  Cash-only shadow economy dwellers (illegals, etc.) pay. Everyone, EVERYONE is in, no exempted elected officials or government workers, no special union deals for teachers or firemen, none of that. Only possible exception might be for military on active duty, who have a unique requirement for a separate medical care system.

To accomplish this I invoke the KISS principal:  Don’t get all wrapped up trying to micromanage, keep it simple, and what follows is the simplest way I know. 

It doesn’t appear to be widely understood that in our capitalist/consumer society, in the final analysis all money comes out of the pockets of the consumer.  If you tax a company or corporation, the tax is actually paid by the consumers who buy its service or product.  Using a water pipe analogy, the corporation is merely a pipe that moves money from the consumer to a myriad other destinations.   Given this fact, my preference for financing universal health care is (gasp!) a tax directly on consumers, or more accurately on consumption.  I would go for a dedicated Value Added Tax (VAT) on goods & services for the simple reason that it fits my philosophy that if everyone benefits, everyone pays.  A VAT insures everyone pays something, yet is progressive in that the better-off in society consume a lot more goods & services and therefore would pay proportionally more in tax.  

The VAT would not be as much a new additional tax as a restructuring of things.  The money now paid by companies (and governments) for health insurance would go away and should be directed (by regulation if necessary) right into their employees’ pockets to offset the VAT.  Individuals who currently pay their own insurance would just pay it a different way, and at what should be a lower rate due to economy of scale.   Taxes for Medicare & state programs like MediCal would go away, reducing that tax burden on the worker.  Plus, our productive but currently untaxed cash-society (such as the millions of illegals) would pay their share.  Even the totally non-productive, those who live entirely off the largesse of society, could be said to be “paying” at least something back via their purchase of goods & services even though the money would still actually come out of the pockets of the productive.  And everyone would be able to see exactly what health care costs them, every time they make a purchase.

Tort Reform: In conjunction with implementing single-payer I would institute comprehensive tort reform.  Virtually all "malpractice" claims would be shifted to arbitration boards staffed by experts and "pain & suffering" awards virtually eliminated.  Medical providers could still face criminal penalties for gross misconduct but would otherwise be shielded from civil lawsuits for less-than-satisfactory outcomes when standard care (see below) was given.  Baby turned out stupid or ugly? Too bad.  Grandma died at 93 even though you are sure she could have lived to 96?  Too bad. Uncle Lester was one of the 20% who died after receiving a treatment with an 80/20 success/failure ratio? Too bad.  You are a lawyer and this would put you out of business? Too bad, but hey, you'll have health care.

Standards of Care (AKA "Rationing"):  This is a real hot potato that overwhelmingly affects the "end of life" crowd (see below), but implementing it certainly would be eased under the single-payer concept.  The payer (the government working with health professionals, essentially) would generate standards of care that everyone could expect to receive.  If an individual wanted something more, they would be responsible to pay for it themselves, possibly through secondary private insurance.  The idea is that expenses could be kept under control if there were limits on what an individual patient or his family could demand.  The standards would be based on what works and what doesn't.  Is there only a demonstrated 6% chance that the super-costly treatment would produce a cure or provide continued survival with a reasonable quality of life?  Not good enough, you don't get it unless you want to pay for it yourself somehow.

End-of-Life Care:   This is a sub-set of the Standards of Care / Rationing argument.  I really do think that many older folks would, if given straight-up honest information, elect to blow off the quality-of-life destroying, incredibly expensive and ultimately useless treatments that are cranked out today for terminal illnesses.  I also think that, relieved of the threat of lawsuit, doctors would be much more honest and forthcoming in their dealings with the elderly and the dying and would offer better advice on the true prognosis. 

Face it, spending many hundreds of thousands or even millions of dollars to keep one person more or less alive for a few months or even a year is just not a good thing to do.  This is a tough call, certainly, but facts is facts. Being of 'that age' now, I have recently been intimately involved as close friends died while absorbing incredible amounts of health care resources that were both ineffective and very unpleasant to endure.  I don't WANT to die, but I accept that is my ultimate fate no matter what and I am not selfish enough to want or expect society (via Medicare) to spend a half million dollars on something that statistically has only a 20% chance of keeping me going for an additional six months and a 4% chance of giving me five years.  This may all be more a social thing than something that can be regulated, but definitely we all need to be more accepting of death as the inevitable result of life.

Contracts (AKA "Bundled payments"):  While the current insurance groups are out, the single-payer could contract with medical provider groups or hospitals for flat-rate payments to provide standardized care for their patients rather than paying 'per patient'. It's sort of a sub-insurance scheme, and with large medical groups this would very likely lead to cost savings.  However, this should not be allowed to unduly penalize individual providers, such as, for example, those practicing in rural areas where the efficiencies of scale are not available.

Illegals, Non-Citizens & "Shadow Lurkers" within society:  Illegal residents are yet another hot potato.  Many Americans would cut them out completely.  I would not do that, and the fact that they will pay via the VAT just like everyone else should help defuse the matter.  One thing, however: I would make it necessary that everyone getting health care would have to agree to be enrolled into the national health care system and be positively ID'd if necessary.  If they show up cold without an ID or enrollment it would be done on the spot, to include biometric/DNA data that would positively identify that individual from that point onward.  This is consistent with another rant of mine, that EVERYONE who is present in the USA should be positively ID'd, something a lot of my fellow Americans are dead against.  I firmly believe that if you are here, using our (my, your) society and its resources, then society has the right to know about it and to know who you are, and if that isn't acceptable take yourself somewhere else.

Final Word:  Some of the stuff above will be anathema to many, possibly most, of our citizens, and I agree there is a lot of harshness in it.  But there are some unavoidable harsh decisions that have to be made.  The idea of being guaranteed unlimited anything, health care included, is a fantasy.  There are not enough resources on the planet to provide unlimited amounts of anything to everyone, so there is no avoiding the fact that there have to be limits set on the amount of care that society will provide to the individual.  At least, however, the outline above insures a good measure of fairness & equality for everyone