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Words You Don't Want to Hear about
Health Care
J breaks ranks with fellow conservatives (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 |