Universal heath care has been out there as the great liberal hope since the age of Roosevelt. Its roots as a concept go back all the way to Bismarck’s Prussia, and FDR reluctantly cut it out of what became Social Security in the 1930s. Almost all Democratic Presidents since (and a few Republicans) have tried to move the ball on increasing the public role in providing health care, with varying degrees of success – but the most recent effort, in 1994, is the one that sticks in the public mind. The American public was told that if “Hillarycare” became the law of the land, you wouldn’t be able to pick your doctor and faceless bureaucrats would be in between you and your doctor. So Hillarycare went down to defeat…and we got all the threatened side effects after all with none of the benefits.**
The key thing that makes the US different from all other major industrialized nations is that our system of health care provision largely came about as a result of wage and price controls during the Second World War. Unable to offer money, employers instead began offering health insurance coverage to employees. Somehow, the notion that your health coverage is provided by your employer became more or less standard, proving the old French maxim that “nothing lasts as long as the makeshift.” And employee-paid insurance covering fee-for-service medicine was more or less the way things went for the next fifty years or so.
The situation became more complicated with the rise of HMOs as the keys to containing health care costs. Almost all employers replaced classic indemnity coverage with some form of HMO or PPO in the 1980s and 1990s. The biggest problem with this is that large-scale for-profit provision of health care services breaks in the free market – one doesn’t normally shop for kidney replacement surgery the way one would price watermelons or tennis shoes, so comparison shopping and competitive pressures are diminished. Worse, though, is the fact that making a profit depends on taking in more money than goes out – which means that for-profit HMOs and insurers have a financial disincentive to provide the services their customers pay for. When a company’s financial health relies on not providing the goods and services for which it is paid, something has broken down in the world of capitalism.
For some reason, there is a general consensus that moving to a system of government-run health care is beyond the pale and not open for discussion. Fine. The Brits seem to be perfectly happy with the NHS in the main, but that’s had sixty years to become an institution. Right now, the far horizon of discussion is universal single-payer health insurance (i.e. the government becomes everybody’s insurance company) and various measures short of that are being kicked around.
Personally, I don’t know what the best option is. These are the things in the forefront of my mind, though, and I would like to see them addressed at some point in the process.
1) A lot of people have said that administrative costs are a big part of the growth in what we pay for health care in the US. This is not surprising for several reasons. Anecdotally, I can say for myself that getting reimbursed from one’s Health Savings Account varies from irksome to right-royal-pain-in-the-ass, and I can only imagine what it’s like for a doctor’s office that deals with a dozen different insurance companies, all with unique forms and different co-payments and varying requirements. I would not object to a single-payer system, irrespective of who ran it, just for the sake of not having to deal with all the damn papers anymore. And God help you if you go through three different insurance providers in 18 months and have to sort all that out. Anything that can reduce the paperwork – some sort of standardization of forms? Some sort of info portability (see below)? – would be an unalloyed good.
2) I realize that it’s a potential IT security nightmare. I don’t care. In the year 2009, a country that put a man on the moon forty years ago with sliderules and adding machines can bloody well figure out a way to handle a patient’s medical information that goes beyond “a big manila folder with colored tabs on the side.” It is absolutely crazy that anybody can pull my credit history in about thirty seconds but it takes a couple of days’ worth of faxes and phone calls to get my chiropractor, my physical therapist and my orthopedic surgeon on the same page.
3) If you take regular medication, it should be butt-simple to get on a system where you get the drugs mailed to you instead of standing in the damn line at Walgreens every month with the extras from the Star Wars cantina.
4) In the late 1980s, “cat health” was added to Medicare – in exchange for a small increase in premiums, things like prescription drugs coverage and complete coverage for catastrophic health incidents were added to Medicare. It was a great scheme – the axis of Reagan and Rostenkowski angling for a repeat of the Gucci Gulch victory of 1986 – but within a couple of years it was repealed, because the people who were going to benefit from it balked at paying any more. Fifteen years later, a prescription drug benefit – unfunded – was slapped together as Medicare Part D, and as for catastrophic coverage? Well, medical expense is now the number-one cause of personal bankruptcy, so plainly something got lost along the way. People need to get familiar with Luckett’s Law: “shit costs money.” Everything – health insurance, tax cut, F-35 fighter jet, fine bottle of 18-year-old Jameson’s – costs money. And some things are worth paying for (the Jameson’s, for instance, which is about the only way you can come home with an 18 year old and not get your ass beat down).
5) The same year that I got married, I also got a will and an advance health care directive. I was 33. If you’re married – hell, if you’re not married, and especially if you have kids in either case – you should have both. The time to think about whether you want to “live” hooked up to a machine in a 10-year coma is not after you’re comatose. You should have a plan, in writing, notarized, and you should revisit that shit on a regular basis in case it suddenly doesn’t seem like such a good idea for your ex-boyfriend to be the one in charge of whether you get put on the heart-lung machine or not. Should the government make this kind of advance planning mandatory? Well, obviously not. Should they make it as cheap, simple and easy as a Chi O on bid night? Hell yes.
6) If I get one more call from the pharmacy saying that they need a doctor’s authorization before filling my order, I will take a hostage. You have a doctor’s authorization, ass honk, it’s called a prescription. Shut up and give Daddy his pills right fucking now. (see #3 – ed.)
7) The way insurance is supposed to work is that you have a bunch of folks paying in but only some of them pulling out at any given time. This is one place where the economy of scale actually works in health care – the more people you have in the pool, the better off you are. Something that lets small businesses team up into one big thing that gives them GM-size negotiating power with insurers is probably a good idea, whatever form it takes.
8) There is a very good case to be made that General Motors went under because it was no longer a car company – it was a retirement fund and health insurance provider that tried to defray costs by building vehicles on the side. The figure of “$1500 a car” gets thrown around as the premium paid for a car built in a country where the company is paying for the health care, and I don’t know how accurate it is, but I will bet you any money that if GM didn’t have to pay for the health care of its workers and retirees, it wouldn’t have gone bankrupt. The question of whether the employee’s share of taxes for health care would be covered by just giving them the cash difference that GM was paying is one I am not qualified to answer without a lot more time in the books with Excel and Excedrin, but it merits thinking about (viz. #7 above).
9) “Anybody can go to the emergency room” is not a universal coverage plan. For one thing, ER-based medicine could not be more expensive if it came wrapped in unicorn eyelashes and soaked in dragon tears. For another, the sorts of folks who only go to the ER, and only as a last resort, are probably the least likely to be able to pay for it later. Look at it like this: would you rather pay to change the oil, or wait until the engine blows up and pay for a new one? Now, if you have to choose between paying for somebody’s oil change or their engine rebuild, which would you rather get stuck with?
10) Looking around the world, there are a lot of different systems and a lot of ways of doing things. But if you look at the other industrialized nations, two things stand out: 1) Nobody else copies our system. We are the only ones who do it like this. 2) Nobody spends as much money on health care as we do, and yet nobody seems to have appreciably worse health care overall. There may be something to be said for looking at what other countries without single-payer or single-provider do, how it works, and whether there is anything worth considering for our own future use. Remember Jobs’s Axiom: great artists steal.
11) I don’t have any answers. I am open to suggestions. (Note that spittle-flecked invocations of socialism do not count as suggestions.) All I know is that if we can find some way to spend less money on this stuff, it will be easier to handle all the other problems coming down the road in future (the forthcoming physical infrastructure collapse, the ass-backward broadband and wireless coverage in this country, the inevitable inflationary pressure when the Fed tried to reel in the post-stimulus oversupply of money, etc etc).
12) I have a one-inch crack in my skull from puzzling all this out. I just figured out the banking thing this weekend, that’s how zippy I am.
* Team Black Swan East gets a nickel. I told you he was smart.
** You may or may not see this as a benefit, but it’s pretty much a lock that Ted Kennedy would have retired ten years ago had universal health coverage become law.
