My take on health care

After a long hiatus, it looks like I'm blogging again. Sorry that my return to blogging is political in nature, but it took something like this to get me back to the blog. A lot of conversation is going on today about the health care bill, but a lot of it is happening on Twitter and Facebook. As great as it is that Americans are debating and discussing an important issue, this issue is too complex to be boiled down to 140 characters and status updates, and it tends to devolve into people trying to get off one-liners that are more clever than their opponents'. That's not helpful. I've had a lot of family and friends asking me why I support health care reform, and the only way I can give my thoughts on it is if I have more than 140 characters to do so.

I think the easiest way to explain my position is to lay out the problem and the various proposed solutions as I see them.

Most people who are covered get their insurance from a private insurance company through their employer. That's how insurance works - people pay into the pot even when they don't currently need health care so that people who do get sick or hurt can tap into that pot and pay for expensive care. But a few flaws in the system have made it so that people who need coverage the most can't get it - people who are sick, people who get into an accident, or people who are unemployed, self-employed, or employed by small businesses that don't have a large enough pool of people to qualify for affordable rates. Pre-existing conditions, dropped coverage when you get sick, and prohibitive premiums for individuals buying insurance without the backing of their employer prevent these people from getting the coverage they need.

The way to solve this is to have everyone in the country paying into the insurance pot so that there's enough money that the sick don't lose their coverage, that pre-existing conditions don't bar you from coverage, and that you can afford insurance regardless of your employment situation. There are a number of ideas that have been used to achieve that, and here is my description of them, listed from most liberal to most conservative:

• Socialized medicine, like they have in England. In this model, the government runs health care. That means the service providers - hospitals, doctors, dentists, etc. - are government employees, and the costs are totally covered by taxpayers. This has always been deemed way too liberal for the United States and was never up for discussion in this health care debate. It's the kind of model where you're most likely to find that doctors are underpayed and therefore underqualified, where patients face long wait periods before they can get an appointment, etc.


• Single-payer health insurance, like they have in Canada. In this model, health care providers are private companies, but they bill the government rather than an insurance company. Because the providers are private companies, there is more room for competition, innovation, etc., but there is still a strong government role, so there is arguably still a risk for many of the problems that go along with socialized medicine. In my mind, it's a workable system, especially because the insurance coverage is a nonprofit endeavor, so premiums, deductibles, etc. aren't jacked up to turn a profit. But again, too liberal, so no one seriously discussed this option during the debate either.


• A plan that keeps private health care providers and private health insurance intact or at least in the mix. Within this option, there are a couple of approaches, again from most liberal to most conservative:
  
  
  
  • A public option, the most liberal option actually considered during the American health care debate. In this plan, private health insurance remains as an option, which individuals and employers can continue to buy into. But there's an additional option, a government-run insurance plan, that individuals and employers can also choose. Health care providers (doctors, hospitals, etc.) are still private, but you can choose to buy insurance from a not-for-profit government insurance plan. Competition from the public plan forces private insurers to be less reckless in raising rates and cutting coverage, but the fact that private options remain means that those who distrust or dislike a government plan are free to remain on the private market. It's a lot like the education system: There are private schools, and there are public schools. Private schools are more expensive, but you are able to shop around for one that most closely meets what you're looking for; public schools face problems like overcrowding, tight funding, etc., but they at least provide SOME option for people who can't afford a private education. I really liked this approach and would have liked to have seen it given more of a chance in this debate, but again, conservatives were able to paint it as too liberal, and it died.
  
  
  • The plan that passed. In my mind, the plan that passed is the most conservative workable solution to health care. There is no government-run insurance here (except, of course, Medicare, veterans' care, care for federal employees, etc. - government-run plans that already exist). The government does, of course, play some significant roles in this plan. For one thing, the government mandates that all Americans have health insurance. This is necessary to ensure that there is enough money in the insurance pot to cover people when they need it, but it also requires the government to create subsidies to help people afford this now-required purchase. (This is where the cost comes in, but remember that taxpayers already subsidize a HUGE chunk of health care coverage when people go to emergency rooms, when people go bankrupt because their health care costs too much and end up defaulting on their medical bills, etc. - not to mention Medicare, veteran's benefits, etc. The non-partisan Congressional Budget Office says this plan will reduce the deficit over the next 10 years.)
    
    So once we're all buying into insurance, the government is able to ban insurers from setting up bans on pre-existing conditions, dropping kids from their parents' plan when they hit age 21, increasing premiums willy-nilly, etc. And for individuals buying insurance on their own (rather than through work) or for small businesses with too few employees to be able to afford insurance on the open market, the government will set up health care exchanges. Those are basically like catalogs of approved insurance companies, companies that are required to follow certain regulations to be approved (regulations regarding pre-existing conditions and things like that). It allows individuals who are in the same boat (self-employed, unemployed, or employed by a small business) to pool their buying power the same way larger companies can. Basically, employer insurance plans are like discounts for buying in bulk - since you're buying insurance for a lot of employees, you get it cheaper - and on a health care exchange, individuals can also team up and get the same bulk discounts.

Of course, there are a lot of peripheral issues – abortion, coverage of immigrants, etc. – that muddied up the debate. But those are not central to the debate over which model of insuring all Americans is most cost-effective.

And, of course, there are a lot of flaws in this plan. For example, one way that health care costs could have been dramatically cut would be if we could import drugs from Canada, where they are much cheaper. This was illegal under the existing health care model, and it remains illegal under the new plan. But this isn't a sign of liberals mucking up the bill; it's the influence of big pharmaceutical companies and conservative/protectionist interests that want to protect the profits of American pharmaceuticals. Taxes on elaborate "Cadillac plans" that could have helped cover the costs of this plan were left out, partly because of the influence of unions and also because of conservatives' tendency to label ANY tax as excessive. And in a lot of ways, the private insurers win big because they now have 32 million more customers who are being required by the government to buy private insurance. But that's what happens when you want to lower health care costs by making sure everyone is insured but you don't want to provide for a publicly run, not-for-profit plan.

I'm sure I got some of the details wrong. I'm certainly no expert. But I have followed this debate closely and tried to wrap my brain around all the different issues, ideas, claims and counter-claims, and this is how I've been able to make sense of it. In my mind, the bill that passed last night is the most conservative option that stands a chance to clean up our health care mess.

As I see it, the only way you can deny that this was the right thing to do would be if you believed the health care system was working just fine as it was. But I can't imagine how you'd believe that. People who are employed by large companies that provide them with good health insurance may feel comfortable with the system as it was. But first, under this plan you don't have to abandon that coverage at all. And secondly, and more importantly, you will now be protected from being dropped by your insurer if you get sick or get into an accident.

I had a realization the other day. Under the health care system as it existed before this deal, imagine this scenario: If I went to the doctor tomorrow and found out I had a terminal illness with one year to live, I'd be in a tough situation. I have great insurance right now, paid for entirely by my employer. But the insurance company we use is a private company, and there's the risk that they would find a way to drop my coverage once I got sick. But even if they didn't do that, I'd have a problem.

I live several thousand miles from my family, and if I was dying in a year, I'd want to move back to Utah and spend my last days with them. But, of course, that would require me quitting my job and losing my insurance. And once I got to Utah, it would be impossible for me, as an unemployed individual with a pre-existing condition slowly killing me, to find new insurance coverage that I could remotely afford. So I'd probably be stuck, forced to stay in D.C. and keep my job so that I could afford health care at the time I needed it most. In my mind, that's a fundamentally flawed situation, and it's a situation that no one should find themselves in. It's why I believe that health care is a basic service that we should all be entitled to, just like military protection, education, fire and police protection, mail service, sewer and water, garbage pickup, etc.

The right to life, liberty and the pursuit of happiness hinges on the ability to do what you need to do to keep yourself as healthy as possible for as long as possible. This bill is the most conservative step we could take as a nation to work toward securing that right for everyone.