Monday, March 22, 2010

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.


Marie said...

I was excited when I saw you had posted on health care. I always love your honest, even-tempered approach to political matters, and your post was helpful for me. I haven't been following the issue as closely as I would like -- something about chasing kids all day -- so thanks! Keep it comin'.

Doug Gibson, Steve Stones said...

Well done analysis. The only dishonest part, and that's probably due to partisanship, is blaming conservatives for allowing bribes to Big Labor and Big Pharma. As you know, Republicans never were offered any chance of input to this bill. It belongs to the Democrats.

Doug Gibson

Emily Matthias said...

Well said. :)

One thing worth noting is that the bill allows parents to extend coverage to their children up to age 26. This is a big deal too as it opens up the possibility of college for young people with chronic conditions. Prior to this they'd have no choice but to work (and probably not simultaneously go to school) for a company that provided coverage.

I never understood anyway the idea that it's a good thing to tie health insurance to one's employer. That cripples the workforce's ability to move between jobs, and I believe it's vital to our economy that companies compete for workers. When health coverage is tied to employment, that translates to a workforce without the freedom to quit a bad company, or the freedom to move across the country, etc.

Kristen {RAGE against the MINIVAN} said...

I think this is the best explanation of the whole thing that I've seen. Couldn't agree more.

Daniel said...

Hopefully you know me well enough to know that my FB comment on this blog post was an attempt at irony, and funny probably only to me. But then I read your blog and it got me thinking: what if I am one of those religious people who does not believe in modern medicine? I believe that god will just take care of me and if I get sick and die, well then it was God's will. Will I be required by law to pay for health insurance that I never intend to use? I think that this general idea might apply to a couple of other specific cases (I.E. I believe Ned Flanders rejected the idea of insurance as he considers it a form of gambling). Admittedly, this argument would apply only to a minute (and/or fictional) slice of the population, but these are the kinds of things I think about at 1:15 in the morning when I'm reading blogs about politics.

Ericka said...

Hi, I came over here from Kristen's blog - in response to Daniel, you are able to opt out of buying insurance for religious reasons.

King Jimmie said...

Doug Gibson: I recall very specifically, Obama asking the Republican members of congress to give their input. In fact, in the state of the union, he said something along the lines of, (and I'm not going to use quotation marks here becasue this is by no means a quote...) There is no perfect bill, and (to the Republican members of congress) if you have a better solution, please let me know. (End not-quote.) He made it very clear throughout this process that he wanted input from every angle possible. Unfortunately, the Republican response was to shoot everything down rather than try to work together for real solutions. I am not a hater of the Republican party, and I quite often side with them, but in this situation, they have been afraid to WORK toward a solution for fear that Hannity has convinced their voters that anything that assists Obama in any way is Socialism, and they don't want to lose votes.

Chris said...

Doug I really appreciate the manner in which you address issues. Politics are so important but I am sooo turned off by the climate right now. Everyone is so bitter and defensive.

People love to throw around words like Fascism at the drop of a hat. They feel they should be so angry.

I just read a facebook update comparing the passing of this bill with secret combinations in the Book of Mormon. What that means is that these people seriously think that people supporting this bill are absolutely evil and have sold their allegiance to the devil. Any seeming good intentions are a facade. People won't consider the simple facts that you have clearly laid out when they feel that Satan himself has positioned the players to bring about the Apocolypse.

So many people seem to think that their position on a bill like this really has something to do with which side they are on when the world comes to an end. They are more concerned with being on the right side for that event rather then recognizing the fact that our society is trying to improve itself. Progress requires forward movement. Everyone seems to agree that we needed reform and as you pointed out this has been a pretty conservative solution.

Thank you for your post. I found it very informative and helpful.

Jacelle said...

Here here Doug! I really appreciate this post. An the is going to help me explain my own stance to my blindly conservative-crazed fam lol

The Bullocks said...

hi, so I found you blog from a facebook post. I do think you bring up some great points. and it does seem to make sense. my big fear is I just don't feel like I can trust the government. Maybe this is the perfect solution if we were dealing with honest trustworthy people who I felt had our best interest at heart. I feel like this is a way to get a foot in the door and then they can change and add to the bill later once it's passed.
I know that this whole thing is pretty complicated and over my head. I've tried to follow what I can. and to understand as much as I can, but I just have an uneasy feeling in giving the government that much more control over something. so I guess that's my conservative side of the debate. thanks for you views.

Emmalee said...

Thanks for helping me understand...I just have one question. What happens to people that still can't afford insurance? I know they are required and have to pay a fee if they don't have insurance, but what if they can't afford it? Does the government pay?

Iggy said...

In my office we've just hired a Nurse Practitioner and developing a Patient Center Medical Home Concept to prepare ourselves for the upcoming changes in HealthCare Reform

LC @ Let Them Eat Lentils said...

Welcome back Mr. Smeath! Missed you.

There is an awesome NYTimes (I think) article about how different countries do health care and how it's worked for them. I'll search around to send it to you.