On health care reform

posted by Jeff | Tuesday, March 23, 2010, 2:31 AM | comments: 7

I'm still slightly shocked that Congress managed to pass the health care reform bill. It was interesting to see that even a party majority didn't guarantee it, as even some Democrats voted against it. I'm also shocked at how toxic the debate was, and frankly disappointed. More on that in a minute.

While I'm not convinced that the bill was entirely the right thing for the right time, I think it does do a lot of things that make sense, and that are long overdue. It's just that I'm not sure if the make sense parts should've been bundled with the other parts that are a bit more questionable and don't really address the underlying issues.

So the good stuff: All of the middle finger gestures toward insurance companies. These are things that aren't even moral issues to me, but rather basic consumer protection. Denying benefits to those with pre-existing conditions, or cutting them off and dropping them, putting caps on benefits, etc., these are all WTF's in the first place. You participate in an insurance pool to spread the cost of care, so it seems to me you should get something for that in return. Forcing them to pay for preventative care, which doctors have long advocated as money saving in the long run, is also a huge plus. That the insurance companies have been able to deny this, making the decision instead of doctors, has bothered me for a long time. One would argue that's a win for doctors and hospitals making more money, but I think that's bullshit.

First off, a great many hospitals are non-profits, and the industry average profit for hospitals is only 3% at best. That's a shitty business to be in. While anecdotal, I know a lot of doctors, and I've seen many, and these are not people who strike me as the greedy type. We keep hearing about how many drop out of the profession because of the insurance and lawsuit nonsense.

Meanwhile, insurer WellPoint, at the center of the California controversy, reported profit of around 8%. I don't have a problem with that margin at all, but when you want to boost premiums by 40%, with lives literally in the balance, they've got some explaining to do.

So that's the good stuff, which I would classify as being in the consumer protection space. The other provisions of the bill (or let's call it law, since it will be by the time you read this), I'm not sure they fix the right problems. There are three issues for me:

  • Requiring insurance: Economists and proponents of the bill suggest that having more people "in the system" increases the pool by bringing more healthy people in and contributing, thereby bringing individual cost down. I'm not interested in a debate about whether this is socialism or redistribution of wealth or whatever, because I truly don't think that ideological debate matters. Right now, someone eats the cost for the uninsured and you're going to pay for it one way or another anyway, with higher care costs for you or by local taxes for government supported hospitals. At issue is whether or not the larger pool actually reduces the cost of coverage overall. Economically, I would think yes, but only if there is specific regulation in place that forces the insurers to adjust accordingly. I'm skeptical.
  • Requiring employers of 50 or more people to offer insurance: I hear a lot of bitching and moaning about this already, but frankly I think it's the right thing to do. I don't consider a 50+ head count a "small business" at all, so the attack ads suggesting this would bankrupt mom-and-pop typewriter repair shops is bullshit. I worked for local government for a long time, and I'm fully aware of the breaks, incentives and tax abatement that companies can get just for choosing to open in a particular town, usually at the cost of school districts. This law doesn't even require you subsidize the full amount of insurance.
  • Subsidizing insurance for the poor: I don't think you can not do this if you're going to require everyone to have it. I hate to sound like a politician, but this should be in place for the kids who don't get to pick their parents.

Much of the biggest criticism comes around the cost, and justifiably so. The Congressional Budget Office estimates a reduction in the deficit over ten years, which I suppose is only real of the estimates are true. I still think of it relative to other government spending. The seventh anniversary of the Iraq war just passed, and it has cost $700 billion in that time. These reforms will cost around $950 billion over ten years. So for the price of war, you can get this, which is designed to help people instead of kill them. I'm not entirely willing to justify the expense just because of that comparison, because I think deficit and eventual debt reduction is critical, but I'm just not sure why the most vocal critics seem to be OK with one but not the other.

The issue of additional taxes, which apply to families making more than $250k, and apply to their investments, I actually am OK with. I see it this way: I don't make that much now, and I live a very comfortable and high quality of life. That extra .6% (or .8% or whatever it was) wouldn't harm me now, let alone if I made that much. Did I earn that money? Yeah, I did. But I don't have a problem having to pay for something like that, given my stance on the morality of it all (which I'll also get to).

So if I were to pick a position on this, I'd probably say that the cost parts of the law are probably not in our best interest... right now. And I'm also willing to concede that Obama's question of, "If not now, when?" is probably valid. See, it's too complex of an issue for me to apply some dogmatic ideology and pick a side, which is precisely what the folks in DC (and political pundits) do.

The bigger question is whether or not this fixes the bigger problem: That we now spend 16% of our GDP on health care. Advocates of the law aren't arguing that it does, but why not? Canadians spend only 10% of their GDP on health care, with a significantly smaller economy of scale even. The US government spends more of its budget, as a percentage, than Canada does, and it doesn't even cover everyone. Think about that. And don't start telling me about how much their system sucks, because you'll be hard pressed to find a Canadian who thinks so (ask Captain Kirk), and Canadians live to be 2.5 years older than we do. I'd be 100% OK with moving to a similar system, having researched it, and I have pretty much the best private insurance in the galaxy. Wipe out billions in wealth from insurance companies. I don't care. :) The only two negatives in the Canadian system are longer average wait times for scheduled stuff (four weeks for a family GP visit, compared to around three here), and they don't typically cover prescription drugs (though they're cheaper anyway, and most people do have private insurance for that).

While this isn't a government takeover, and there is no public option for insurance, I'm not sure why people were so against it. Well, yes I am. Our culture right now believes government can't do anything right. And yes, they do suck at a lot of things. So do individuals and companies, but it doesn't make any of these entities inherently prone to failure. The feds put people on the moon, and local municipalities have grown thriving private and public enterprises that contribute to their communities. I guess I'm not that jaded. It would seem to me that if you are jaded, you help drive the right change by supporting elected officials who align with what you think is right.

Central to the debate, particularly as it applied to what was once called "universal health care," is whether or not there is a moral obligation that everyone have access to health care. This is where I get annoyed with those who take a staunch and inflexible ideology and apply it to this issue. I believe there is a strong obligation that health care is available to all, for many of the same reasons that I believe education should be generally available. We as a nation owe much of our rise to economic domination because of education. Say what you will about the failures of public education, because we'd be nowhere without it. (For the record, the drop-out rate did not start to rise until the late 90's.)

It stands to reason, in my mind, that if we as a nation find it prudent to foster a healthy mind, it only makes sense that we foster healthy bodies. I don't think very many people agree with me, but I'm also not sure that those who disagree have ever spent any time without health insurance, or worse, paid for it out-of-pocket. I have, far more than I would have liked to. And that wasn't even good insurance, that was save-you-from-bankruptcy-if-you-get-hit-by-a-bus insurance. It was useless for basic preventative care, minor injury or even serious flu treatment. Even "typical" insurance is inadequate. We're still paying for Diana's treatment around her vertigo issues, from a year and a half ago. That changes your perspective.

Do you still pay for it if it were a true government-run system? Yeah, of course you do. But going from a 16% of GDP rate to 10% sure sounds like a win to me. And again, we would even have an economy of scale benefit that Canada could never match, given our population.

But again, there's the vocal opposition that starts throwing around words like socialism, which stupid people start applying as a Nazi tactic (because, you know, covering everyone's medical bills is just like slaughtering millions of Jews). The thing is, I'm for smaller government, lower taxes, etc., many of the core beliefs of every political interest, but not about this. I can't apply a rather basic ideology to every complex problem. It doesn't make sense to me.

As I said early on, one of the things that I found troubling is how toxic the debate has been. And there are already video clips on YouTube of protesters being interviewed who can't tell you even one reason why anything in this law is bad. I mean, shit, I can find plenty of things, and I was leaning toward hoping it would be passed. Then you've got these ignorant fucks standing on the Capitol steps shouting "nigger" and "faggot" at representatives. Classy. Of course, it doesn't set a good precedent when peers start shouting "baby killer" on the floor of the house either.

One could argue that the Democrats have abused their majority, which I might be inclined to agree with (though I'm not sure how having a majority is an abuse exactly), but wow did the Republicans miss a huge opportunity here. Instead of making any kind of critical or rational statements about why any of this was a bad idea, you've got people like Boehner saying it's the end of our country, and shouting "hell no" like a teenager on the house floor. (Seriously, dude, like Ohio needs any more reasons to be embarrassed.) At no point did the Republican leadership come out and say, "Yeah, health care is broken, but these are the things that we would change." Unless they just don't believe it's broken, but if that's the case their problems are far deeper. The party is in dire need of new leadership that leans more to the center. That's what got Obama elected, and honestly made Democrats hesitant about putting Pelosi in as speaker (which is odd since it obviously helps them).

The biggest issue with the toxicity isn't even that much of it isn't rooted in any actionable points of debate. So much of it is rooted in the opposition mentality. That there's a complex issue in front of people doesn't matter. If so-and-so is for it, I'm against it, and that's that. People vote for the dog catcher now based on their party affiliation, instead of whether or not they can catch a fucking dog. And I'm under no illusion that much of it is a race issue in middle America. You don't see a lot of black protesters at these things. There was never this toxic of an opposition for Bush or Clinton, and the former barely had the votes to get elected, twice.

So yes, I have mixed feelings about the passage of this bill, but I also have the confidence that it can be revised, and the crappy parts can be repealed. I don't believe it's the end of the world. And a part of me is even optimistic that eventually enough people (and maybe even political "pundits") will actually talk about real issues in detail again, and not treat everything like a for or against, black and white thing.



March 23, 2010, 7:52 AM #

You've managed to summarize the thoughts I've had swirling in my head very well. As someone WITH "pre-existing" conditions (Type 1 diabetes -- something no sane insurer would voluntarily cover in a true free market) I'm glad to see even just that small change.

Reform was needed, no doubt. Too many people who would BENEFIT from it make blind statements like "Well, I'm sure we have the best system in the world, don't change it" without understanding the big picture. We DON'T have the "best" system by many metrics. We pay more without even treating everyone -- how does that make sense?


March 23, 2010, 5:26 PM #

In my opinion, one of the most intelligent things you have written. (and that's not a knock on previous writings!) Well done, Jeff. On top of the great thoughts you have, I applaud anyone - regardless of conclusion they reach - who researches an issue, examines it through multiple lenses, and keeps things as complex as they are. A rare feat in our discourse.


March 23, 2010, 8:52 PM #

I have to agree with the first two commenters: you've written an excellent piece. I'm with Greg on the pre-existing condition list (even after my surgeries many insurance companies still consider me suffering from UC). I know many people who, even after going through what I have to be healthy, still have to stay at their jobs in order to remain covered.

In my mind the key to this who discussion is a misnaming of what just happened. Congress did not pass "healthcare reform" on Sunday; it passed "healthcare insurance reform." Very little in that bill addresses providing *better* care. What we're getting is more affordable care.


March 24, 2010, 1:55 PM #

Ok, I don't necessarily totally understand or agree with what I'm about to point out so keep that in mind. :)

"But again, there's the vocal opposition that starts throwing around words like socialism, which stupid people start applying as a Nazi tactic (because, you know, covering everyone's medical bills is just like slaughtering millions of Jews)."

I've seen you use that a couple of times. I understand the absurdity of the contrast as effective in making the other side's view seem silly, but I'm pretty sure that's not the comparison at all.

From what I understand it's the potential socalism aspect that certain people fear. The Nazi party was all about socialized health care and these people argue that it was that kind of "what's good for the whole" mentality (that you even similarly mention comparing health care to edumacation as things that make us better able to compete globally) taken to the Nth degree that became the catalyst that led to the horrible genocide the occured.

Yes, it seems like a hell of stretch to go from total coverage for the good of the whole to eliminating people for the same cause, but it's happened before.

And I think it's that kind of scary-think that makes people go goofy and yell, "Nazi!" I suspect some see it as a slippery slope or something...maybe. I dunno.

But I'm pretty sure Nazi Germany did more than kill people...even if that's what they're famous for.

Again, I don't agree or understand it beyond that, so feel free to rip it apart as I have no stake in it. It's just how I understand the thought process to be, I might be way off.


March 24, 2010, 2:46 PM #

Every time the topic of Nazi Germany comes up, I tell myself I really need to read more about it. I'd love to get a better understanding of how it all played out... more from the psychological perspective of it all (how did Hitler persuade people?, what made anyone follow him?, how did the average German at the time make sense of things?, etc.) We hear a lot about the emotional side of the persecution, but I'm also interested in understanding how a nation gets to that place.


March 24, 2010, 9:49 PM #

That's a bullshit dodge, Gonch. "Hitler-izing" photos of Obama is not these mental midgets making commentary on socialism. Hitler was against capitalism in that he thought it was part of the "Jewish conspiracy," but he was also not strictly a socialist. In fact, he felt that Marxism in particular, a variety of socialism, was wrong (apparently because he thought that was a Jewish conspiracy too, though I'm not sure why).

There are way too many examples of socialism to use, more modern in history, to flippantly be comparing an American president to a dictator who wiped out millions of people.


March 25, 2010, 1:14 AM #

Then I guess it happens for the same reasons it happened to Bush.


There's a vocal minority of extreme-leaning nutjobs who get attention because they are nutjobs on the extreme left and right.

Best to ignore them rather than get caught up in their insignificance.

(and yes, there's a part of me that feels compelled to point out that it's not a one-way street - even if no one is saying it is)

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