Beth and I and Gus had close and deep encounters with the U.S. healthcare machine earlier than most of our contemporaries. Beth and I were in our 20s when we got a birds-eye view of the Rube Goldberg mess that we call a system.
Right now, it’s kinda’ like this.
We did get mostly good care most of the time. But the time spent in waiting rooms, sorting out bills that came from providers and statements provided by insurers, and calling and calling to get answers to reconcile things was a burden on an already burdened household.
We had insurance for most of the time and the worst of our health care needs, but if one bad thing had happened for the short period we didn’t, I don’t know what would have become of us. I can say this for certain: The arc of our lives would have been much different.
Even with insurance, we couldn’t always keep up with our health care bills. And so, I know exactly how it feels to bring my son to an appointment and then, while in the waiting room, get summoned to the finance office to talk about unpaid bills. And wondering whether at some point, the clinic wouldn’t see him.
I ranted, I raved, and I bored our friends and anyone who would listen. Most had been healthy enough to have avoided dancing with the system, and I came off to them as a maniacal kvetcher.
Fast forward 30 years. Health care has become a bigger issue than ever. I proselytize less. But I’ve remained an interested student of health care policy.
Here’s how I look at it: From a moral point of view, everyone should have a humane level of coverage and access for their lifetime. What’s humane? Well, I think we can sort that out if we try. But that’s where the discussion should start in my view. I don’t see it as a right, and I don’t see it as welfare. It’s a responsibility we have to one another. We can do it if we commit to it. We should.
I believe in universal access no matter how we get there. Single-payer can be fine. There are both negative and positive myths about single payer. But it’s not the only route to universal coverage—many nations have, essentially, hybrid systems.
I repeat: I don’t care how we get there; I don’t care if Republicans, Democrats, or Martians propose it. I just want an honest and intelligent and responsible discussion.
Which is why I encourage you to read a very thoughtful and detailed and informative piece in The Atlantic that my friend Dmitry shared.
It’s headlined, somewhat unfortunately in my view, How Republicans Can Fix American Health Care. Unfortunate because I think it would be better left at how WE can fix health care, but I get it, and it doesn’t diminish the article.
It’s written by David Frum, who used to write speeches for George W. Bush, and has some conservative bona fides.
Frum, by his own words, takes a “mend it don’t end it” view of the ACA. He looks at the nuts-and-bolts of the problem, most especially at the financing structure and how to make it sustainable.
To my liberal friends, don’t dismiss it out of hand. For example:
I’ve long urged a carbon tax as a way to fund health-care expansion. President Trump’s abrupt and unconsidered call for a federal Internet sales tax raises another possibility. The U.S. has entered a revolution in retailing that threatens literally millions of jobs. The continuing de facto subsidy to online shopping looks even less justifiable now than ever. Why not a federal tax set to some averaging of state sales taxes on physical stores? Such a tax would raise far more than $35 billion and would equalize the playing field between retailers in a way that helpfully slows the creative destruction of retailing jobs.
To my conservative friends, don’t expect a market-solves-all bromide.
Republican thinking on health-care cost control has been premised on the idea of “skin in the game.” The theory is that health-care costs have been driven by bad consumer choices—and could be restrained by better choices. If consumers shouldered more of the cost of medical care themselves—say, up the $6,750 per family level implied by health savings account legislation—they would think twice before calling the doctor, and maybe even generally take better care of themselves. The power of the marketplace would bring down overall costs.
Even as theory, this idea is not looking very credible. Americans do bear more and more of their own insurance costs these days. Average out-of-pocket spending on health care has risen by about 50 percent since the year 2000—faster than that for Medicare beneficiaries—even as American health outcomes have deteriorated.
I still don’t think Frum addresses cost containment head on. In Germany, the system is a hybrid of private and public options—the government is centrally involved in partnership with private insurers. Systems like Japan’s, which allow people to buy into the national system if their employer doesn’t provide insurance, still rely on the government setting price ceilings for services.
But Frum believes—as I always have—that providing insurance and access universally is at heart, good for the economy at large:
A future in which health-care anxieties trouble Americans less will be a future more open to arguments on behalf of entrepreneurship and free enterprise. Economic risk-taking will become more attractive, not less.
Like always, the politics is the bugaboo. The pursuit of ideologically pure, all-or-nothing solutions is getting us nowhere. Getting something done well will require some courage on a lot of peoples’ parts.
Including our own.