Thursday 28 March 2013

You got a better idea?

Health care is a human right, not a privilege of the wealthy.  A civilised country ensures that medical care is available to all its citizens, without regard for ability to pay.  The details of the provision of universal health care vary by country, but the basic premise is the same:  Health care is simply available to all, not on a fee-for-service basis.  When I lived in the UK and went to a doctor, there was no paperwork, no bills, no co-pays or dealing with insurance companies, no questions of what or how much insurance would cover.  The medical staff were paid salaries rather than paid on a per procedure basis, so they had no incentive to order unnecessary procedures.  They weren’t paid more if they squeezed more appointments in per day or if they ordered more tests.  Medical costs were contained because there was a single payer, the government; there was no ability of providers to charge higher rates to some customers the way the uninsured pay higher prices than the rates negotiated by insurance companies and the government in the U.S.

The U.S. is the only developed country that does not provide universal health care to its citizens.  It is also the only country where a citizen can be bankrupted, lose their house, and become unemployable due to medical expenses.  In case you are scratching your head over how medical bills can make you unemployable, here’s how:  Potential employers routinely run credit checks on potential employees.  Unpayable medical bills on an applicant’s credit history can cause them to be passed over for jobs, a vicious circle making it even harder for them to pay their bills.  The U.S. is the world’s richest country and the rest of the world is appalled that people can die here due to being unable to afford medical treatment.

The U.S. needs to adopt single-payer universal health care as soon as possible—better late than never.  But that is not politically viable at present.  In fact, an interim measure, the Affordable Care Act of 2010, popularly known as Obamacare, that takes baby steps in the direction of increasing health care coverage for Americans, has generated considerable backlash.  Now, backlash for not going far enough would be legitimate, but this is ire from people who think the Act goes too far in trying to patch together some form of health insurance coverage for Americans who would otherwise be uninsured.

The legislation has many provisions, and you can find someone who objects to each and every one of them, but the gist of the argument against Obamacare seems to be that we, the taxpayers, cannot afford to provide health care coverage for those who cannot afford to pay for it themselves.  Subsidizing coverage for people who cannot pay their own premiums, the thinking goes, will place an enormous and unfair tax burden on those who work hard to pay their taxes and their own insurance premiums.  Moreover, since insurers will not be able to turn away high-risk customers, everyone’s premiums will go up to compensate.

The premium cost complaint is easy to address:  Legally cap premiums.  It is not as if the status quo ante was a paradise of affordable premiums.  Most people without employer-provided insurance could not afford to purchase coverage or, if they found a plan they could afford, the coverage was so meagre that they were egregiously underinsured.  Many Americans are walking around who technically have health insurance but who find the coverage worthless when they need it.  Underinsurance is actually a bigger problem than lack of any insurance.  Small businesses have always struggled to be able to provide health insurance to their employees, many of them gave up long before Obamacare.  Some people stick with jobs they hate because they need the health insurance.  The best option would be a single-payer system that would take private health insurance out of the equation altogether but, until the political power of the insurers can be overcome, an interim solution would be to legally limit what they can charge.  Obamacare does do this, but the limits are weak, and insurance companies have been rushing to jack up premiums before the law goes into effect in 2014 so that the new higher rates are grandfathered in.  A better interim measure would be to mandate minimum coverage to end the problem of underinsurance, and to cap premiums.

What’s that you say?  That if insurance companies were forced to provide more coverage for lower premiums they might get out of the health insurance business?  Gee, wouldn’t that be a pity.  So, they should be allowed to continue to charge extortionate premiums for useless coverage because that is the American way?

Moving on to the complaint about the cost to taxpayers to cover the uninsured.  One obvious point is that the taxpayer already pays when the uninsured use emergency services and/or are unable to pay health care bills.  Those charges are passed on to others.  Another obvious point is that we have a patchwork of taxpayer-subsidized health insurance that covers certain segments of the population, such as the very poor and those over 65.  Extending this coverage to other segments of the population would actually be more efficient than the current system.  As mentioned above about countries with single-payer universal health care, the government can tell providers what it is willing to pay for services and they can like it or lump it.  Costs can be kept down based upon what the government is willing to pay.  I realize there is a counter-argument that providers could stop accepting patients if their profits are limited in this way, but that is an unfounded fear. If it started happening, it could also be addressed with legislation.  This may come as a shock to some Americans, but some countries do not allow the private practice of medicine.  You accept government rates of payment or you don’t practice.  It’s not the American way, I know, but neither is it likely that providers will stop taking public patients.

But Obamacare is a weak law written with the cooperation of insurance providers, to their advantage.  Instead of taking away their customers and putting them in a universal single-payer system, it requires everyone to purchase private insurance, greatly raising the number of customers for the industry.  It is a huge boom to the insurance industry, and it does not decouple health insurance from employment, which is long overdue.  Companies started offering health insurance to employees after WWII as a perk, to lure good workers.  Over the years, employer-provided health insurance became expected, even though it makes no sense and places a senseless burden on employers.  Believe me, most employers would be happy to get out of the health insurance business.  Although they are increasingly trying to pass the cost of health insurance onto their employees, it remains a huge, unwanted expense, not to mention the fact that smaller companies simply cannot afford to offer it.  Instead of disconnecting insurance from employment, Obamacare provides incentives for employers to offer it.  This is a mistake.   In the short term, it can be addressed by states providing counter-incentives for employers NOT to provide health insurance.  In the long run, we simply have got to decouple employment from health care coverage completely.  There is no logical connection between the two.

My last point is a question to those who oppose Obamacare:  How do you propose handling health care costs for those who cannot afford to purchase insurance and do not receive it from their employers?  (I include in this statement those who are underinsured, which is essentially the same as being uninsured except that instead of merely not having coverage you are also flushing money down the toilet every month paying useless premiums.)  There are, as I see it, three options:

1)   Those who cannot afford care do not receive it.  If you cannot afford to pay for your own health care costs, or those of your family, you should suffer and die if you become ill or injured.  Health care is not a right; it is a privilege for those who can afford it.

2)   Individuals and private charities should provide health care for those who cannot afford it.  Such care will be purely serendipitous—if you are ill or injured, there may or may not be a private charity willing to provide care at that place and time.  But relying on the kindness of philanthropic strangers should be your lot if you cannot pay your own health care costs.

3)   The status quo is fine.  If people cannot afford their health care costs, it is the right of creditors to sue them and confiscate their assets.  If they cannot get a job due to a poor credit rating from unpaid medical bills, they should have thought of that before they got ill or injured.

       - Corollary to status quo option can be split two ways: 1) Taxpayers should continue to absorb the costs when people who cannot afford care use emergency rooms.  This is a huge waste of money, but it is more acceptable to us than comprehensive coverage.  2) The law that emergency care must be provided to everyone, regardless of ability to pay, should be overturned.  We should not cover emergency room care for those who cannot afford it, let them die.

So which will it be?

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