Wednesday, February 18, 2009

Health Care Reform: What Do We Want to Accomplish?

I am going to turn my attention away from 'negative' writing about Republicans or corporations and focus back on 'positive' issue-related material this week.

The health care debate is raging again. Howard Dean and Kathleen Reardon are writing busily about the subject of national health policy on HuffPo and one gets the idea they are targetting each other: especially when the latter singles the former out by name. I see that as sort of a dead give away. Both make highly valid points, and it is a shame that they are spending time beating on each other over tactics instead of writing more of actual substance on the subject. I understand why Governor Dean feels that Professor Reardon is mistaken to give credence to congressional Republican posturing about the stimulus bill's medical content and agree with his characterization of the representatives in question and his defense of government studies into the cost and efficacity of medical treatment. Yet I also understand Professor Reardon's reaction to the governor's column.

So I am not going to write about the health care elements of the stimulus bill, or again mention either of the two authors for whom I have an equal and healthy respect. Nor, despite my strong temptation, am I going to write about one of the most well-meaning but wrong-headed ideas I have ever seen from a purported expert. Said expert linked their idea in reply to Governor Dean's posting, and I will simply say I am slightly aghast at the cold-blooded utiliatarianism implicit in the notion.

Instead I am going to be practical and ask a straight-forward question.

What do we want health care reform to accomplish?

This is not a simple question. There are many ideas from various people on the right (yes, ideas from the right, it's true) about how to widen 'health coverage.' Some of them, when examined on face value, sound very practical. However, all 'coverage' is not equal and 'coverage' does not guarantee 'care'. If one spends half the year arguing with one's carrier about whether one's flexible spending expenditures are legitimate and is expected to provide documentation of those expenditures not explicitly required in the paperwork received with the program, while one's flexible spending account is frozen and one is still required to pay for it while frozen, clearly 'coverage' isn't good enough in that instance. So simply covering everyone, as Governor Mitt Romney did in Massachusetts, is not enough.

At the very base minimum, then, health care reform should provide more people currently being sued by hospitals for expensive procedures that rich people get for far lower fees because of their insurance with health care and legal protection from such lawsuit. Medicaid could be extended to cover everyone who does not receive health insurance from their employers, period, while private health insurance could be required to meet minimum standards based on Medicaid or Medicare. Neither of these programs is perfect, but compared to some HMOs they are a dream come true. This is roughly along the lines of the program President Obama described in his election campaign.

I believe we can do better. I favor a national, single payer medical program. I believe the HMOs can be nationalized quickly and efficiently and incorporated into and expanded Medicaid/Medicare system subsidized by payroll taxes. Everyone who works pays their payroll taxes, everyone who does not receives traditional Medicaid until they are working again. This is superior to the existing, separate systems of shared costs used by the HMOs because everyone would be sharing costs on a national level. Essentially, this would be a national HMO. It would have government oversight and be accountable to elected representatives, who would be accountable to their constituents. Oversight power should be strictly defined and limited: the oversight committee should not have the power to gut the system or to dictate policy, only to audit and review performance and police corruption. Bureaucracy should be vastly trimmed over its present level in private HMOs: qualified doctors and informed patients should make medical decisions together without the interference of a man in a suit with a friendly smile, a plastic name tage, and a roll of red tape and a black marker in his pocket.

In many cases, single-payer health care would be preferable to even the best private health insurance. It would eliminate a major financial strain on corporations struggling to survive difficult economic times. Freed of the responsibility to pay for their employee's health care, they would also lose one of the powerful levers that allows them to feel a sense of ownership of their employees. In that sense, single-payer would be good for employer and employee.

I see only one true objection to nationalization and that is the issue of liability. HMOs, with Republican support, have sought to eliminate their accountability for the damage their decisions to provide or not provide health care cause and have frequently been successful. It can be argued that with nationalization, the government will have even more incentive to limit the patient's right to hold health care professionals and provider's liable. However, I believe that the genuine difference between legitimate and 'frivolous' complaints is much clearer than conservatives like to pretend. Ultimately, the strength of any claim is proven in court. If someone wins a lawsuit, then a judge and jury clearly did not find it frivolous. A single payer system could formulate a uniform system of compensation and accountability for malpractice, something lacking in our private system. This too could actually be an improvement. Most importantly, with no bureaucrat empowered to deny care based on cost, the issue of HMO negligence would cease to exist. The course of care recommended by the doctor and agreed to by the patient would always be followed.

The losers in this system are the various health insurance corporations in the medical business and trial lawyers who represent or sue them. However, the management of the corporations in question are hardly paupers. They have their golden parachutes ready, whatever happens. Trial lawyers will never lack for cases.

If one really looks at the big picture, socialized medicine isn't radical at all.


The Snarking Lot said...

It is astounding to me that with the cry of the American people for this issue to be addressed ever-growing in volume and intensity, we still as a people have avoided a serious discussion.

Pollsters can continue to ask voters if they favor universal health care (terminology that is a blanket that can be stretched and twisted to cover nearly anything in the neighborhood of the health care debate) and talking heads can likewise extend the never-ending shouting matches about it on the boob tube. Neither of these, however, makes any sort of contribution to solving the universally-recognized problem that is the way we obtain/deliver medical services.

A national debate must be had. It will need to involve specifics. I know specifics are frightening things, America, but come on, now! Do we really expect our leadership to wave some sort of magic wand and declare "A la peanut butter universal coverage!" There will be no razzle-dazzle poof of smoke that will disappear revealing the solved problem. No debate means no definitions, no parameters. No definitions/parameters means more of the same.

Chris Richards said...

Very well said. I literally do not think I could agree more, and I am struck by the lack of sanity on the issue in this country. My friends outside the US have a hard time finding the capacity to believe that someone can't just 'make a doctor's appointment' when one is sick.