Tuesday, August 18, 2009

Health Care Reform

I've been reading all the rants about this, and this isn't any attempt to analyze the issues and cite sources. This is just my personal opinion on the situation.

First, I agree with my blogger friend Linkmeister, who commented in a post today that the Republican party has now made its position clear. They aren't interested in health care reform. They are only interested in defeating whatever President Obama tries to do. This being the case, the hell with bi-partisanship.

Second, I've thought about this a lot, and I'm convinced that we will never get health care costs under control until we separate health care from capitalism. Health care isn't something you should plan to get rich at. It's a service that should be provided to everyone, like fire and police protection. (Okay, in Oakland, California, "police protection" as a service provided to everyone is kind of a touchy subject. But my point stands on the "should.") The profit motive in health care is what's driving costs inexorably upward, and we won't get costs under control until we come to a common agreement that for-profit health care is a Bad Thing. It's the defense of the Bottom Line that causes companies to cancel people's coverage the minute they come down with something that will be really expensive to treat, like cancer.

Yes, this means I want a "public option." Actually, I don't - I want single payer. So far, the Repubs have managed to shove that off the table. Maybe, now they've made their position clear, we can bring it back; since they aren't going to agree to anything anyway, we can ignore the fact that they don't like it.

But there's one more thing we have to do to make this work: we have to reform medical education. Becoming a doctor is fiendishly expensive; people come out of their training fully qualified and hundreds of thousands of dollars in debt. That training has to be subsidized, as part of the subsidy for medical care itself, or no one will go into medicine. This is just part of providing the service. Hopefully such reforms will attract people who want to provide health care, instead of people who want to become filthy rich doing specialties like cosmetic surgery and neurology. I have nothing against either cosmetic surgery or neurologists, I use the specialties as a general example; I am aware of a shortage of general practitioners, because it's so hard to pay off your medical school debts on a GP's income that everyone wants to get into the high-stakes specialties.

And this is personal. I'm in favor of single payer (or at least a "public option") because I expect to need it. Right now my access to health care depends on my husband's employer; I have a fall-back position at my own former employer. I have no faith that either of those companies will continue to support health care for retirees. I really think we need to separate health care from employment, and if that means taxing employer-provided health care, then let's tax it.

I'm hearing a general consensus on several critical points: everybody should be have health insurance; nobody should be refused coverage because of a pre-existing condition; nobody's coverage should be dropped just because they got sick. The only thing we're still arguing about is "socialized medicine," AKA "how do we pay for this?"

People have been bitching about this for fifty years, for Crissakes; I remember the screams of "socialized medicine" in the '60s when Medicare was passed. We're now in the 21st century, and most of the major industrialized countries have universal coverage, and none of them is Socialist. (You really think Canada or Great Britain are Socialist?? You don't know what "socialist" means.) And they all look at us and shake their heads and say, "Crazy Americans." Can we please get on the train that everyone else is on, and start figuring out how to control the costs??


  1. Hedera: My heart is definitely on the side of angels, here, as yours is.

    But I think there's a failure to acknowledge how much it really costs to provide the kind of care the people at the very top of the economic ladder get, either as a result of privileged coverage packages, or because they have the money to buy it (i.e., they're rich).

    Everyone thinks his or her life is precious. I do. You do. Even the drunk lounging in the doorway of the abandoned business on Market Street does.

    Medical care, even if it is not done "for profit", costs way more than 99% of the people in society can reasonably afford to pay. Is that cost the result of "greed" or "capitalism" or creeping inflation? Only to a limited degree.

    The insurance companies get blamed because they make choices based on the bottom line. Their bottom line probably looks a lot different than the Medicare bottom line, because the incentive is different. But the important fact is, there HAS to BE a bottom line, at some point. Who's going to draw it?

    People tend not to make intelligent choices about their health, especially if they think "Uncle Sam" will take care of it. Middle class people like me--who's almost never used his health care (and I'm still relatively healthy at 62)--resent having to pay for people who don't take steps to insure themselves and smoke and drink and ride skateboards and have unprotected sex and all the rest. Insurance is not something you fob off on society, it begins with YOU and ME. You "insure" yourself by living in a reasonably responsible manner.

    If one well-off person is taxed to pay for three irresponsible ones, is that an expression of Jeffersonian Democracy? I don't follow that line of reasoning, but it's a legitimate objection by people.

    In Britain and Canada, the jury is still out on whether society can truly "afford" to provide Cadillac coverage for "everyone."

    I don't know what the answer is. Obviously we already cover "everyone" through Medicaid--we really already have universal health coverage in America. What people don't like is giving up all their assets and living at the poverty level to obtain their care.

    The real debate is about how much people have to pay to obtain the highest levels of care. It's the cost that's at issue.

    I'd like to believe that we could cover all those who don't have coverage or can't afford it, without breaking the proverbial bank. Is that possible? Do YOU know what the cost of doing that actually to be? IOW, the Medicaid be offered to people who have assets and income but simply don't "want" to pay for what it actually costs to obtain it?

  2. Pls note corrections to last paragraph:

    It should read "the cost of doing that actually would be"

    It should read "should Medicaid be offered"

  3. I think the idea of supporting primary care physicians education is a very good idea.

    I'd favor that the federal government offer direct student loans at a modest 4% interest to medical students who intend to become primary care physicians (general practitioners), and then forgive 8% of their final student loan amount for each year that they practice as a primary care physician. Thus their loan balance would reduce by a net 4% a year (and faster later) even if they made no payments. Also, further tax breaks could be established to make primary care overhead costs smaller, such as for instance a tax rebate for the FICA taxes on nurse practitioners in a practice.

    The other big availability/cost issue is illustrated by Atul Gawande's piece in the New Yorker a few months back. That when there are more specialists, the result is simply more use of specialists. This odd economic outcome is possible only and precisely because of the fee-for-service model, and the information asymmetry -- that the doctor is the only expert. Both parts of that equation can be changed, but the fee-for-service part is the most inflation-driving.