THE DONUT

Posted in Rants on July 7th, 2009 by Ed

Although it has gotten the news back-burner lately (and what hasn't, with all the famous idiots dying) the President is pushing ahead with the second Democratic attempt at legislation that provides healthcare for every American. Strategically this is a poor idea. Rather, the timing is poor. You will never meet a more ardent proponent of universal healthcare than Ed, but I think the public and certainly Congress are a little stunned at the moment. Sticker shock might be the right term. While it doesn't make me flinch, the idea of another initiative costing another trillion-and-a-half dollars is giving even Congressional Democrats cold, cold feet. It's not the right time. To try it now ensures another colossal failure. The President needs to re-accumulate some political capital, a process that will take time and hinge on the success of one or more of the big ticket items he has already gotten through Congress. In short, when people aren't so scared shitless about the economy we can have a real conversation about trillion dollar healthcare proposals.

Here's what I don't understand. Why does it have to cost a trillion dollars?

Since the moment I formed an opinion on the subject I have been convinced that a successful universal healthcare proposal in the context of American politics must have two things: a user-end cost for those who can afford it and the ability to opt out of it in favor of private health insurance. This addresses two fundamental aspects of the post-Reagan era public mind. First, charging people something allays the impression that it is free and thus will be abused. It won't be the government "giving" people something as much as selling them something, albeit at a heavily subsidized discount. Second, European nations have discovered by trial and error that rich people may be willing to shoulder the costs of national healthcare, however grudgingly, if they are allowed to retain their Right to be treated better than the rest of us. They may eventually consent to having their taxes provide insurance for dirty poor people, but they'll vehemently refuse to sit in the same waiting room with them. If they want to buy their way into the proverbial gated subdivision, we must let them.

And, of course, the 800-pound gorilla in our policy debates is our insurance and for-profit healthcare industries. We have to find some way to let Humana and Wellpoint line their pockets. Because of these three conditions, proposals for reform inevitably become convoluted in a hurry. Remember the 10,000 page clusterfuck that was "HillaryCare?" But taking these factors into account I think there is a much, much simpler solution that is rarely mentioned. Perhaps I'm just overlooking something. You be the judge.

We already have this big healthcare donut. The wealthy and the poor are covered while people in the middle often are not. The truly indigent either qualify for Medicaid or receive Emergency Room services that they simply do not pay for. I say that without condemnation or judgment. It is what our system encourages. As inevitably as poor and starving people will steal bread for which they would pay if they could, poor people who are really sick will go to the ER and welch on the bill. They know that ERs must provide service irrespective of ability to pay. Afterwards they will receive a bill that goes unpaid. The hospital will refer the account to collections (my former line of work) who will see that the debtor hasn't a pot in which to piss and close the account. Just add it to the pile of billions in write-offs that happen every day in the industry. On the other end of the spectrum, the wealthy can afford simply to buy insurance. So the rich and poor are already taken care of. Add in the fact that a government program already covers the elderly and we have the framework of a system already in place.

So here's EdCare. Tell me where this admittedly simplistic take is missing the boat:

  • 1. Keep Medicare. That takes care of everyone over 65.
  • 2. Expand Medicaid to cover everyone making under $15,000 before taxes.
  • 3. Using Federal money, have governments at the state level act as group purchasers of private sector insurance. Offer everyone not covered by Medicaid and Medicare the option to purchase insurance on an income-based sliding scale. Part of the cost would be subsidized by the government, part of it borne by employers who fail to offer their employees insurance (punitive taxation, so to speak), and part borne by the insured. This is how the system already works for those of you who have insurance; the boss eats part of the cost and takes the rest out of your paycheck.

    In my opinion this addresses all of the key obstacles to reform. Insurers stay in business and get some Federal cash to boot. The poor are covered at no cost without resorting to the misuse of emergency medical services. The elderly are covered by a Medicare system to which they have contributed. People who work but are not offered insurance pay a reasonable dollar amount – say, $50 to $300 monthly depending on income and single/family coverage – to get coverage which is only partially subsidized by the government. See, the entire debate as framed by opponents of universal healthcare is a red herring. No one is asking for "free" healthcare. We want access to health insurance at a reasonable cost. Employers used to provide that access but many no longer do so. This is where Congress needs to step in. The uninsured will gladly pay for insurance if they are able. They simply need a better option than the kind of high deductible, low benefit rip-offs that pass for private health plans in this country (As Seen on TV – usually after 3 AM).

    The uninsured here in Indiana would be perfectly happy, I think, to pay whatever State of Indiana employees pay every month and get the same coverage. What is so hard about that? The entire insurance industry is based on the idea of large groups pooling resources to buy coverage from private insurers at a lower cost than any individual member of the group could get on his or her own. The easiest solution, therefore, is simply to re-define the way we think about who is and is not given the option to buy into the kind of plan that you buy into through your employer right now.

    Crazy, I know.