Health Care Reform: Why So Damn Difficult?

Confession time: I’m still all over the board on the health care reform debate. I share the cost concerns of the cost concerned. I share the coverage concerns of the coverage concerned. I like the “cooperatives” idea; but I’m not opposed to the “public plan” idea, especially if it can be honestly structured to “compete on a level playing field with private insurers,” as suggested by Sen. Schumer and seconded by Sen. Specter. Better yet, “the Schumer proposal is in line with the principles of the major reform campaign Health Care for America Now” or HCAN.

Great. I hope it works out, although what still bothers me about this debate is why such incredible energy is spent on seeking an administrative role for government, rather than keeping its role focused on setting rules.

For instance, Congress could develop a comprehensive set of rules, starting with some of the features of Medicare cited by frequent TMV commenter “GreenDreams,” including …

no eligibility requirements or physicals
no exclusion of pre-existing conditions
no cancellation for excess use of services
no penalty for moving or changing jobs
no re-applying for coverage if moving or changing jobs

Congress could then add to or elaborate on those rules with HCAN’s principles, including …

Health care benefits should cover all necessary care including preventative services and treatment needed by those with serious and chronic diseases and conditions.

Health care coverage with out-of-pocket costs including premiums, co-pays, and deductibles [should be] based on a family’s ability to pay for health care and without limits on payments for covered services.

[Establish a] watchdog role on all plans, to assure that risk is fairly spread among all health care payers and that insurers do not turn people away, raise rates, or drop coverage based on a person’s health history or wrongly delay or deny care.

And then, rather than create another massive, complex government program, Congress would do nothing more than require every current and would-be insurer — public or private, for-profit or not — to either follow the rules or face penalties or get out of the way.

Sure, those rules are tough, and they might force every private insurer to respond, “Go to hell; no can do.” And then we end up with a single-payer, government-run system, after all. But I doubt that happens. I doubt it happens because, in my limited experience, where there’s a daunting challenge, there’s a million or more people willing to tackle it. It’s the ultimate American genome: “Hey, there’s an unclimbable mountain; let’s climb it.” (I know that sounds “pollyanna,” but I also think the point stands.)

And thus, I’ll repeat (with great naivete) the question in the title of this post: Why is this so damn difficult? If we all effectively agree that everyone should have a shot at good health care, why do we insist on complicating it with discussions about massive programs rather than forceful, comprehensive, fair-minded rules of the road? Wouldn’t the latter get us to the same place without all the associated trouble and cost and concern?

ADDENDUM In the comments, DLS and CStanley raise the “gotcha” factor that I conveniently overlooked in the preceding text; it’s essentially the same “gotcha” factor that Dr. Darshak Sanghavi raised in his June 23 contribution to Slate:

Not everybody can have everything, and the sooner we admit that, the sooner our health care debate will get realistic.

In other words, the “rules” suggested above can’t be the only rules. Any entity — private or public — to stay solvent, will need to exercise limits (and be allowed to exercise limits) on what and how much is covered. Even in the fairest plans, there will be a percentage of people who face the prospect of either paying more out of pocket or, to be blunt, suffering and perhaps dying. There’s not enough money or good will in the world to prevent that from happening.

But none of that counters the fundamental point of this post: That government might best fulfill its purpose by establishing rules/guidelines rather than administering programs.

That said, I’m intrigued by CStanley’s combination, rules-plus-programs scenario:

The best system IMO would be govt encouragement of healthcare savings accounts for our routine care, affordable catastrophic care packages for most working people (insurance companies would offer these and can also offer boutique coverage for more stuff if the market will bear it, but premiums would be appropriately high), keep Medicaid for the working poor or unemployable, and create a govt funded option for a pool of high risk patients.

And with that, I think I have answered why this subject is so damn difficult: Because, it seems, there’s always another factor to consider; there’s always another intriguing proposal to debate. So it goes.