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Posted by on Aug 22, 2009 in At TMV | 40 comments

Does anybody really understand the health care debate?

Early this summer as the health care debate began to heat up I recall reading a very smart critique from one of TMV’s sharpest regular commentators – CStanley. She argued that each of the individual goals set out by Obama and advanced in the then-progressing HR3200 attack serious problems with the health care system. But the problem was in reconciling a whole bunch of mutually contradictory elements, namely reduction of health care costs AND expansion of health insurance coverage to those without it. How, she argued, was it really possible to do both at the same time (of course she framed it far more eloquently than this).

As the health care debate has progressed I’ve found myself comforted by partisan and ideological frames, but essentially lost on the substance of the health care debate. I’ve finally come to realize that I don’t know much about this issue. Even worse, I find it nearly impossible to learn about it without running into obviously biased sources one way or another.

Now, as an academic, I pride myself on my ability to sift through subjectively produced texts in order to draw out greater narratives and arguments. I study and teach primarily the American Civil War, which is about as passionately divisive a topic there is. On most subjects outside my field I deliberately seek out the nuances of the debate to find the points of contention and the meta-frameworks for the discussion.

But on health care I must admit: I’m lost.

I know the politics of, say, the public option. But I couldn’t tell you how the public option would actually work, what its effect might be on care for the indigent, private health insurance plans or, well, me. I certainly like the IDEA of “keeping the insurance companies honest.” And I tend to find the hopes on the left – and fears on the right – that the public option will be the Trojan Horse that brings down the private health insurance business to be a bit overblown. If the public option is so limited, as HR3200 has it, how could so many people suddenly launch themselves out of the private market into the new AmeriCare, or whatever it would be called? On the other hand, if government is so awful at running things, WHY would people choose to abandon the private insurance market – presumably the government is too wasteful to actually compete with private insurers, even with the leverage of taxpayers behind it. Do the small-scale public models really show us anything – failures in Maine and here in Tennessee, success in San Francisco, and widespread though imperfect success everywhere else in the industrialized world?

But the public option is really just scratching the surface. If you actually read through the massive HR3200 you discover just how arcane medical law really is. A hodge-podge of public, private, Federal, state and local plans and jurisdictions already overlap in inefficient ways. Is it even possible to alter one piece of the American health care morass and know what will happen to everything else? I understand the frustration voters have with legalese and the prolixity of the legislation. But, just as with tax reform, simplicity does not necessarily mean better.

One of the biggest question marks is cost. Everybody talks about the inefficiencies of the current system. OK, so is it really possible to make it more efficient without completely reshaping it – either on some sort of libertarian model or a single-payer system? And something about this whole cost debate strikes me as dishonest. Health care is expensive because modern medicine relies on expensive new forms of technology and research. Yes, there are all sorts of perverse incentives out there for doctors to waste resources on these newfangled drugs and devices – and all kinds of legal reasons why doctors defensively run MRIs for no good medical reason. But can anybody honestly say that removing all these extraneous services would lower costs over the LONG term? I doubt it’s really that simple.

The only way to cut medical costs is to cut medical care – rationing. But who does the rationing? Right now private insurers ration care by denying service to certain people; the government rations via its Medicare reimbursement rates; and individuals ration care themselves based on increasingly unaffordable deductibles. I gave an example in earlier posting where I was charged $1,400 out of pocket for my son’s two-night stay in the hospital for the croup. What an utter and complete waste of money and care. He could have gotten prednisone for about five bucks and been cured – as he has been for the subsequent times he’s gotten it (including right now). As a result, I will avoid hospitalization or any expensive medical procedure for myself and my family if at all possible. We’re rationing ourselves!

And then there’s the total opacity of medical costs. Is there any other product or service that you buy where you have no idea how much it will cost – not just because the procedure is up in the air, but the byzantine process of insurance reimbursement will leave you with a bill ranging from zero to thousands of dollars? Does anybody really understand how and why they are charged what they are charged after visiting the dentist for a root canal? And is it really such a great thing that insurance companies routinely deny reimbursements until patients call their hotlines with questions?

I can only wonder what millions of other families are thinking. We’ve been blessed with generally good health as a whole. But many people I know have not been so lucky. For some of them a good insurer has posed little financial burden on top of their health problems. For others, a newly discovered medical condition has resulted in bankruptcy. Did one really make responsible choices to get good insurance and other not? Hardly. It seems more dumb luck than anything else. If you have the misfortune of working for a small company with cheap medical care then you are a diagnosis away from financial ruin. If, on the other hand, you are lucky enough to work for some corporate or governmental behemoth then you are probably in luck if the doctor tells you you need expensive medical treatment.

So, I don’t see how we really cut medical costs over the long-term. Most of the plans out there – better recordkeeping, tort reform, bulk purchasing agreements – seem likely to produce short term savings at best. As we live longer, and as medical care becomes increasingly sophisticated, medical expenses will continue to go up and up.

There are a lot of ideological debates surrounding health care, but most of them seem secondary to any actual solution to the problem of access and cost control. The private market serves some very well, and others less well than they realize (which I discovered before the hospital check arrived in the mail). For still others it means the ER is the only source of medical care; the side debate over whether or not health care is a “right” is the silliest of all. Until people are literally kept out of the emergency room, health care in this country is, for all intents and purposes, a right. And yes, the same goes for food and water. Nobody starves in this country because we won’t allow it – even for those who do not work. It’s not part of the Constitution, mind you. But it’s certainly a part of the American social contract shaped over hundreds of years.

Still, that “right” to health care does not necessarily mean the same thing as the “right” to the same health insurance as somebody fortunate to work for a large corporation with a great group health plan. How do we reconcile the two, when “merit” does so little to account for the discrepancy between the coverage offered to the cantankerous and lazy DMV worker and the small-firm software engineer? Is there really some grand defensible principle at work here, the “Don’t Tread On Me” protesters notwithstanding? Access to quality health insurance coverage seems more random than anything else.

Alas, our health care system is both costly and unfair in any meaningful sense. What’s worse, it seems to get even more costly, more inefficient and more unfair with each passing year. My premiums go up faster every year than my salary – in absolute dollars! Like tens of millions of other Americans, the increasing cost of health care is making me poorer – even though I and my family eat healthily, exercise and keep ourselves in generally good health.

Will “health care reform” or “health insurance reform” (as it’s occasionally framed) really make things better? Or worse? Can anybody thinking outside ideological and partisan lenses really know the answer? I can see why people are afraid of reform. But I can also see why failure to reform things will make things even worse than they are now.

I suppose the best and most fruitful way to approach health care reform is as a process. Some sort of reform bill will almost undoubtedly be passed and signed by President Obama. It almost certainly will neither solve all the problems of cost and access that Democrats promise, nor create the Soviet dystopia of rationed death care so feared by those on the right. So then what? Will this process mean that the next Congress will keep tweaking away as emerging issues make the older system falter? Or will Congresses in the future leave this domestic third rail alone for the foreseeable future?

My hope is that this bill will be the first of an ongoing process of reform, examination, experimentation, and more reform. Ideological debates are perfectly appropriate, but political leaders should use them to clarify and not to obfuscate. There is no perfect “free market” for health care. And there is no National Health Service. There is a hybrid. We should expend our energy on making that hybrid work the best for the most people and leave all the maximalist rhetoric from both sides out.

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