Rest and Repair: Progressive Dreams and Conservative Nightmares

When last we spoke, the topic was moving from how to stabilize the individual health insurance plan market toward how best to deliver the services and do so without bankrupting American workers. Now we’re in the land of Progressive Dreams and Conservative Nightmares.

Republicans use the expression “patient centered medicine” as code for a system n which the individual (and individual policy holder) is responsible for how much, and what kind, of insurance coverage he or she may have.  This system works in theory, but has severe implications when it collides with reality.  As noted here, and in other analyses, the delivery of health care is not a “market” in the true sense of the term.  A market requires a voluntary transaction, and a diagnosis of a serious illness or the result of an accident aren’t voluntary in the sense of a face life or other form of elective medicine.  Not only is there not a market in the economic sense of the term, but health care is not necessarily an “individual” matter.

Philosophical Review and Reality Check

If I choose not to seek treatment for a communicable disease, perhaps because I don’t feel I can afford the treatment, I am placing my co-workers, neighbors, and heaven only knows who else, in peril.  If I choose not to seek rehabilitation after having an accident causing injury, then I place my own productivity in jeopardy, and reduce the value of my services to my employer and co-workers.  If, for financial reasons, I choose not to have something such basic as an annual physical exam, then I have chosen to ignore the ramifications of this decision on those around me.  My ‘freedom’ places the freedom of others to function in a safe and secure environment in jeopardy.

Arguing that “freedom” requires I accept responsibility for my own health — and health care — in turn requires that everyone else accept the same responsibility even though we have no control over the actions and decisions of others which may impact our own health.  This would be caveat emptor carried to irrational extremes.

If we’ll accept the notion that we are herd animals in our present form, and our socialization requires we not place others in jeopardy willfully or involuntarily, then what options are available within the current system to make sure we are healthy enough to be productive and not ‘infect’ the neighbors?

Dreams and Nightmares

At the risk of inserting more artificiality into this discussion, let’s assume that we maintain our system of paying for medical services with a combination of out of pocket and insurance resources.  What systemic changes can we make to expand the resources to more people in the individual (and employer) markets without changing the fundamental nature of our system?  The options range from tweaks to overhauls.

At the tweak end of the spectrum Senator Claire McCaskill (D-MO) offers a plan to allow residents in areas abandoned by health insurance corporations to purchase insurance offered by companies on the District of Columbia Insurance Exchange.  As discussed yesterday, a more middle of the spectrum suggestion is to revise or renew insurance company options for risk adjustment, risk corridors, and reinsurance to encourage the corporations to remain in rural markets.

The public option model moves us along the spectrum, and is available in legislative form in the text of HR 1307 in the 115th Congress.

“For years beginning with 2018, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.”

The public option provides insurance plans which could be restricted to abandoned areas or extended nationwide depending on the final structure of the legislation.

Republicans see a slippery slope in the public option proposal — today the public option tomorrow the single payer plan.  As noted previously, there’s nothing “socialized” about proposals establishing Medicare for all, because the Medicare insurance plan pays for privately delivered services.  However, again, Republicans see any extension of access, with public support, as a step towards nationalized health care.  This makes for intriguing intellectual disputation, but it doesn’t really further the process of making more Americans healthier, or easing the burden of health care insurance from American businesses.  The burden is illuminated by the often quoted:

“For large multinational corporations, footing healthcare costs presents an enormous expense. General Motors, for instance, covers more than 1.1 million employees and former employees, and the company says it spends roughly $5 billion on healthcare expenses annually. GM says healthcare costs add between $1,500 and $2,000 to the sticker price of every automobile it makes.” [CFR]

A pre-ACA Rand study supported the general conclusion that employer sponsored health care insurance combined with rising health care costs was a drag on economic growth:

“The analysts found no significant relationship between the percentage of workers with ESI in the U.S. industries in 1986 and the percentage change in employment in the corresponding Canadian industries over the 19-year study period. The lack of a relationship suggests that excess growth in health care costs does have adverse economic effects and that these effects are more pronounced in industries that have a higher percentage of workers with ESI.”

While the Republicans may envision nightmares of nationalization, some of the industries which provide employer sponsored insurance who support their agenda are simultaneously encumbered with expenses not shouldered by their foreign competitors whose employees are provided with public sponsored health insurance.

Perhaps we could advance our public discourse on health insurance if (1) we would stop discussing the topic as if it were an ethereal scholastic issue in which generalizations and speculations replace hard data and human experience; (2) we would look at a variety of proposals ranging from small technical changes to the Affordable Care Act to technical changes to stabilize the insurance market to full public support for privately delivered health care services.

*H/T to Mark Stufflebeam and @Karoli for suggestions and resources!

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