Mimsy Were the Borogoves

Editorials: Where I rant to the wall about politics. And sometimes the wall rants back.

Universal Health Care

Jerry Stratton, December 12, 2007

I’m a little envious of Halsey Frost. When I wrote in Simplified Welfare that I’d quit my job if I didn’t have to worry about health care, I wasn’t joking. While I often enjoy my job, there are things I could do that I would enjoy more with less stress, but that don’t provide health care. Frost is using SCHIP to overcome the health care hurdle that keeps me from doing something more interesting.

There is no real debate about universal health care. Even in the SCHIP microcosm, both Democrats and Republicans want to expand the program. The disagreement is only over how much to expand it. It’s not even clear that SCHIP needs expansion. It’s one thing to claim that health care is broken and then bring out examples of people who can’t get necessary care. But it’s strange to claim that health care is broken and then bring out examples of people who are getting the health care they need just fine. The Democrats have brought out three high-profile examples of why the program needs to be expanded, the Frosts, Bo and Dara Wilkerson, and Dolores Sweeney. But the Frosts, the Wilkersons, and the Sweeneys are already covered by SCHIP. They’d still be covered under either the Republican or Democratic expansion. They’d even be covered if we didn’t change the program at all.

But beyond that, we already have universal catastrophic health care. When you need emergency health care, you get the treatment and then you either pay or don’t pay the hospital. It is against the law for hospitals to refuse emergency care. The problem with that model is that it sucks for both the hospital and the patient. I believe we do need some form of universal health insurance or health care. It is as important as universal education and more important than universal car insurance.

But we definitely don’t want public health care to be like public schools. Even the Frosts send their kids to private schools rather than trust government-run schools.

It should be easy to transition from public health to private health: any family who raises themselves above the requirements of public health care should be able to afford to continue paying for their own insurance. The current system fails there: the current system discourages individuals from handling their own health care by driving up the cost of both private insurance and private care. If my job didn’t provide health care, I couldn’t afford it—despite my never using it except for a checkup once every few years.

Employers shouldn’t provide health care

Employers shouldn’t be between the health care customer and the health insurance company. Our employers do not generally provide us with cars, houses, education, or any other necessities of modern life besides money. They don’t—or shouldn’t have to—have the expertise to provide us with health care.

Requiring employers to provide health insurance drives up the costs and reduces the quality of services, because employers don’t have the same concerns that the health care customer does. Yet this is what our health insurance laws and tax laws require and encourage.

When most health care is employer-provided, it disconnects patients from their health care provider, driving up prices by encouraging insurance for every piece of health care. This creates a vicious cycle where individuals can’t afford health care and demand more subsidized health care, further driving up prices.

The insurance and laws we already have are so complicated that employers, health care providers, and insurance companies have to hire people just to understand it, further driving up prices for both insurance and care.

Routine care shouldn’t be a part of health insurance

Last night I called my mechanic about a routine checkup, and brought my car into the garage this morning. When it’s done this afternoon, I’ll pay for the entire cost by check or by cash. If auto insurance worked like health insurance, I would not have been able to afford to handle a routine checkup as an out-of-pocket expense. The quality of employer automobile insurance would be one of the benefits I’d have to consider when looking for a job. I’d be limited to a list of mechanics supported by my company’s insurance plan, or I’d have to pay more to get a preferred mechanic.

Mechanics themselves would be impossible to find. Oh, there’d be lots of Assistant Mechanics, and they’d know enough to handle most car troubles, but in order to reach them I’d have to book an appointment with the Mechanic first. Most likely I’d never even meet the Mechanic. The Assistant Mechanics would handle my appointment, but I’d have to pay as if the Mechanic did.

Regular checkups should be easy and inexpensive. Instead, they’re time-consuming and costly. We can’t afford to go without health insurance, because health insurance drives the price of regular health care beyond the reach of individuals. Under a sane system, health care would become something we could budget for without having insurance for every tiny little thing.

If routine health care could be taken off of insurance, and insurance was reserved for catastrophic health care, routine care would be easier to pay for and easier to find.

John Stossel points out that some medical procedures that ought to be expensive and rare, aren’t: because they aren’t covered by health care.

Dr. Brian Bonanni has an unusual medical practice. His office is open Saturdays. He e-mails his patients and gives them his cell-phone number. Bonanni knows he has to please his patients, not some insurance company or the government, because he’s paid by his patients. He’s a laser eye surgeon. Insurance rarely covers what he does.

His patients shop around before coming to him. They ask a question that people relying on insurance don’t ask: “How much will that cost?” He has to compete for his patients’ business. One result of that is lower prices. And while the procedure got cheaper, it also got better. Today’s lasers are faster and more precise.

When government and insurance companies are kept away from the transaction, good new things happen.

Let consumers pay for their own insurance

If the people who need health care were the same people who bought health care and health insurance, both costs and quality of service would re-align to benefit them. Whoever pays the cost is the customer, and today the customer is not the person receiving health care. Today there are usually at least two organizations—employer and insurance company—between the person receiving care and the person giving care. To the doctor, the insurance company is the customer. To the insurance company, the employer is the customer. And that’s where it stops, because few employees consider themselves customers of their employer.

Health insurance should encourage ownership of costs, just as auto insurance does. But unlike auto insurance, it can’t simply be part of the cost of owning a car. If you can’t afford a car and insurance, you do without a car. That’s part of what keeps auto insurance down—people can choose not to buy it. There is no such option with catastrophic health insurance; we don’t let people’s past choices cut them off from live-saving medical care, nor should we. Ultimately, we have to face up to the fact that we will not refuse emergency health care. That’s the bottom line for any universal health care or health insurance program. One way or another, we’re going to pay for emergency care.

With education there’s a relatively simple solution: require universal coverage but put the money back into the hands of parents, to use as they see fit. I don’t know if something similar would work for health care, but whatever we do it needs to be flexible and in the control of each individual who needs it.

If, instead of bringing health care closer to the individual we move it further away from the individual, we will end up with a system that cares even less for individuals. One that will reduce consumer choice, reduce medical innovation, become a tool for punishing people who make unapproved lifestyle choices, and which builds up an infrastructure that itself will lobby for its own inflexibility.

  1. <- NBC Talking Heads
  2. Christmas bells ->