Now that the Republican alternative to the Affordable Care Act has gone down whimpering, we can gaze ahead in sober daylight and think about how a capitalist republic might deal with health care. US health care costs rise well above inflation, and we pay more than anyone in the civilized world, and yet our overall outcomes are below average. How do we fix this?
The more you look at the actual numbers, the more you realize that Obamacare, or some revision of it, might be as good as it gets.
How We Got Here
If (when) you become sick or injured, health care is not a purchase you can realistically delay or avoid. In the United States, you have no enumerated right to receive it. This puts providers in a position of being able to say, effectively, “your money, or your life.”
Costs and profits in the healthcare field have soared accordingly. Medical costs for similar procedures have risen well above inflation and well above average wages for decades. The majority of personal bankruptcies in the United States have their root cause in healthcare bills. While insurance companies complain about the low margins on the individual exchanges under the ACA, they somehow seem to report record earnings to their investors. Not hard to figure out where the money went.
The reason the Republicans could not come up with a plausible alternative to Obamacare (other than they, collectively, have little experience in actually governing) is that the Affordable Care Act is essentially a Republican plan. It’s core outlines can be found Newt Gingrich’s short lived alternative proposal to Clinton Care back in the 1990’s, and the revised and updated version that Mitt Romney managed to install in Massachusetts (Romney had help for the Mass dems in that regard).
The Obama administration ditched single-payer (which they could have passed on party line) for the orphaned GOP plan because they were (one) futilely hoping for some Republican buy in (they got zero) but (two) more importantly, they did not want to go to war with the insurance industry, which is how Clinton Care went down in flames even with a Democratic majority.
The Affordable Care Act is Newt Gingrich’s plan as revised by the insurance industry. Now, because they were Democrats, they added some needless bureaucracy, and some taxes to pay for it. It passed by a single vote on reconciliation. And then they bungled the roll out. And then the Democrats were rewarded for their efforts by being booted decisively out of office by GOP foes fueled by insurance company contributions.
So this band-aid, compromise, duct-tape and bailing wire solution does not lower costs. But it has, overall, lowered the rate at which those costs rise, and it has, overall, marginally improved outcomes, and it has actually decreased the number of uninsured, though most of that was achieved by pumping more money into existing Medicaid programs. (Sigh.)
The true slogan of the Obama administration : It Could Have Been Worse.
Since we have just seen that there is no viable Conservative alternative, let’s look to the other side.
Medicare for Everybody
Medicare for Everybody is touted on the left as The Answer. It leaves delivery of healthcare largely in private hands (thereby saving us from something like the VA). It provides universal coverage – or at least the option of coverage – to anyone on the tax rolls at greatly reduced costs to those typically faced now. It would be effectively group health insurance coverage for US citizens.
NOTE FOR DEMS: You want to start calling it “group coverage for US citizens”. You want to outlaw the phrase “single payer”.
Conservatives respond to this by imagining all manner of administrative obstacles and pitfalls, and those are plausible with any large bureaucracy. Then they will cry about the unfairness of redistributing wealth. These arguments waste everybody’s time. Private insurance companies are notorious for deciding it is cheaper to pay court-ordered settlements for wrongful death than actually deliver the services they were contracted to deliver. The summary term for that is “evil”.
Plus, your scheme to exempt the rich from contributing to the health care of others just went down to defeat at the hands of your most conservative partisans. So quiet now. Grown-ups are talking.
Here are the real problems with Medicare for Everybody:
The US government would have a financial interest in promoting, and perhaps requiring safe and healthy behavior for its citizens – because they pay the hospital bills. There would be a real impetus to outlaw foolish behavior, and mandate safe and sound, from everything from food to paragliding. By gaining an effective right to healthcare, we might give up our freedom to be foolish.
You might wonder who would miss half-toxic food and paragliding, but these rules will creep towards eliminating all voluntary risk. The ability to take risks is a key component in innovation, which is a required component of capitalism. Plus – paragliding is fun (I would assume).
In a working republic, diligent citizenry can mitigate the excesses of the Safety State, but this would remain a constant struggle. It is however, the lesser of the obstacles.
Medicare for everyone presents an existential threat to private health insurance. For all conservatives rouse their rabble about the sweet purity of the market, and the inherent incompetence of any government program, no private insurance wants to compete against Medicare.
Medicare has a 3-7% operating cost (depending on whose figures you go by), no real marketing or sales costs, and no investors to satisfy. They have provided insurance coverage to the least profitable cohort imaginable (seniors) at substantially reduced cost to both the institution and the enrollees compared to private alternatives. Medicare works.
Not only that, but an expanded Medicare’s ability to set prices cuts into the margins of every entity currently providing service for something other than charity. Consequently, the insurance companies, and big pharma/big medicine are going to go all out to kill Bernie Care or anything remotely like it.
They will see this struggle as life or death.
You’d need to be polling in the 70% range to overcome that. Bernie Sanders couldn’t beat Hillary Clinton among Democrats with this idea. How are you going to convince half of Republicans?
Well, redirecting hundreds of billions of dollars out of insurance coffers and into the rest of the economy would have a positive effect, both for individuals, who could make bigger purchases instead of declaring bankruptcy over their strokes, and small and medium businesses who would no longer have to pay to provide and manage insurance for their employees.
Name one Democrat who is talking about it like this. No, they are talking about “single payer” and “healthcare as a right” and basically making themselves conservative archery targets. And the poll numbers demonstrate this.
Even so, the overall economic benefits of M4E are theoretical, while the massive adverse impact to the medical/industrial complex are a certainty.
So we are left with what is possible: Obamacare, for the foreseeable future. Perhaps, when the smoke clears and the blood dries, our leaders will pause for a moment from biting each other to slap a fresh layer of duct tape on the thing, see if that will hold a little better.
That doesn’t seem likely, but it at least seems possible.
Universal health care, Medicare for All, will establish cost efficiency that eliminates major health care bills and medical related bankruptcies. It will simplify our way of paying for health care and lower the total cost for the United States. It will be good for the physical and financial health of Americans and America.
[This is a zealous advocacy group for this program.]
The classic problem of monopsony buying power, however, is underprovision of services. The medical market is no exception. This problem manifested in Medicaid years ago — as states started to clamp down on payments, providers exited the market, leaving us with the patchwork system we have today. Could the same happen to Medicare? We are already hearing reports of doctors who do not take Medicare patients. In a 2010 survey of 9,000 physicians, the American Medical Association reported that 17 percent of doctors restricted the number of Medicare patients; among primary care physicians, a whopping 31 percent did. With universal Medicare, is the population really going to accept, and would Congress really allow, the continued reductions in prices?
[Least whiny of the con arguments I came across.]
The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although life expectancy and survival rates in the United States have improved dramatically over the past century, Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries. The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people: even highly advantaged Americans are in worse health than their counterparts in other, “peer” countries.
A new survey released by the number-crunching technocrats at NerdWallet last month clearly illustrates how extending Medicare coverage to all Americans might cut costs for everyone. According to NerdWallet, Medicare generally pays out no more than $0.27 for every dollar that hospitals bill it for medical services — a savings of 73%. Put another way, an uninsured patient receiving the same care as is provided to a patient covered by Medicare can expect to pay nearly four times as much.
If an individual consumers think they’re better off with a private health insurance plan from WellPoint — or from UnitedHealth Group, Aetna, or Cigna — then fine. They could still sign up for one of those, either as a supplement to Medicare-for-all or, if they prefer, as an exclusive plan, and choose not to participate in Medicare at all. For that matter, there should be no need to require anyone to buy any insurance whatsoever.
[The last is Motley Fool imagining a plan. It is unclear whether the plan proposed by Senator Sanders – almost certainly the Democrats’ first offering – would require compulsory enrollment or not.)
[Speaking of which:]
[This is essentially a campaign document.]