But I think the problem goes deeper than distortions and falsehoods, and the health care debate is a great example. There is a terrible lack of clarity in our public discourse on the purpose of health care reform. Policies like exchanges, the public option, and cost-cutting measure have little meaning to people when they don't even know why we need reform! If we forget why we need to reform health care, then people can only become confused and stay out of the debate. I believe that is partly why ratings for the President's health care reform proposals are way below his personal approval ratings. Most people have been confused out of the debate, leaving only far right-wingers who will believe what they want to, dedicated progressive activists, and the Beltway crowd, dominated by corporate lobbyists.
It was clear well before 2009 that our mainstream media, especially on the television, is failing us in terms of getting the facts out to the people and focusing on what really matters. However, pro-reform politicians and to a lesser degree progressive organizations are also responsible for failing to ground their arguments in the flaws of our health care system.
Here's the goals of health care reform as I see it and as I think most people in favor of reform see it (correct me if I'm wrong). This isn't anything new, but I want to get it out to drive everything else that I write about health care. The deeper we dig into why we need reform, the clearer the policy details will be. Also, these goals aren't mutually exclusive (as the Blue Dogs and others seem to think).
1) Universal health care coverage
Basically this means making sure everyone has adequate health insurance. In 2007, 46 million Americans (15.3% of us) went part of the year without health insurance. An additional 25 million are under-insured, meaning that despite having insurance they paid more than 10% of their income in out-of-pocket health costs. With the proliferation of high-deductible and high co-pay insurance plans, the problem is growing, as the number of the under-insured increased by 60% between 2003 and 2007 (see above link). Health insurance companies are allowed to deny coverage to those with pre-existing conditions, and even drop coverage to people that get sick. The Center for American Progress finds that in this recession 14,000 Americans are losing their insurance every day!
First of all, lack of health care coverage threatens basic physical well-being, and can be a matter of life and death if it means foregoing important treatment. Ethically speaking, I agree with those like Amnesty International that regard health care as a human right that societies must provide. Functionally speaking, we rank a disappointing 37th globally in terms of health care performance according to WHO, and that probably has a lot to do with the huge amount of people who don't go get treatment.
Secondly, uninsurance and underinsurance puts low and middle-income American families at tremendous risk. If they get sick and have to pay out-of-pocket, they have a lot less money to pay for the mortgage, college loans, credit card bills, utility bills, and even food. One study found that over 60% of bankruptcies are related to medical costs. Lack of good insurance forces a lot of American families out of the middle class.
Our health system is inherently discriminatory. Working class people in this country cannot afford health care unless they are poor enough to qualify for Medicaid or they are covered by their employer. Sick people can't get health insurance because insurance companies are allowed to deny coverage to those with pre-existing conditions.
2) Lowering health care costs
The US has the most expensive health care system in the world. We spend 16% of our GDP on health care, $7290 per person. France spends the next highest percentage of GDP, and they merely spend 10.6% of GDP. Meanwhile the OECD average for health care spending is $2964 per capita, and only 8.9% of GDP. That's bad enough, but our health care costs are projected to grow by 6.2% per year over the coming years, much higher than inflation.
These costs come not only from the delivery of care but also the overhead cost of insurance administration and the cost to doctors and hospitals of managing insurance claims.
American families experience higher health care costs in higher insurance premiums. Those who get insurance on the individual market tend to have plans with higher deductibles and co-pays. These folks see not only rising premiums, but much higher payments when they get sick and have to get care, putting them at even greater risk of medical bankruptcy.
The majority of American get health care through their employer. As health care costs more, employers have to spend more money to pay their share of their employees' insurance premiums. That robs them of capital to improve and expand their operations, and discourages them from hiring more workers. Obviously this means less jobs and thus less demand in our economy. Furthermore, it puts us at a comparative disadvantage to countries who have less health care costs, encouraging companies to go elsewhere.
Workers with employer insurance feel the pain as well. More and more employers are dropping coverage completely. For workers who retain coverage, many find their employers paying a lesser share of their premiums, which reduces their paychecks. Because buying health insurance on the individual market is so risky and expensive, unions find themselves having to fight for benefits instead of getting their workers better wages.
Ultimately health care is an economic issue. The result of rising costs has been more outsourced jobs, stagnant wages, and reduced consumer demand in a time when our economy is struggling enough.
One more thing to note: the cost of health care to our economy is related to, but not synonymous with, the cost to our government. A lot of people are concerned about the effect of health care costs on our federal budget deficit. They are right to do so, but many of them oppose any additional role in health care by the government on account that it might increase the deficit. If bringing more of health care spending under the aegis of the government can reduce the overall cost to our economy, then it makes sense. Deficits can be cut through efficiency and taxes instead of just cutting spending, as deficit hawks rarely concede. The important thing is the total cost to our economy, not how much health care spending is done by the government.
3) Better Health Care Outcomes
I must admit, I'm not a doctor. But it's clear that we need to get better health out of our health care system that we spend so much on. As you can see here, we have lower life expectancy and a higher rate of infant mortality than those of other developed countries.
To some degree this is partially a matter outside of reforming insurance and health care delivery. A lot of our health problems have to do with our personal habits, such as smoking, dietary choices, etc. (not judging, I have some bad habits myself). I think some people have a point that there's only so much government policy can do to change those habits. Still, making America healthier has a lot to do with how our health care system works, and to the other two principles I elaborate upon above.
Increasing insurance coverage simply gives people access to the care that they need. They wouldn't have to wait until their conditions worsens so much they have to go to the emergency room. Also, some studies of Medicare have found that some hospitals and clinics with lower costs have just as good or even better outcomes as Atul Gawande writes in The New Yorker. Perhaps a focus on efficiency can also produce better care.
As I see it these are the fundamental goals of health care reform. These are the goals by which we should evaluate proposed efforts at reform (and the problems to demonstrate why those who favor the status quo are so wrong). The Obama administration and the Democratic leadership need to do a better job of conveying these goals to the American people because right now the American people are confused as all hell. I also think that if they if the Democrats remained grounded in these goals, they would have come up with better reform proposals, as I'll discuss later. The media needs to cover these problems more. Every minute they fail to cover why we need health care reform provides cover for the special interests that benefit from the status quo.
I mentioned earlier that these goals are not mutually exclusive. A policy aimed at reducing costs would free up more money to cover the uninsured, or it might even improve quality of care. If you read this blog later on, you'll come to see that I'm a proponent of single-payer health care, in which the government acts as the insurer for all people while health care delivery remains in the private sector, precisely because it meets all three goals.
I'll leave a detailed discussion of single-payer for another time. For now, check out the great website of Physicians for a National Health Plan. Stay tuned, and drop me a comment if you're so inclined.