It is probably wishful thinking (for both sides) that we could get a re-do of the health care debate. After all of the rancor, the liberals will apparently not get what they want with the Baucus Bill, and the conservatives will oppose it en masse. This effort's predictable lack of vision comes from the rushed political process without presidential leadership. There is no master plan to move from an employer-based system to one based on either the individual or the government. There is no strategy to move from a payment system based on specific treatments to one based on keeping people well. Sometimes it is best that a compromise satisfies neither party; not this time.
Most Americans are satisfied with their own health care coverage. They would agree however, on three problems - it is too costly individually and for the country; there are too many people who do not have coverage; and the administration is too complex. Most voters now oppose the bill, feeling that the current proposals will deal with the second problem, but at the expense of the first.
Much of the debate has centered on the "public option", which is portrayed as a way of dealing with the cost issue since it will bring more competition to the insurance industry. Many of the "public option" advocates would really like a "single payer" system where the federal government manages all health care insurance, but recognize that they do not have the political support for that proposition, and hope, like Obama and Barney Frank, that it is a step in their direction. There are three general arguments against the "public option" and it's extension to "single payer":
1. As a basic consideration, conservatives prefer that services be provided by the private sector, believing that market forces drive innovation, customer service, and cost containment. The point was made unintentionally by Obama who, in arguing that the "public option" wouldn't drive out private insurers, spoke of UPS and Fed Ex as doing just fine while competing with the Post Office which has "all of the problems". We have all sat in a DMV office.
2. Political forces make it impossible for a government provider to control costs by limiting benefits. On a national basis, this has been demonstrated by Medicare (loved by doctors and patients, but going broke within eight years), and by the experience in Massachusetts where there remains considerable pressure to increase state subsidies, despite government costs being substantially above projections,and insurance rates - already the highest in the country - increasing at double digit rates. There is no limit to what can be required - dental; mental health; Viagra. And there is no stomach to give the recipients of government programs less than "the rich". It is also a cruel fact that requiring equal coverage and premiums for everybody, regardless of "preconditions" and life style decisions does raise the cost which must be covered somehow. (That is the error of Olympia Snowe's "trigger option - rates will go up substantially, as they did in Massachusetts, and the "public option would be imposed.)
3. While the government is not capable of rationing health care - the emotional "death panel" discussion; Medicare and Medicaid - individuals can, by determining what structure of insurance plan to purchase, and what non-covered expenses they choose to incur. The only real solution to costs is to align the benefit recipient with the payment. That does not make us all equal in terms of health care, but society could only afford that at the lowest common denominator.
What is disappointing is that the Republican Party has largely been the "Party of No", without offering coherent alternatives. Those should fall into two categories politically:
1. Those that most everybody would agree with - ability to buy insurance across state lines (and thus escape the lobbyist-induced policy requirements); tort reform to reduce the cost of lawsuits, doctors' insurance, and preventive medicine; ability of the government to negotiate prices with pharmaceutical companies and equipment providers; a large investment in information technology; greater use of nurse practitioners and clinics; and elimination of a financial interest for doctors to order tests.
2. Those that would appeal to most Republicans and independents - a basic catastrophic insurance plan for all legal residents, subsidized for the truly poor; a few standard templates to facilitate shopping among companies for the rest of us; restrictions on expenditures by medical providers for lobbying and advertising; and Medicare reform. Perhaps most important would be a gradual shift away from employer-based policies to private "health care accounts", a move that would help restore business' competitive global advantage, and reflect the current mobile work force. Couple that with a personal responsibility for "wellness", and you would have a winner.
Aside from the government run insurance plans, most of the rest of what is being discussed can be reversed in the inevitable Phase II. But a more open and reasoned approach would surely have saved a lot of national anguish.
This week's You Tube, which captures the optimism of the tea parties and town hall meetings, comes from a friend in Massachusetts.
bill bowen - 9/30/09