Sunday, March 01, 2009

Maggie Mahar on Universal Health Care

This week I read an angry post from a cynical critic of Everything Obama which went to the trouble to put in extra HTML tags to read "Universal Socialist health care." Some critics won't leave that nasty label behind, even as Obama bends over backward to accommodate the free market.

Without knowing the details, I was an early supporter of Hillary Clinton for two reasons. One was realpolitick: I didn't believe Barack Obama, the scholar, the thinker, the calm, reasoned no-drama Obama had the chance of a snowball in Hell to get elected. (I've never been so glad to be wrong about anything.) And second, I heard that one of their few disagreements was on health care. She called for "mandates" while he said candidly that no one would be obliged to have health care if they didn't want it. That, to me, sounded crazy. After all, the whole point of insurance is that the healthy population shares the costs with the sick ones, but we have no way to know which group we might fall into.

So the discussion has started and my attitude is changing. The more I read the more I know how little I understand. It's like going to college. You finish knowing more than when you started, but worse, you also know how very much more you left unknown. For example, I had the mistaken opinion that if we could just recaplture all the money being wasted on administrative costs and corporate profits and bonuses, it would be enough to cover everyone.

Not true. Administative and private-sector profits might help, but the real challenge is healthcare inflation. Aggregate costs are swelling out of control, over and above any other inefficiencies.

Contributing to an already heated and messy discussion is a confusion of terms.

Health Care refers to the overall mission which involves everyone.
Universal Health Care means having health care available for everyone.
Insurance refers to a variety of ways to pay the costs of health care.
Private Insurance is what non-government insurance plans do.
Private Plans are mostly for-profit but there are also a few not-for-profit plans.

Health care in America has at least six distinct tiers or sources.
Private Insurance is the most widespread, including individual plans, group plans, and workers compensation.
Medicare and all its permutations is for those 65 and older.
FEHBP stands for Federal Employees Health Benefit Plans (and the titile is self-explanatory)
Indian Health Service is a separate government plan for Native Americans. (I know nothing about that except it is mentioned in the Medicare and You book from Medicare)
Tricare is the plan covering military families and dependents. I don't know, but I think military personnel all over the world plus the VA facilities are involved with Tricare.
Veterans Administration/ VA Hospitals

Anyone not covered by one of these either pays for services and medicines as needed, does without or presents at a hospital emergency room as the need arises, whether or not the problem is truly an "emergency." By law, hospitals are not allowed to refuse treatment, so any costs incurred in this way must be recovered by other means. Some people do pay their bills even if they do so on an "installment plan." And it is a little-known fact that in some hospitals if the patient pays cash there could be an immediate fifty-percent discount.

It is important not to confuse insurance with medical care. Terms are frequently interchanged carelessly that have different meanings.
Insurance and health care are not the same.
Actual health care comes from providers. Costs are administered by administrators.
Medicare, then is an insurance plan.
A VA Hospital or a military hospital (Walter Reed or Brook Army Medical Cente) provide actual medical care.

To use a term like "government health care" without defining exactly what it means confuses any conversation. It m,ight mean actual delivery of health care, as in the case of VA hospital or a dispensary such as the one where I was assigned with the Army Medical Service Corps (and yes, we took care of civilians) or it could mean a Medicare beneficiary whose actual care is from any number of providers.

It is more correct to call Medicare "government insurance" than "government health care" because Medicare has no way to provide medical care. Medicare is an administrative function. It is for this reason that those who argue a "single-payer" system (think Canadian) is better, because it leaves the private sector to the business of providing. Those who object to single-payer have a valid argument because it empowers the government, rather than "the market" to dictate prices.

I started this post over an hour ago to introduce Maggie Mahar, one of the smartest commentators yet in this very important discussion. I have run out of time, so all that is left to do is furnish this link to her most recent, and most comprehensive essay.

The President's Budget

...the discussion of healthcare reform both in the blogosphere and in the mainstream press is becoming more realistic. This is both refreshing and encouraging. No more rose-colored glasses. No more “we’ll worry about how to fund it later.” Or “it will pay for itself.”

This is an administration that is based in reality (in contrast to the faith-based governance that we enjoyed for the past eight years.) The Washington Monthly's, Steve Benen notes “The administration seems well aware of the fact that a $634 billion over 10 years would not cover literally everyone. Neera Tanden, a top Obama health adviser, acknowledged , ‘We know that this is not enough to achieve our overall goal of getting health care for every American, but it is a significant down payment.’”

A hard-headed administration is dragging, us, however reluctantly, into a world where numbers matter. At the New Republic, the usually optimistic Jonathan Cohn acknowledges that “the amount [set aside in the budget] will not be enough to finance full universal coverage . . .The budget will call for finding that money, although that obviously raises another question: Just how much more would it cost to get everybody (or nearly everybody) covered ?”

“The answer,” Cohn writes, “depends in part upon how you define ‘decent’ and how quickly you want to get there. Passing a universal coverage plan in 2009 wouldn't necessarily mean covering everybody in 2010. Or 2011. Or, well, you get the idea . . .”

... President Obama is focusing first on controlling healthcare inflation: “Clinton started out with the goal of covering everyone. Obama has framed the problem in a different way: slowing the increase in costs, so that eventually everybody can be covered.

“Obama is asking Congress: If you're going to cover 48 million uninsured people in the world's costliest health care system, how do you pay for it?” As I wrote in a comment on the president’s speech published on the New York Times’ “Room for Debate” yesterday, Obama is bouncing the funding problem back to Congress. He has come up with suggestions that will not be popular with everyone. Now it’s their turn. Fair enough.

"’The approach he's taking is to put some tough decisions on the table, and then bring people together to have a conversation,’ " Christine Ferguson, former senior Republican health policy aide at the federal and state levels told AP. "’You put those on the table, and if people want to have this discussion, they have to propose alternatives .’"

This is just part of her opening lines.
The reader who wants a harsh, clear overview of the healthcare debate from a card-carrying expert with a boatload of facts in her portfolio is invited to go learn something.

1 comment:

Gary Baumgarten said...

Health care reform will be the topic of News Talk Online on Thursday March 5 at 5 PM New York time.

You can connect to the conversation via my blog at