Every American citizen should have access to affordable, quality health care.
Most of us would agree on the principle; it is the implementation that has everyone befuddled. It’s not just that the implementation of the ACA has been marked by cronyism, bad decisions, failures, fraud, political floundering, lies and stealth taxes. It is that the program itself will not work because there is no one-size fits all solution to health care.
What we have in the ACA is a political fantasy designed to shill out health care in order to raise taxes for other purposes and programs. Its architects, we now know, had no intention of actually providing affordable health care to Americans or anyone else.
As a died-in-the-wool fiscal conservative, however, I believe that we can do a better job than we are doing with health care today if we simply adopt a few guiding principles and then let the two sides work incrementally toward solutions for the outstanding problems.
I’ll note at the outset that I am a fiscal conservative, not a social conservative. I believe in smaller government, in a balanced budget and in paying down the $17 trillion plus in government debt. Socially, I believe you should be able to do anything you want, so long as you do not encroach on my rights. If you want to burn a US flag in protest, I will loan you a match. Think gay couples should be allowed to marry? Fine by me. Want to have an abortion? That’s your choice – just don’t ask me to pay for it. You catch my drift.
So what do we do about national health care?
Our present system grew out of the Post WWII-era, founded on the hospitals Kaiser Steel built for employees who built Liberty Ships and other projects. It rapidly expanded into other forms of corporate-sponsored care as a benefit of employment.
It eventually evolved into a five-tier system:
- If you have no resources at all, and no money, you can simply appear at a local emergency room, and they have to treat you. At little or no cost.
- If you are poor but cannot afford health care, your state offers Medicaid as a basic health insurance program. The programs are under-funded, but work.
- If you are disabled or over the age of 65, you were eligible for MediCare. Many seniors choose not to use MediCare because it has a cost for premiums each month, but it does exist and functions fairly well.
- If you are employed, you have health insurance through your employer or can buy it from a private insurer, even if that coverage is only for catastrophic events like cancer or hospitalization.
- If you are high-net wealth, you can self-insure for your health needs and take the tax write-offs.
What are the problems with this system? Start with these:
- We have not yet figured out how to treat chronic conditions which cost great sums of money to manage. Cancer. Type II Diabetes. Neurological disorders.
- The high cost of new product development for drugs and treatments.
- Fraud and waste in MediCaid and MediCare.
- Whether to provide health care at any level to those who are not citizens and/or do not contribute to the system.
- The fact that the leading causes of bankruptcies in the US are medical bills incurred in a single event by a family that does have health insurance.
More generally, and agreed to by both ends of the political spectrum, is that the current system encourages the worst kinds of health care behavior. No one knows – or even cares – what a treatment or procedure will cost, so long as it is covered under a health insurance program. People use the most expensive emergency facilities for routine health matters – often clogging the waiting room so that true emergency patients wait for hours (and sometimes die) waiting to be seen. Treatment takes precedence over prevention. Health services are not estimated in advance and payment is based on efforts rather than outcomes.
In the face of spiraling costs, insurers, consumers and governments have engaged in efforts to address these problems. From the outset, these efforts have been hampered by unrealistic expectations, complicated programs and even higher spiraling costs.
So what would a fiscal conservative do to fix health care? In simple terms, keep the things that are working within the current system, and fix the things that are broken.
Begin by overturning the ACA. I do not buy the argument that the law cannot be rescinded – we managed to give women the vote, end slavery and allow a person have a drink of alcohol when they like, all by overturning laws that in retrospect turned out to be a bad idea. Same applies here.
Then, consider these as guiding principles:
- Put control of health care back in the hands of consumers, not governments or insurance brokers. There may be some things that governments manage well, but that list is short and does not include health care management. One way to do this is through expanded use of Health Savings Accounts, into which employees can place pre-tax earnings to cover the health needs of their families. These could eventually replace company-sponsored health insurance, eliminating that imbalance. But while favored by many conservatives, this is not the only workable approach. The point is that we put health care on the same footing as any other consumer service, and empower individuals to choose what they want.
- Forget the fantasy of universal healthcare; focus on fixing the problems. No culture on the planet has yet managed to make universal health care work without raising prices and cutting services, both of which result in worse instead of better care. In the short term, identify and solve the problems to move toward a better solution.
- Quit treating quality health care as a partisan issue. Conservatives don’t want to deny health care to seniors; Liberals do not want to give health care to illegal immigrants for free. At last, not in general terms. By engaging in only the most destructive partisan arguments, both sides marginalize and alienate the very people who can best solve the problems of health care. Health care is a management problem, not a political problem.
- Reform tort laws to limit malpractice suits. As Wikipedia notes: “Tort reform advocates argue that by limiting the threat of frivolous lawsuits, the medical industry would migrate away from practicing defensive medicine. This would reduce the number of unnecessary tests and procedures, typically performed under patient request, thereby reducing the costs of medical care in general. As an argument against the current system, tort reformers link the rising costs of premiums for physicians' medical malpractice insurance to the rising cost of personal and group policy health insurance coverage. California's Medical Injury Compensation Reform Act has been cited as a model for tort reform in health care.”
- Take the American Medical Association out of the medical school selection process, which currently limits how many doctors get into and through medical schools. The New York Times puts it this way: “The American Medical Association, like other professional associations, suffers from a split personality. While it is devoted to improving the quality of medical care, education and the profession, it also operates as a cartel to protect the economic interests of its members. Although the A.M.A.'s recent report on physician manpower reflects both personalities, the cartel strain is dominant. The report's assertion of a physician surplus and its recommendation that the surplus be eliminated by curtailing medical school enrollment are a blueprint for anticompetitive action.”
- Properly fund MediCare. If we are all going to live longer, we need to bank more toward our long-term health care. That means that each individual should pay a little more toward MediCare to keep it solvent and working. It also makes sense to raise the monthly premium paid by those who use Medicare. The current rate of just a little over $104 per month is too low. Keep private “gap” insurance to cover what MediCare does not, but allow consumers and their families to use a health savings account to pay these premiums.
- Use health care money only for health care. Congress has a habit of raiding funds that have been set aside in trusts whenever they want to spend more on pet projects and pork-barrel spending. Even the ACA ultimately became a shill to collect taxes to pay for environmental and regulatory programs that have nothing to do with health care. Set the money aside and keep it safe until needed.
- Give the states more money for MediCaid. This is a critical and useful program, paid for with Federal dollars but administered by the states. If we can afford to give billions of dollars to banana-republic dictators to try to make them like us, surely we can put like amounts into the funding to cover health care for poor Americans.
- Give private hospitals tax incentives to operate “rapid response rooms.” Many hospitals have already moved to a model in which their emergency room is complemented by a “rapid response room” where poor and indigent persons can get treatment without interrupting the whole triage/emergency room workflow. This can be made to work if properly incentivized.
- Loosen the regulatory grip on health care plans. All too often, states impede progress by limiting some programs and mandating others in the mistaken belief that the judgment of a political appointee is better than that of a healthcare professional. Given the known connection between dental care and heart health, for example, it only makes sense to allow dental plans to be included in a package. Vision, disability, and long-term care should be included as well.
- Learn to let go. We all die, and some sooner than others. It is sad that nearly all of the money a person will spend on health care in their lives will be spent in their last 90 days in a futile attempt to extend life by a few weeks or days. It does not take a “death panel” to decree that some people cannot be saved. Nor does every effort to extend life have to be rejected out of hand, based simply on the actuarial tables.
For some, simply setting out guidelines and expecting elected leaders to work out the kinks may seem overly simplistic. On the other hand, there was nothing terribly complicated about other issues that have become law. “All men are created equal.” “The government cannot steal your land to give to another person for their profit.”
Sometimes, keeping your ideas simple and realistic make them possible to make happen.