Now that the Donald has admitted that health care is more complicated than he thought, it might be a good time to consider what we really want from a health care system. The failure of the Trump/Ryan AHCA bill illustrates the great disconnect between Republican rhetoric and reality. We’d all be a lot better off with some serious self-reflection. Voters and their representatives need to ask some hard questions and then articulate and communicate their answers clearly. Conservatives say that they want to get the government out of the health care business. But they are unwilling to actually do what actually needs to be done and then face the voters’ response. And therein lies the real dilemma.
A little history is in order. There are three basic options for a health care system: 1. Government subsidized health care for everyone 2. No government health care for anyone 3. The government gives health care to some groups but not others. Option three is what we have had since WWII. Prior to the passage of ACA, the following groups had free or government subsidized health care: active military, military retirees, veterans, people over age 65, federal workers, state workers, county workers, city workers, police, firemen, and teachers. Then, in WWII, the government gave tax breaks to businesses and individuals who get medical coverage through their corporate jobs. The end result left about forty million Americans who had to buy insurance on their own.
Up until the eighties, people who didn’t fall into a government-subsidized group usually couldn’t afford insurance. A fact that Republicans conveniently forget in the health care debate is that Saint Ronald Reagan opened a Pandora’s box of health care problems by enacting a law that forbids hospitals from turning away patients based on their ability to pay. The result was that poor people began using emergency rooms as their primary care physician. This became very expensive and the medical community turned to the government for help. Enter the Clintons and the Republican genius for marketing.
After extensive research, Hillary proposed a single payer health care system. Insurance companies, scrambling to keep their jobs, spent 1.2 billion dollars convincing the public that “Hillarycare” would lead to the immediate death and destruction of all they hold near and dear. Meanwhile, Senator Bob Dole proposed an alternative to “Hillarycare” that had been developed by the Heritage Foundation, a conservative think tank. This plan allowed insurance companies to stay in business but with heavy government oversight. Then President Clinton put healthcare on the back burner while he dealt with his sex scandal. Surprisingly, the Republican plan actually worked when Mitt Romney implemented it as “Romneycare” in Massachusetts.
President Obama dusted off Hillary’s ideas, used “Romneycare” as a framework, and created the ACA. The Republicans responded by renaming it “Obamacare” because why mess with success? What they didn’t count on was Obama’s ability to craft the law in such a way as to make it difficult to repeal. First, he wrote into it sections that became very popular with the middle class. Exhibit A is letting college students stay on their parent’s insurance. Then Obama put in enough fine print to make it hard to get rid of ACA due to procedural difficulties. It turns out a Harvard educated lawyer understands writing laws better than a Wharton Business School graduate. Who’d a thunk it?
All of this brings us back to some fundamental questions. If we want the government to get out of the health care business, then shouldn’t we get the government out of all of it? It seems unfair that some groups get subsidized health care and some don’t. It would be fairer to get rid of the VA and military hospitals as well as government worker health insurance. We also need to get rid of tax subsidies for corporate health care plans. Make every American compete in the market place for health care. People will get what they can afford and the free market will adjust prices accordingly. To their credit, some conservatives actually support this idea.
Practical politicians, however, point to the fact that taking away government health care will result in many Republicans having to look for new jobs. I get it… party before principles. But changing the law about ER’s having to treat all comers shouldn’t stir up too much pushback. Politicians could continue to support the military and veterans by giving them vouchers to use in civilian medical facilities. I know that’s not a popular idea now but Republicans are great marketers; they could sell it if they put their mind to it. Besides, it probably would be cheaper in the long run.
Such a hands-off approach to medical care by the government would result in a more fair but Darwinian system (ironic since many people who support this approach dismiss evolution) in which the amount and quality of health care would be determined by how successful and how prepared a person is. To some extent that is true today, even with ACA. Wealthier people with better education and jobs get better health care than those who lack these advantages. The question is whether we want to live in a country where old people and poor people die because they can’t afford a doctor’s visit or the medicine they need to survive?
I suspect that most Americans are not keen about letting the elderly and poor die due to lack of money. My evidence is that Trump promised cheaper better health care to everybody, while Clinton promised to improve the ACA. If I am right about how most Americans feel, then we should be fair and open up basic health care to everyone, not just the privileged groups. Republicans often repeat the canard that the US has the best health care system in the world. That’s a bold-faced lie except when it comes the rich. By most statistical measurements such as life expectancy, hospital deaths, infant mortality, our country doesn’t even make it into the top twenty. The only two categories that we excel at are cost and treating gunshot wounds. We spend the most money on medical care of any western nation. And we have the best trauma surgeons in the world.
I honestly don’t care which path we choose as a nation. But I do know that what we did until 2010 wasn’t working. Other countries prove we can do better. But first we need to be honest with ourselves about what we really want and then have the courage to fight for it.
