Eccentric Flower:200908/What Does It Mean

... when the most reliable sources for news commentary that actually tells the truth in this country these days are satirical?

Onion:

...

I'd be laughing if it wasn't true.

I said I wasn't going to write about health care again. But I can't get away from it. Everywhere I turn. No one is posting a lot of personal writing to distract me right now, and all the news/political commentary sites I read are just babbling about this endlessly.

Another forum I read has a very long-running health care argument going on, sustained by one person who is maintaining a radically different perspective from everyone else there and will not let it drop. I admire the man for sticking to his guns, but someone needs to point out to him that when the stoic, detached-to-the-point-of-comatose Dutchman wakes up from his coma to call you out, this is a sign you need to dial down.

Said Dutchman provided me this link: The Most Outrageous US Lies About Global Healthcare. In keeping with my non-partisan condemnation of this whole can of toxicity, I note that not all of those lies are right-wing ones.

I have already noted that no one on the national stage is asking the real question, the question "Why does our health care cost so much more than everyone else's?" We are not getting good value received, and until we work on that, the question reduces to "Who will pay the costs for our poor-value health care?" As I say, I think arguing about that point is less useful than solving the other issue, but everyone else seems to want to have the second argument.

The contention over at the other forum is that the gent in opposition really, really doesn't want the government to do this. He believes it is going to be an enormous boondoggle that is going to be even less efficient at providing healthcare than what we have now, and is going to cost us a ton of tax money to no great gain. He has a point.

But who do you trust more? Or, more precisely, in this context, who do you trust less? I don't trust my government as far as I can spit - but I've seen the track record for what the insurance companies do and I'm not impressed with that either. To say the least.

Let's consider this in bullet points.

INSURERS PAY.

PROS:

- Theoretically this is an incentive not to spend too much on raw health care costs. Doesn't seem to be working, though.

CONS:

- Massive bureaucracy.

- Insurers make money by, in essence, collecting fees from everyone but only paying costs for a small percentage of the people they collect cash from. Insurance is profitable only when a majority of the policies/clients do not involve outlay for the insurer a majority of the time. This means that, as a health care payer, insurers are in the business of not paying for health care as much as they possibly can. Do not ever forget this.

TAXPAYERS PAY.

PROS:

- Profit incentive removed. No good reason to deny healthcare to anyone.

- Possibility that usefulness-of-treatment decisions are unlinked from cost-of-treatment factors.

CONS:

- Massive bureaucracy.

- Will not lower raw health care costs. (Think defense contractors and $300 toilet seats.)

- Usefulness-of-treatment decisions become more obvious to those who were previously shielded from them.

Notice how I phrase that last bit. It's become clear that there is a sharp class divide in these discussions. To wit: If you have employer-backed health insurance and you have never seen its bad side - which means you are above a certain income level and have had steady employment for most of your working life, or are way above a certain income level and have never needed to care, then taxpayer-backed health care looks like a net loss to you. Suddenly, it seems, all the costs go up; suddenly someone else is making decisions about what health care you can get.

But this is illusory. In fact the costs have always been there. Ask someone who's paid for COBRA coverage or has had to self-insure. Ask an employer. As much as I hate the corporate complex, in this case they are not just crying crocodile tears: Subsidizing employee health care costs is breaking them. Not just small and midsize businesses either. Some very large ones are being slowly ground down by the costs of their health care obligations.

And the decisions about care have always been there too; they've just been taking place silently in the cogs of the infernal actuarial engine, where you don't find out about them until you fall on the wrong side of them. Better to get them out in the open, perhaps? Wouldn't you prefer to at least know the formula someone is using when they decide it is no longer a good idea to pay for a particular prescription of yours? And whose decisions do you think it will be easier to appeal? Government schemes, however flawed, do generally build in a complaint mechanism. The complaint mechanism for Kaiser Permanente is a courtroom you probably can't afford.

I suppose it's probably clear that I favor the government method - reluctantly. I don't trust them to do it right, but I think we have to remove the profit motive. Health care cannot be run as a for-profit business. It just doesn't work. The human cost is horrible, from untreated patients to overworked doctors.

But I also can't blame the people who don't want to pay for this with their taxes. Taxes are already high, and often it seems like we're not getting much value for our money. (See comments.) And I admit it: I'm not thrilled with the idea that I don't just pay for my own care under a government system; I pay little bits of your health care. In fact, in my case, I'd pay more towards yours than my own. I go to a doctor maybe once a year if forced at gunpoint. I have had one major hospitalization in my life. I am clearly not going to get value for money. My tax contribution is mostly going to go help someone else's health. And I'm not always charitable-minded enough to countenance that.

I can be a mean Republican. It's very easy to do. There are certainly days where I feel mad enough at the world to do it. There are certainly days when I'm like, "Well, if you can't pay for your own health care, tough luck; if you're a smoker, go die of emphysema somewhere; if you're obese, here's hoping for your swift heart attack; all you sick and poor people get the hell out of my road and off my lawn." There's some Darwinian appeal in that: Take care of your own health and pay your own way, or you don't deserve to be in the gene pool.

But.

Even the people who keep themselves healthy do have accidents sometimes. Things happen beyond our control. It seems wrong to penalize someone who Did Everything Right just because another car broadsided them, or because they happened to be in a room with a person who didn't know they had swine flu at a critical moment for contagion. Or because they wanted to have a baby! You would have to be a truly black-hearted Malthusian to argue there was a benefit to keeping the costs of having a hospital delivery so damned high.

Furthermore, the people who are sick and too poor to pay for it - which is becoming an alarmingly high number - do sometimes get sick enough that they can't ignore the problem. What do they do? Well, unless they live in the few places where somehow a free clinic has managed to thrive, they go to hospital emergency rooms. Gradually, in this country, ERs have become not just the place for urgent and traumatic care - which is their true role - but also de facto free clinics. ERs generally do not refuse treatment to anyone, even if that person is a walkup to an ER with the flu. This is slowly bleeding ERs to death.

And further furthermore, there is such a thing as social cost. If we all get the flu but two-thirds of us can't afford to go get drugs for it, then the collective effects of it, the time it takes us all to shake off this wave is greatly increased, and our ability to recuperate in time for the next wave is greatly diminished. We all get a little sicker. For want of a nail, etc.

(Another example: The resurgence of tuberculosis in New York City in recent years is partially attributable to drug-resistant strains, but a large additional factor was the closing or curtailment of public health facilities in that city. Once upon a time we knew that TB was everyone's problem. We seem to have forgotten that, and other lessons like it.)

In short, the problem with the harsh Darwinian argument is not just that it's harsh, but that there are Hidden Costs. You may want to sweep the under- and uninsured under the rug, but they don't stay swept. They don't vanish just because you've decided they're not worth the consideration, and eventually they will come back to haunt you in various ways.

Better, I think, to just deal with them in an aboveboard manner. Which means, yes, paying out some cash.

The problem is that it's so much cash. We pay more, and get less for it, than most of the other industrialized countries. Why the hell does it cost so much? I guarantee that reduction of raw costs would take a great deal of the anger out of this discussion. It's much easier to say to someone "please pay five dollars a month to help other people have health care" than to say "please pay fifty" or "please pay five hundred." Right now the numbers are high enough that I can, as I say, understand perfectly why people are getting so pissy.

Which is why I am so bewildered that no one is seriously discussing raw costs. Not even the Onion.