Wednesday, September 02, 2009

Five Dumbest: things said about health care reform

I don't often write about politics, primarily because I consider myself a radical moderate and a proud non-voter.  (Yeah, you read that right.)  But once in a while, a topic comes up and people (usually, on both sides) say things that are so insanely stupid that... well, read on.
1) We're looking to reform the system so that everyone can have affordable insurance.

Maybe I'm wrong (I am married, after all), but it seems that all of the other things that I buy with the word "insurance" on the end do very different things than "health insurance" is supposed to do. As a rule, Americans don't really want health insurance. Sure, insurance is nice, and I want to be covered if a major medical catastrophe happens, the same way that I want to be covered by my car insurance if I have an accident. But that's not really the point of medical insurance. Consider what Americans want in a "good" health insurance plan. Doctor visit fees covered. Prescription drugs covered. Hospitalization expenses covered. In essence, there should be little or no out-of-pocket expense for any health care procedure. Essentially, Americans want an all-you-can-eat medical buffet. They want a health subscription service.  A lot of commerical health plans are set up in this way.  Someone (not you, of course) pays the subscription fee and you get access to whatever medical services you need.  That's nice covereage if you can get it.  After all, the nice thing about an all-you-can-eat buffet is that you don't have to think about whether you want to pay 60 cents for that scoop of mashed potatoes.  You can just scoop it on and figure out whether you wanted or needed them at the table.  In medicine, where you're dealing with silly things like your life and well-being, it's nice to have to not make decisions based on out-of-pocket cost, but someone is paying for that additional bloodwork your doctor ordered.

Then there's that interesting word "affordable" which is conveniently never defined.  Putting aside the massive "government" expenditure (i.e., your tax money... either taxes will go up, programs will be cut, or... and this is probably what they'll pick... we'll put it on the national credit card) that will be required to finance this plan, what exactly is an "affordable" premium.  Considering that this program seeks to be "universal", part of the population you're going to be looking at are people who have no job, no income, and no skills.  They live from day to day.  (Don't get romantic about "the spirit of the American people."  There are plenty of folks out there who don't have anything going, some of their own fault, some by circumstance.)  It doesn't seem sporting to exclude them, but what exactly do you charge that guy for a premium that's "affordable" to him?  Or will it simply be free?  Come to think of it, ask Americans who have health insurance through their job how much their premiums are.  You'll probably get a blank look.  My guess is that people think that health care is simply free already, because the company pays the premiums.  They'd probably balk at even a small fee that they really can afford.  After all, it's more than they're paying now.

Something I have yet to get an answer to on this "health reform" bill is whether the "public option" will be more like the "all-you-can-eat" policies that are out there or one that's more like the catastrophic coverage that I have.  It's said that there are 46 million uninsured people in the United States.  To quote that number is something of a sleight of hand.  For political purposes, it makes for a great tagline to draw up pity points.  But, when figuring out the costs of the plan, the important question is "what sort of plan will this be?"  If the answer is anything more than "catastrophic coverage", then you're also paying for an upgrade for however many million people fall below that level.

Bottom line: it's not that health care isn't worth spending money on.  It's that it's not free.  We can have a rational conversation about whether it is an appropriate use of government resources to provide health care to everyone and if it is, if that's high on the list of priorities.  But let's stop the fiction here.  This costs real money.  Sometimes, something can be a really good idea, but if you don't have the resources to do it, then it's a dumb idea to go ahead and do it anyway.  (That, however, does sum up American consumer behavior in a nutshell.)
2) You can keep your current plan, if you want to.

Personal experience: This past year, I was working for a company (no longer work for them) and as part of my pay package, I got health insurance coverage through one of the big major insurance brand names.  The plan was nice enough.  Decent coverage for what I needed.  However, the economy wasn't going so well, and so the company decided to make some cutbacks.  They re-evaluated the health coverage they provided and found that another company was cheaper.  They sent around the usual memo that goes out to employees when you're getting screwed on something ("Almost the same coverage at great savings!"  Always the exclamation point) and sure enough in January, we switched over.  No one asked me whether I wanted to keep the old plan.  Why?  Because most Americans don't actually pick their health insurance plan.  At best, they pick from 2 or 3 plans provided by the same company.  And because it's hard to find/switch jobs in general, most people don't look at exactly which plan they're getting when they sign on to a job.  It's usually enough to see "medical/dental/vision" in the want ad on  It's not like there's a giant Facebook fan club for Aetna insurance.  If they happen to have my coverage, that's nice.

Then why the insistence on saying "you can keep your current plan?"  I think there are two reasons.  One is that Americans are generally (and probably properly) reluctant... perhaps proud is a better word... to take something that is labeled "government aid."  It's not that the government wants to re-assure people that they can hold on to whatever policy they have (if they even know what it is!), but that they can stay the heck out of the government one.  The other is that people would rather "the devil they know than the devil they don't."  People are afraid of change, even if you can make a reasonable case that the alternative is better.

But then, they might not have a choice.  President B-Rock speaks of the government plan as a competing insurance company.  OK, fine.  The plan will probably be, in one form or another, administered by Congress, the 535 people in America who never say no to anyone, because they might be kicked out of the best job in America: spending other people's money.  Sure, there will be some "health review panel" but it will be staffed by political hacks who can't say no to anyone either.  It doesn't matter which party is in control.  They've both shown that neither has any fiscal restraint.  Eventually, the coverage provided by the plan will be outstanding.  Premiums will be subsidized by the taxpayers, and when Americans inevitably cry that they are "too high", Congress will pass a tax to lower them right before election time.  (In a brilliant feat of accounting logic, people will see that they pay $300 more in taxes per year and see their health premiums go down by $200 per year and will say that they have saved money!)  Eventually, the government plan will be very attractive.  Even before that point, when they're still working out the kinks, why should I, as an employer pay for something that the government is going to either give you outright or sell at a low cost, particularly when economic times are hard?  Since most people have their coverage through their employer, they'll end up like me this past January, switching coverage not because I wanted to, but because that's the way things work.

3) There will be rationing of medicine!

This qualifies as stupid despite the fact that it is technically true.  The romantic notion that you will walk into a hospital, and immediately be tended to by the world's greatest doctors, highest tech medicine, and have 24 hour monitoring in a guest room with wi-fi is sci-fi.  The world's greatest doctors only work so many hours.  There are only so many of those high tech machine thingies that my brother sells.  There will be a line, and not everyone can be first in line.

What gets me about this one that when people decry the probability that there will be rationing, what exactly do they think is happening now?  The only difference now is that it's not a bureaucrat who's doing the rationing, but the market.  There are things that I can get done based on my insurance covereage that other people can't.  There are things I can't have done that other people who have better insurance can.  Generally, it comes down to what sort of job that I have.  I agree (see above) that what is now "health care reform" eventally becomes a national health care plan (if you want to call that "socialized" be my guest... frankly, that word is used primarily as a scare tactic... but again, probably technically proper.)  The thing about a national health care plan is that I would have the same coverage as you, no matter what my job/income.  I'd have no claim to jump in front of you in line because I have better insurance.

Claims of rationing are usually followed by examples involving Canada, in which people who would have to wait 4 months for a procedure come south to the US to have it done in 15 minutes.  Usually, they forget to say "because they can afford to pay for it."  In the US, you can jump ahead in line if you can pay more.  That's a market system.  In Canada, there's probably a system of assigning places in line, perhaps based on medical need, but eventually, places are assigned by something that boils down to "first-come first-served."  And for some procedures, the line is very long.  Which is the more just system.  That's what the whole debate boils down to.
But the reason that I think cries of "rationing!" are so effective is that it gets people thinking about how decisions on rationing would happen.  Rationing requires a system of who should go first.  Whether that's first-come first-served or whether it's based on age, medical need, etc., there's the very real thought that we're dealing with people's lives and the possibility that in putting someone toward the back of the line, they may die.  We all like to believe that we value all life equally, but this is a case where you just can't do that.  Having those conversations is really really really uncomfortable.  It's a lot easier to let the market do it for you because you can honestly say that it wasn't your fault.

4) Anything said by Sarah Palin

Sarah!  Good to see you again.  See that clock over there that says 14:59?  Can we talk about what's actually factually in the bill?
5) Just about any of the details of the plan.

Americans have a curious and well-documented pattern of answering that they would like "less government" but would like more spending on specific government programs such as education or infrastructure.  This holds even if you ask the same person.  We want one thing overall, but when it comes down to the details, we want another.  Selling the brand of "health care reform" is a winner.  Everyone has something that they don't like about the health care system.  The problem is that they all have things that they do like.  The more details you release, the more likely you are to be stepping on something that someone doesn't want changed.

What's strange is that people will oppose something that is 90% what they like and 10% what they don't like.  So, the more vague you are, the more likely you are to get people to line up behind whatever it is you're selling.  One would think that the human teleprompter himself (B-Rock... or President Obama, as some of you insist on calling him) could give one of his trademark speeches of pure fluff which sound great (remember "Yes We Can!  Hope!  Change!  Pickles!"... OK, I made the last one up).  He's good at that sort of thing.  Herein lies B-Rock's weakness.  He's a smart guy and so he's interested in the actual details.  Can't say that I blame him, because more people should be interested in the details.  But B-Rock makes an awful salesman when it comes to details and in any case, the more details you give, the more people will find some fault with one of them.  If B-Rock really wants this bill passed, he should come up with a slogan ("To your health!") and ram it through that way.  It's horribly cynical politics, but it's about the only thing that's going to save him.

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