By now, the refrain against public healthcare in the United States is numbingly familiar. A government-funded insurance counterpart to the private system is a "slippery slope" that will take us "down the path to socialism" and undo "all the good" in our current system. But just for once, let's toss the first two parts of that rote sing-song of the lobbyists and right wing, and focus on that last bit. Ask yourself this: do you know anyone - any single American citizen - who is entirely satisfied with her access to healthcare?
OK, if you know someone with eight figures in the bank, then sure; they can pay for the best of the best and jet anywhere to get it. But anyone else?
I don't. Literally nobody. Everyone I know is either under-insured, fearful of losing their insurance, crushed under the weight of costs, frustrated with complexity - or all of the above. And almost everyone I know favors public healthcare insurance of some kind. Indeed, so do most people. This week, a CBS News/New York Times poll found that a clear majority of Americans - 72 percent - support a
government-sponsored health care plan to compete with private insurers.
Yet what isn't blocked by the ideology of the right, seems to run into the swamp of disinformation - namely, that we have a decent system that works well and if a bunch of bureaucrats tinker with it, we're liable to lose it.
The week after President Obama's inauguration, the New Yorker writer Atul Gawande set the stage for the coming healthcare battle with a piece that recalled the founding of national healthcare systems in England and France, and called for a realistic reformation of the broken American system:
Every industrialized nation in the world except the United States has a
national system that guarantees affordable health care for all its
citizens. Nearly all have been popular and successful. But each has
taken a drastically different form, and the reason has rarely been
ideology. Rather, each country has built on its own history, however
imperfect, unusual, and untidy.
[snip]
This is the trouble with the lure of the ideal. Over and over in the
health-reform debate, one hears serious policy analysts say that the
only genuine solution is to replace our health-care system (with a
single-payer system, a free-market system, or whatever); anything else
is a missed opportunity. But this is a siren song.
Yes,
American health care is an appallingly patched-together ship, with
rotting timbers, water leaking in, mercenaries on board, and fifteen
per cent of the passengers thrown over the rails just to keep it
afloat. But hundreds of millions of people depend on it. The system
provides more than thirty-five million hospital stays a year,
sixty-four million surgical procedures, nine hundred million office
visits, three and a half billion prescriptions. It represents a sixth
of our economy. There is no dry-docking health care for a few months,
or even for an afternoon, while we rebuild it. Grand plans admit no
possibility of mistakes or failures, or the chance to learn from them.
If we get things wrong, people will die. This doesn’t mean that
ambitious reform is beyond us. But we have to start with what we have.
Dr. Gawande went on to argue (and remember, the Inauguration "change" glow was turned up to eleven) for a sort of "lifeboat" to help get that broken, patchwork system to an eventual public program that mandates (and pays for) coverage for everyone. The cancer specialist followed up with a fantastically incisive story four months later, looking at healthcare costs in McAllen, Texas - the highest in the country - and how an entrepreneurial business-oriented system has incented institutions and doctors to run up massive costs that do not improve either individual outcomes or community health.
The case is pretty clear, and as Dr. Gwande's reporting (and experience) illustrates, there is a path to massive reform and away from market-dominated healthcare - which, by the way, will relieve American companies of a burden that holds down both hiring and innovation during a killer recession. Yet we're starting summer in full staff mode: the Senate has entirely rejected any public options. The House says a public option is a prerequisite to any action. And the Obama Administration still seems to be listening and reflexively yearning for compromise, despite an incredibly rare political opportunity. Amazingly, the Administration may fail in its central healthcare promise - even without going to the mat.
I think that Digby, who has been doing important work in blogging this issue and taking on the reluctant and rudderless Democratic Party, has it entirely right:
It's not only necessary for the health of the economy to make some big systemic changes --- it's a political
opportunity to challenge this free market, CEO worshipping
fundamentalism as well. It doesn't appear that the Democratic party is
interested in doing that, at least not yet, since they are as wedded to
the system as the rest of the ruling elite. But it's an opportunity for
someone.
Recommended reading:
Matt Yglesias: Public Opinion Strongly Favors Public Plan
Glenn Smith: Slavery and the Health Care Crisis
And the always vigilant Bob Stein
from Amazon.
Just to be (slightly) contrary, I do know people who are quite satisfied with their healthcare - young office workers, mainly, who are largely healthy and who are comfortably insured by their employers. They are the people insurers want - people who go to the doctor occasionally, whose biggest concern is an allergy pill or birth control, whose basic relationship with the system is a copay at the doctor and another at the drugstore. Remember, some 85% of the population is insured, and many may favor a public plan... even though they'll never need it. The "it's nice... for someone else" may mean that the vague support for a "public plan" lowers when you get into specifics.
I like Gawande well enough, and he's got some good observations... but he's a doctor, with a doctor-centered notion of how we fix healthcare... and the real fixes we need - changes in the way doctors practice, changes in the way people access care, and even more fundamental changes to patient expectations - don't favor the status quo. And they're not easy. We shouldn't oversell what's under discussion just now - at best, we're creating a new system where some percentage (though not all) of the uninsured will be able to get insurance... whether that means they get better, affordable care remains to be seen... but the possibility that we'll simply expand the insured without bringing down costs is also very real - that's been the basic unfolding of the situation in Massachusetts.
A "public plan" is not necessarily the "hill to die on" about what's under discussion; it's a key piece, yes, but it will be less than meaningful if, for instance, the subsidies for the working poor aren't in place to make it possible for people just over the poverty line to pay for it. Similarly, no one has examined the real elephant in the room - Medicaid, which, has enormous funding problems, and 50 different operations across the states, which are not delivering equivalent operations, or care, to the most needy.
A public plan that "looks like Medicare" is as much a kind of hazy propaganda as the kind of opposition the right is giving - it's taking some nice hot button words and stringing them together, without examining the reality in detail. Medicare has problems - reimbursement rates for one thing, are an enormous issue that's being deliberately ignored, and Medicare has not, really, shown itself able to incentivize "best practices" or really question poor care (remember those "low administrative costs"? That's because Medicare doesn't have a large operation to question the billing of procedures). A public plan, really, is a vehicle to getting closer to a 100% insured population. Without it, we have no realistic hope of achieving that goal... but the rest of what it can or might do... is really very debatable.